35. Anemia Flashcards by Yerin M

Immature RBCs are known as ___

reticulocytes

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After ___ days, the reticulocytes mature into ___, which have a lifespan of about ___ days

1-2 days
erythrocytes
120 days

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Erythrocytes are removed from circulation by macrophages, mainly in the ___

spleen

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S/sx of anemia

Fatigue, weakness, SOB, exercise intolerance, HA, dizziness, anorexia and/or pallor

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What symptoms can develop with iron deficiency anemia?

Glossitis (inflamed sore tongue)
Koilonychias (thin, concave, spoon-shaped nails)
Pica (craving and eating non-foods such as chalk or clay)

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What can cause anemia?

Nutritional deficiencies (e.g. iron, folate, vit B12)
CKD
Malignancy

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Patients with vit B12 (cobalamin) deficiency can present with ____ symptoms

neurologic symptoms (including peripheral neuropathies, visual disturbances, and/or psychiatric symptoms)

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A low MCV means RBCs are (smaller/larger) than normal and high MCV means that RBCs are (smaller/larger) than normal

low MCV = smaller RBCs (microcytic)
high MCV = larger RBCs (macrocytic)

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Likely cause of anemia if MCV <80

Microcrytic
likely cause: iron deficiency

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Likely cause of anemia if MCV 80-100

Normocrytic
likely causes: acute blood loss, malignancy, CKD, bone marrow failure (Aplastic anemia), hemolysis

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Likely cause of anemia if MCV >100

Macrocrytic
likely causes: vit B12 or folate deficiency

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Reticulocyte count is low in untreated anemia d/t ____

iron, folate, B12 deficiency and with bone marrow suppression

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Reticulocyte count is high in ___

acute blood loss or hemolysis

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___ deficiency is the most common nutritional deficiency in the US

Iron

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Common causes of iron deficiency

Low iron intake (vegetarian/vegan diet, malnutrition, disease-related (e.g. dementia, psychosis))
Blood loss
Decreased iron absorption (high gastric pH (e.g. PPIs), GI diseases (e.g. celiac, IBD, gastrectomy, gastric bypass)
Increased iron requirements (pregnancy, lactation, infants, rapid growth (e.g. adolescence))

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Laboratory findings consistent with dx of iron deficiency anemia (IDA)

Low Hgb, MCV < 80, reticulocyte count, serum iron, ferritin, and TSAT
High TIBC

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Common treatment dosing for iron deficiency anemia (IDA)

1 tab once daily or every other day (no superior oral formulation, typically 40-80mg per dose)
Take on empty stomach (1hr before or 2 hrs after meals) for best absoprtion

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What meds should be avoided when taking oral iron therapy for IDA?

Avoid H2RAs and PPIs
Separate from antacids (2hrs before or 4 hrs after taking antacids)
Rationale: Decrease iron absorption by increasing gastric pH

Separate from iron:
Quinolone and tetracycline abx
Bisphosphonates
Levothyroxine
INSTIs
Rational: iron can decrease absorption of these drugs

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T/F: Sustained-release or enteric-coated formulations of oral iron therapy are recommended d/t less GI irritation

False - they do cause less GI irritation but not recommended d/t poor absorption

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Goals of treating iron deficiency anemia

Increased serum Hgb after 1-2 weeks
Continue treatment for 3-6 months or until iron stores return to normal

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What is the difference between strength of ferrous sulfate vs ferrous sulfate, dried?

Ferrous sulfate (FeroSul, Fer-In-Sol): 325mg (65mg elemental iron)
Ferrous sulfate dried (Slow Fe, Slow Iron, ER formulation): 160mg (50mg elemental iron)

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Boxed warning for oral iron

accidental overdose causing fatal poisoning in children
In case of accidental overdose, got o ED or call poison control immediately (even if asymptomatic)

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Side effects for oral iron

Constipation (dose-related), dark and tarry stools

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What is the antidote for iron overdose?

Deferoxamine (Desferal)

IV iron administration is typically restricted to which patients?

CKD on HD and/or receiving ESAs Unable to tolerate oral iron Severe anemia or losing iron too fast for oral replacement (e.g. chronic blood loss) As an alt when blood transfusions are not accepted by the patient (e.g. religious reasons)

____ can increase absorption of iron (using together may enhance iron absorption to minimal extent)

Vit C (ascorbic acid)

Why is IV iron administration typically restricted to certain patients?

Adverse reactions and cost

Boxed warning for IV iron

serious and sometimes fatal anaphylactic reactions with iron dextran or ferumoxytol All pts receiving iron dextran should be given a test dose prior to first full therapeutic dose (fatal reactions have occurred even in pts who tolerated test dose)

All IV iron products carry a risk for ____

hypersensitivity reactions (including anaphylaxis)

Common IV iron products used for iron deficiency anemia

Iron sucrose (Venofer) Ferumoxytol (Feraheme)

Macrocytic anemia is caused by ____ or ___ deficiency, or both

Vit B12 or folate

_____ anemia, the most common cause of vit B12 deficiency, occurs due to a lack of ____ factor (required for adequate vit B12 absorption in the small intestine). This type of anemia requires lifelong parenteral vit B12 replacement.

Pernicious Intrinsic

Other causes of macrocytic anemia include ____

Alcoholism Poor nutrition GI disorders (e.g. Crohn's disease, celiac disease) Pregnancy

Long term use (≥ __ years) of ____ can decrease absorption of vit B12, resulting in serious ______ (may be irreversible if undiagnosed)

≥2 yrs Metformin, PPIs or H2RAs neurologic dysfunction, including cognitive impairment and peripheral neuropathies

Folic acid deficiency causes ____

Ulcerations of the tongue and oral mucosa and changes to skin, hair, and fingernail pigmentation

Diagnosis of macrocytic anemia

Low Hgb and high MCV Low reticulocyte counts and vit B12 and/or folate serum levels

Treatment of macrocytic anemia

Vit b12 injections as first-line for severe deficiency or neurologic symptoms

Treatment options for vit b12 deficiency

Cyanocobalamin (vit B12) - comes in IM, deep SC, PO/SL, and nasal Nascobal - one nostril once weekly

___ is a hormone produced by the kidneys that stimulates the bone marrow to produce RBCs

Erythropoietin (EPO)

___ deficiency causes anemia of CKD

Erythropoietin (EPO)

Treatments for anemia of CKD

Iron therapy and eryhtropoiesis-stimulating agents (ESA)

What is the role of ESAs in anemia of CKD?

Maintain Hgb levels and reduce need for blood transfusions but ineffective if iron stores are low

IV Iron is first line for ___ patients with anemia of CKD

Boxed warnings for ESAs

Increase risk of death, MI, stroke, VTE, thrombosis of vascular access Use lowest effective dose to reduce need for blood transfusions CKD: increase risk of death, serious CV events, and stroke when Hgb > 11 Cancer: not indicated when anticipated outcome is cure, shortened overall survival and/or increase risk of tumor progression or recurrence in clinical studies in some cancers

Warnings for ESAs

HTN Others: seizures, serious allergic reactions, serious skin reactions (SJS/TEN) Epoetin alfa - contains albumin (remote risk for transmission of viral diseases)

Monitoring for ESAs

Hgb, Hct, TSAT, serum ferritin, BP

___ route is recommended for HD patients on ESAs

IV route

Storage for ESAs

Refrigerator, protect from light, do NOT shake

Darbepoetin half life vs epoetin alfa half-life

darbepoetin half-life is 3x longer than epoetin alfa

Epoetin alfa (Epogen, Procrit) CKD dosing frequency

IV or SC 3x/week

Epoetin alfa (Epogen, Procrit) should be initiated when Hgb _____ (both cancer + CKD pts)

Hgb <10

At what point should Epotein alfa (Epogen, Procrit) dose be decreased or interrupted in a CKD HD patient?

When Hgb approaches or exceeds 11

Side effects of ESAs

Arthralgia/bone pain Others: fever, HA, pruritus/rash, N/V, cough, dyspnea, edema, injection site pain, dizziness

What are the 2 most common mechanisms by which drug-induced hemolytic anemia occurs?

Immune-mediated (identified with + Coombs test) G6PD deficiency

The G6PD enzyme protects RBCs from ____; without sufficient levels of G6PD, RBCs hemolyze 24-72 hrs after exposure to oxidative stress.

oxidant injury

What can increase risk of hemolytic anemia in pts with G6PD deficiency?

Select drugs Certain foods (e.g. fava beans) Severe stress

What meds should be avoided in pts with G6PD deficiency d/t risk of hemolytic anemia?

Dapson Methylene blue Nitrofurantoin Primaquine Pegloticase Rasburicase Quinidine Quinine Sulfonamides

What meds should be avoided in pts with + Coombs Test d/t risk of hemolytic anemia (immune mediated)?

PCNs Cephalosporins Isoniazid Levodopa Methyldopa Rifampin Quinidine Quinine Sulfonamides