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Pharmacotherapy 1 > 3 - Anemia > Flashcards

3 - Anemia Flashcards

1
Q

Describe physiology of hematopoiesis and blood cells.

A 
decr O2 levels. 
renal release of erythropoietin
stim red bon marrow
enhance erythropoiesis
incr RBC count and O2 capacity
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2
Q

Explain the etiology of anemia.

A 
erythrocyte loss (bleeding, pregnancy)
decr production (low erythropoietin, decr marrow response-->iron/b12/folate def; anemia chronic dz)

incr destruction:

genetic: sickle cell, G6PD, thalassemia, hereditary spheocytosis
acquired: TTP, hemolytic uremia synd, malaria

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3
Q

What are anemia-related lab values?

A

Hbg
Hct
RBC

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4
Q

Id risk factors for microcytic anemia.

A

*most commonly iron def

les common: Cu, Zn def
toxin poisoning
inherited disorders: thalassemias, defects of iron metabolism

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5
Q

Risk factors for normocytic anemia

A

acute blood loss (menses, GIB)
mixed anemias
chronic illness (erthropoeitin def)

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6
Q

sx of anemia

A 
acute: tachycardia
tachypnea
orthostatic hyptn
light-headedness
angina
chronic: 
fatigue
weakness
HA
SOB
dizziness
senstivity to cold
pallor
exacerbation of cardiac dz
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7
Q

Normal Hbg

A

M: 13.5-17.5 g/dL
F: 12-16 g/dL

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8
Q

normal Hct

A

M: 41-53%
F: 36-46%

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9
Q

normal RBC

A

M: 5.2+/-0.7 million/mcL
F: 4.6 +/- 0.5 million/mcL

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10
Q

normal RDW

A

11-15%

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11
Q

Acute bleed anemia considerations

A

drop in hgb or hct may not show until 36-48 h after leed

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12
Q

pregnancy anemia special considerations

A

in 3rd trimester 50% plasma volume expansion w 25% RBC expansion. polycythemic but dilute.

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13
Q

volume depletion anemia considerations

A

may nt show anemia until after rehydration

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14
Q

age anemia considertions

A

increased risk in elderly (.65 yoa)

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15
Q

smoker anemia considerations

A

Hct higher than normal, masking underlying anemia

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16
Q

altitude anemia considerations

A

higher lab values

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17
Q

consequences of iron def anemia

A

pica
angular stomatitis (crusting around mouth)
glossitis
koilonychia (flattening of nail beds)

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18
Q

consequences of iron def anemia

A

pica
angular stomatitis (crusting around mouth)
glossitis
koilonychia (flattening of nail beds)

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19
Q

Evaluating iron status…

High/low TIBC indicates…

A

low/high Fe saturation

for examples: high TIBD and low saturation –> body wants more iron!

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20
Q

normal TIBC

A

30%

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21
Q

IDA tx for peds

A

9-12 mo 3mg/kg of elemental once or twice d

older children: 6 mg/kg/d element dividing into 2-3 doses

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22
Q

IDA tx for adults

A

200 mg elemental iron daily esp when symptomatic

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23
Q

PO iron options

A 
ferrous sulfate
ferrous gluconate
ferrous fumarate
polysacchardie-iron complex (Niferex)
arbonyl iron (Feosol)
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24
Q

What is the tab size, elemtnal iron, and daily regimen for ferrous sulfate?

A

also liquid
325 mg
65 mg (20%)
325 mg TID

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25
Q

What is the tab size, elemtnal iron, and daily regimen for ferrous gluconate?

A

300 mg
35 mg (12%)
600 mg tid

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26
Q

What is the tab size, elemtnal iron, and daily regiment for ferrous fumarate?

A

also liquid

300 mg
99 mg (33%)
300 mg bid

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27
Q

What is the tab size, elemtnal iron, and daily regiment for polysaccharide-iron complex (Niferex)?

A

also liquid

150 mg
100%
150-300 mg d

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28
Q

What is the tab size, elemtnal iron, and daily regiment for carbonyl iron (Feosol)?

A

50 mg
100%
50 mg TID

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29
Q

What are the SEs of PO iron?

A

epigastic distress
ab cramping
N/D or constipation
dark, discolored feces

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30
Q

What drugs interact with po iron to increase Fe abs?

A

ascorbate (vit C)

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31
Q

What drugs interact with iron to decrease FE abs?

A 
H2-blockers
PPIs
cholestryamine
tea
calcium
coffee 
wine
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32
Q

What drugs do Fe decr the abs of?

A

floroquinolones

tetracyclines

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33
Q

What are pt education points for po iron?

A

best abs’d on empty stomach
minimize GI SES by taking w food or smaller amts more freq
prevent constipation w stool softener, fluid intake
sep po iron from ilk/antacids-2 hr before or 2 hr after

keep out of reach of children

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34
Q

What are indications for IV iron?

A 
severe Fe malabs
noncompliance w po fe
severe intolerance w po fe
chronic uncontrollable bleeding
diminisehed erythropoiesis--dialysis pts

**does not reseolve anemia more quickly than po Fe

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35
Q

Which type of IV iron requires a test dose?

A 
iron dextran (INFed, Dexferrum)
25 mg, observe 1 hr
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36
Q

Which IV iron product can be administered to non-HD CKD patients/

A 
iron sucrose (Venofer)
200 mg IV x 5 doses
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37
Q

Which IV iron product can interfere with MRIs?

A

ferraheme (Ferumoxytol)

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38
Q

Which iron product can be administered via TDI?

A

iron dextran

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39
Q

Describe dose, admin, SEs of iron dextran.

A

50 mg/mL inj
bolus inj w max dose 100 mg/d
TDI possible

admin over 2-6 hr

fever, malaise, flushing, myalgias, ANAPHYLAXIS

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40
Q

Describe dose, admin, SEs of iron sucrose (Venofer)?

A

20 mg/mL inj

HD pts: 100 mg IV slow inj for 1-3x /wk for 10 doses
non-HD: 200 mg IV x 5 doses

may admin IVP at 1 mL/min and admin over 20 min

SEs: cramps, hypoTN, N/V,D, HA

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41
Q

Describe dose, admin, SEs of ferric gluconate (Ferrlicit)

A

12.5 mg/mL

125 mg (10 mL) 1-3 x /wk for 8 doses (total dose 1000 mg)

admin over 1 hr

cramps, N/V, flushing, hypoTN, rash, pruritis, hypersensitivity

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42
Q

Descibe dose, admin, SEs of ferraheme (Ferumoxytol).

A

30 mg/mL inj

510 mg (17 mL) inj followed by 510 mg 3-8 d later

admin 1 mL/sec

hypersensitivity
N/D, constipation; interfere w MRI

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43
Q

Agents used for IDA + CKD

A

Injectafer (ferric carboxymaltose), non-HD CKD

Triferic (ferric pyrophosphate)
HD-dep CKD

44
Q

How to calculate LBW? (confused as to what this means)

A

males = 50 kg + 2.3 (in > 5 ft)

females=45.5 kg + 2.3 (in >5 ft)

45
Q

How to calculate PE iron dextran dosing in pts w anemia secondary to blood loss.

A

mg iron = blood loss x hematocrit

mL and decimal fraction

46
Q

What are iron monitoring parameters?

A

monitor TSAT and ferritin q 3 mo

KDIGO: no supplemention of Fe is TSAT >50% or ferritin >500 mg/mL

47
Q

What determines the duration of Fe supplementation for anemia?

A

incr Hb 1 g/Dl q 2-3 wk

for many pts 3-4 mo but could be longers

48
Q

Why do we want to avoid iron overload?

A

gastric ulcer
met acidosis
internal organ damage (brain, liver, d/t iron deposits)

IDA tx is 3-6 mg/kg/d elemetal Fe
toxicity at 10-20 mg/k/d
severe tox @ 50 mg/kg/d

49
Q

What are ind for blood transfusion?

A

symptomtic anemia

Hg <8 g/dL

50
Q

How large is a unit of PRBC and what is the expected change?

A

300 mL
Hb incr 1 g/dL
Hct incr 3%

51
Q

What are complications of transfusions?

A 
iron overload
acquired infx 
hyperviscosity
alloimmunization
volume overload 
transfusion rxns (TRALI)
52
Q

What are causes of macrocytic anemia?

A 
emolyss/reticulocytosis
B12 or folate def
EtOH abuse (nutrition def)
liver dz
hypothyrodism
drugs (chemo)
53
Q

Describe B12 def.

A

pernicious anemia.
must be obtained externally, bound to potin in food, released by HCL, ombine w intrinsic factor for abs.
RDA: 2 mcg/d
body sotres 2-5 mg in liver

drug intx: H2 blocker, PPI, metformin

54
Q

What are Sx of B12 def?

A

paresthesias, peripheral neuropahty, depressed tendon reflex

psych: irrit, mood changes, memory, impairment, depression, psychosis

dysphagia
glossitis
muscle weakness
anorexia

55
Q

What is B12 def Tx?

A 
oral B12 (cyanocobalamin)
1-2 mg d for 1-2 wks then 1 mg d for life 
used in pernicious anemia for maintenance

PE cyanocobalamin
1 mg IM or deep SC inj d for 1 wk then wkly for 1 mo then monthly for life

food (green leafy vegs and meats)

56
Q

What are causes of folate def?

A

inadequate intake ; alcoholism, elderly

decr’d abs: extensive jejunal resetion, dz that imp abs

inadquate utilization

hyperutilization: preg, cancer, chronic inflamm, growth spurts, HD

drugs:
folate antag: methotrexate, TMP, phenytoin, phenobarbital
anti-metabolites: azathioprine, 6-mercaptopurine, 5-flourouracil

57
Q

folate def tx

A

PO supp
1 mg d for most
up to 5 mg d for malabs pts
500 mcg d for anticonvulsant meds

Dietary intake: remember banana bags for alcohols (no longer used)

58
Q

Describe anemia of chronic dz.

A

common form of anemia seen clinically.
dx of exlcusion
assoc’d w incr’d morbidity and mortality

causes: CKD, infx, cancer, autoimm

59
Q

What is the tx for anemia of chronic dz?

A

ESAs: epoetin alpha (epogen), darbepoetin alpha (Aranesp)

60
Q

What is the blackbox warning on ESAs?

A

incr risk of death and serious life-threatening CVEs in pts w a target Hb >12 g/dL

61
Q

What are the differences in ESA doses?

A

epogen 3x/wk

aranesp once weekly

62
Q

What are SEs of ESAs?

A

HTN
HA

epogen: arthralgias
Aranesp: D, hypoTN, infx

63
Q

Describe SCA?

A

sickle cell anemia
inherited dz: 1th chromosome, beta-2 globulin (Hb)’

poor oxygenation, decr pH, decr T, incr osmolarity–> precipitation and polymerization –> long, rigid RBCs –> micovascular infarcts

64
Q

How does SCA present?

A 
chornic anemia
fever and pallor
arthralgia
scleral icterus
ab pain
wkness
anoreia
fatigue
enlarged liver, spleen, heart
hematuria
65
Q

How to evaluate SCA.

A

decr: Hg

incg: bilirubin
reticulocytes
platelets
whte blood cell count
sickled cells on smear
66
Q

What are acute complications of SCA?

A

acute chest syndrome
sickle cell crises
priapism

67
Q

What are chronic complications of SCA?

A 
pulm HTN
bone and joint probs
ocular probs
cholelithiasis
CV probs
depression
68
Q

Describe acute chest syndrome.

A

leading cause of death in pts w SCD (1/2 of pts will have at least once)

pres: new pulm infiltrate, resp sx, fever (sometimes), unclear response to Abx.

69
Q

Tx of acute chest syndrome.

A 
early recog
pain manage
broad-specrum Abx 
supportive care (o2, fluids)--caution: pul edema 
steroids controversial
70
Q

Describe sickle cell crises.

A
  1. vasoocclusive pain crises
    no permanent damage
    lcalized pain
  2. acute splenic sequestration crises: sudden enlargement of spleen and liver.exacerbates anemia, hypoTN, shock
    assoc’d w viral/bac infx
71
Q

Tx of vasoocclusiv epain crises

A

hydration: adults: 3-4 L/d
peds: 1.5-2x maintenacnce

analgesia

72
Q

Tx of acute splenic sequestration crises.

A

blood transfusion to correct hypovol
broad spectrum abx
recurrent=poor prognosis, chronic transfusions

73
Q

Describe priapism d/t SCD and Tx.

A

prolonged, painful erection
can cause impotence

tx: analgesia
irrigation/aspiration
vasoconstriction: PE, Epi
vasodilation: terbutaline, hydralazine

74
Q

How to maintain health in pts w SCA.

A

immunization: flu, pneumo

PCN: <3yo PCN VK 125 mg po bid
>=30 yo and <5 yo PCN VK 250 mg po bid

folate

75
Q

How is hydroxyurea used in SCA tx?

A

anti-neoplasic
incr prod of HbF (fetal)
decr sickle cell crises, transfusion, acute chest, and mortality

***dose 10-15 mg/kg/d (max 35 mg/kg/d)

monitor: Hb, MCV, CBC: q 2 wk until stable then q4-6wk (ANC and platelets)

SEs: bone marrow suppression, skin ulcers, N/D/C

76
Q

Describe the role of butyrate in SCA tx.

A

natural FA
limited data
IV inf req’d
incr HbF not sustained

77
Q

How is pain managed in SCA?

A

mild to mod: NSAID/APAP

mod to sev: NSAID/APAP, opiod if pain persists

sev:
opioid (PCA poss)
resuce opioid
adjuvant meds (NSAID< antihistmines)

78
Q

How are chronic transfusions used in SCA?

A 
used as acute and chronic tx
stroke prevention 
decr acute chest, vassoocclusive crises, organ damage
may reverse organ damage
goal is to decr HbS (sickle)
79
Q

What is thalassemia?

A

inherited dz: too much Hb

80
Q

What is hematochezia?

A

BRBPR

81
Q

What is melena?

A

black, tarry stools

82
Q

If Hg, RBC, WBC, and platelets all low, consider…

A

APLASTIC ANEMIA.

chek meds: NSAIDs (phenylbutazone), sulfonamides, acyclovir, gancyclovir, chloramphenicol, anti=epeleptics (phenytoin, carbamazepine, valproic acid), nifedipine

check parovirus B10 IgG/M,
hepatitis
HIV

83
Q

If Hb and platelets are low consider…

A

TTP or HUS

TTP: thrombotic thrombocytopenic purpura
HUS: hemolytic-uremia synd

–> check smear for schistocytes

if RF, E Coli exposure–> HUS
if RF neurologic changes, fever –> TTP

84
Q

What is the normal RDW according to Kakeeh?

A

11-15%

85
Q

what is normal TIBC, how to interpet?

A

250-400 mcg/dL

if high then need Fe supp

86
Q

What is normal ferritin?

A

15-200 ng/mL male

F: 12-150 ng/dL

87
Q

What is the normal folate lab?

A

1.8-15 ng/mL

88
Q

What is normal B12 lab?

A

100-900 pg/mL

89
Q

What is normal iron lab?

A

M: 50-150 mcg/dL
F: 40-150 mcg/dL

90
Q

What are the drug-induced hematologic disorders?

A 
aplastic anemia
agranulocytosis
megaloblastic anemia
hemolytic anemia
thrombocytopenia
91
Q

Decribe aplastic anemia.

A

pancytopenia: anemia, neutropenia, and thromboytopenia (decr RBC, WBC, platelet)

Dx w 2 of following: WBC <3500 cell/mm^3
platelet <55k
Wb <10 g/dL
reticulocyte count ,30k

92
Q

What are sx of neutropenia?

A

fever, chills, sx of infx

93
Q

What are sx of thrombocytopenia?

A

buisability, petachiae (red pinpoints in skin), bleeding

94
Q

***What are drugs that induce aplastic anemia?

A 
carbamazepine
phenytoin
propylthiouracile
TZ diuretics**
sulfonamides
methimazole
95
Q

Describe agranulocytosis.

A

low levels of all granulocytes (granulocytopenia) and lack of their produciton in bone marrow

–neutropenia–drop in whitecount

Sx: sore throat, fever, malaise, wkness, chills, other s/sx infx

96
Q

What drugs cause agranulocytosis?

A

antithyroid: methimazole, propylthiouracil
psyhotropic: clozapine, TCAs, cocaine/heroin

GI: sulfasalazine, H2-R antag

dermato: dapsone, isotretinoin

Abx: sulfonamides

antimalarials: chloroquine, quinine
anticonvulsants: phenytoin, valproic acid, carbamazepine

97
Q

Describe D-I’d hemolytic anemia.

A

normocytic, incr reticulocyte count, (incr LDH, bilirubin)

genetic: SCA, G6PD def, thalassemias

acq’d: TTP, HUS, malaria

98
Q

What drugs might inducehemolytic anemia?

A

phenytoin, phenobarbital, quinidine, many others

99
Q

Describe glucose-G-phosphate dehydrogenase def.

A

most common enyme in erythrocytes.

brisk hemolysis when exposed to oxidative stress from drugs, infx, or toxins

100
Q

Describe the two types of autoimmune hemolytic anemia.

A

warm-Ab-mediated: IgG Ab binds to erythrocyte suface.
Positive Coomb’s test.
caused by drugs.
tx w CSs or splenectomy

cold agglutinin dz: IgM binds to erythrocyte surface.
does not respond to CSs, but usually mild

101
Q

Describe D-I’d megaloblastic anemia:

A

abnormal devo of megaloblast (RBC precursor)

incr MCV (fol/b12 def)

tx: d/c agent, folate supp

102
Q

What drugs induce megaloblastic anemia?

A

methotrexate
cortrimoxazole
phenytoin
phenobaribtal

103
Q

What drugs induce thrombocytopenia?

A

direct: chemo, organic solv, pesticides

imm rxn: quinine, quinidine, gold salts, sulfonamide abx, rifampin, glycoprotein IIb/IIIa inhib, heparin

platelet-reactive Abs: procainamide

Drug-dep Abs: heparin

104
Q

Describe mech of heparin-induced thrombocytopenia and tx.

A

hep binds to platelet factor $, binds to IgG, binds to platelet.

plateslets removed,
thrombus formation decr platelets.

–> replace w non-hep anticoag (argatroban, lepirudin, bivalirudin)

105
Q

describe methemoglobinemia.

A

> =1% methhemoglobin in blood.
Hb is in oxidized (Fe3_ state)–> can’t bind O2–> fxnal anemia.

deadly

caused by decr in reduction of methemoglobin. (congenital)
or D-I’d

106
Q

List drugs that increase methemoglobin.

A

dapsone

topical anestehetics: benzocaine, lidocaine, prilocaine)

inh’d NO

107
Q

What is tx for methemoglobin?

A

if <20% and asymp: no tx

if >20% and symp: methylene blue 1-2 mg/kg IV over 5 min.

avoid large doses >7 mg/kg

Pharmacotherapy 1 (26 decks)

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