52. Anemia Flashcards
A 48 year-old woman who had been taking aspirin for a flare of rheumatoid arthritis presented with mild epigastric pain. A CBC was ordered, and a guaiac test for occult blood was performed. The guaiac test was negative. The CBC revealed a normocytic anemia (hemoglobin 10.5 g/dL; hematocrit, 32 percent MCV, 90 fL), with a red blood cell distribution width of 44 fL (normal range: 39 to 47 fL). A reticulocyte count and “draw and hold” specimens were ordered. The corrected reticulocyte index was 1.0 percent. Ferritin and serum iron levels were obtained from the stored specimens. These tests revealed an elevated ferritin level and a low serum iron level. Which of the following types of anemia is supported by these findings?
A. Iron deficiency anemia
B. Anemia of chronic disease
C. Macrocytic anemia
D. Pernicious anemia
E. Aplastic anemia
B. This patient has normocytic anemia and most likely has anemia of chronic disease associated with her rheumatoid arthritis.
A father suspects that his toddler may have taken a few of his iron tablets. He is not sure, and has brought the child into the local pharmacy. The pharmacist looks at the child, who is playing with a toy and looks fine. What is the proper recommendation to the parent?
A. Watch the child for the next hour; if he appears to look sullen, or ill, take him to the hospital right away.
B. Watch the child for at least 12 hours; if he appears to look sullen, or ill, take him to the hospital right away.
C. Administer syrup of ipecac when you return home.
D. Administer activated charcoal when you return home.
E. Take the child to the emergency room now.
E. The child can appear asymptomatic (initially) or have already developed severe nausea, vomiting, gastrointestinal bleeding (most often vomiting blood), and diarrhea. If a parent suspects their child took iron pills or liquid, they should be directed to the nearest emergency room immediately-whether symptomatic or not. Left untreated, iron overdose will damage most organs, including the brain, and can be fatal.
A patient with renal insufficiency is going to begin self-injecting Aranesp. She can be instructed to inject the medicine in which of the following areas? (Select ALL that apply.)
A. The abdomen but not within two inches of the navel
B. The deltoid on the upper arm, above the elbow
C. The front of the middle thighs
D. The outer area of the buttocks
E. The chest
A, C, D. Each of these sites are acceptable except for the chest and deltoid (this is the common site for an intramuscular injection-erythropoietin is subcutaneous, unless it is given at dialysis into the port.)
A pharmacy in a hospital has an order for injectable vitamin B12. What medication should be ordered?
A. Pyridoxine
B. Cyanocobalamin
C. Riboflavin
D. Thiamine
E. Nicotinic acid
B.
pyridoxine (B6)
riboflavin (B2)
thiamine (B1)
nicotinic acid (B3)
Charlene’s doctor orders lab work and finds she has low vitamin B12. The physician orders a test to determine if her body absorbs vitamin B12. What is the name of the test that may be ordered to determine if she has adequate vitamin B12 absorption?
A. Coombs test
B. Urine protein electrophoresis
C. Amylase test
D. Schilling test
E. Trypsin-like immunoreactivity
D. The Schilling test is used to determine whether the body absorbs vitamin B12. It indicates that the person is lacking in intrinsic factor, cannot absorb vitamin B12 and therefore has pernicious anemia. Most physicians no longer order the Schilling test; they just order injectable vitamin B12 if the level is low. This can be administered in the physician’s office or self-injected subcutaneously by the patient.
Choose the correct statement concerning iron supplementation:
A. The majority of patients who need iron replacement are able to receive an injection twice yearly to replace iron stores.
B. The majority of patients who receive iron by injection are alcoholics or have a malabsorption condition, such as celiac disease or Crohn’s.
C. The preferred oral iron replacement product is polysaccharide iron complex (such as Niferex-150).
D. The majority of patients who need iron replacement are able to use ferrous sulfate tablets.
E. Iron supplementation is only recommended in patients with severe anemia (Hgb
D. The majority of patients who receive iron by injection are ESRD patients on dialysis. Most patients who have microcytic anemia use oral iron tablets, primarily ferrous sulfate.
Gustavo has been diagnosed with iron-deficiency anemia and is beginning to use iron supplements. He asks how long he has to take the iron. What is a reasonable response?
A. At least one week; your doctor will test your blood and tell you when to stop.
B. At least three weeks; your doctor will test your blood and tell you when to stop.
C. At least a month; your doctor will test your blood and tell you when to stop.
D. At least several months; your doctor will test your blood and tell you when to stop.
E. At least a year; your doctor will test your blood and tell you when to stop.
D. The effect of iron supplementation may be seen in about 3 weeks and the treatment should last until 3-6 months after RBCs, iron stores, and other labs have normalized.
Gustavo is purchasing store-brand ferrous sulfate. Which of the following is a correct counseling point for iron supplements?
A. Take with your heaviest meal of the day, as iron causes nausea.
B. This will cause loose stools.
C. If you become constipated, use a psyllium product, such as Metamucil.
D. If you become constipated, use a stool softener such as docusate.
E. Iron makes the stool light, or chalky colored.
D. Although iron causes stomach upset, it is recommended to take iron on an empty stomach because food decreases absorption by up to 50%. If the patient cannot tolerate the iron and they must take with food, it will take longer to replenish the iron stores and they may need more frequent dosing. The other major side effect of oral iron, in addition to nausea, is constipation. Although fiber is the usual first-line therapy for constipation, a stool softener such as docusate is often recommended because iron causes hard, compact stools and it is difficult for fiber to “mix in” to the stool and make it spongy.
Gustavo uses a variety of different medicines and over-the-counter supplements. Which of the following will interact with iron supplements? (Select ALL that apply.)
A. Aspirin
B. Tetracycline and quinolone antibiotics
C. Clopidogrel and other similar antiplatelets
D. Antacids and other agents that increase pH
E. Atorvastatin
B, D. Antacids and agents that raise pH (H2RAs, PPIs) decrease iron absorption by increasing pH. Antibiotics, mainly tetracycline & quinolones, can decrease iron absorption through chelation (take iron 2 hours before or 4 hours after).
Gustavo went to his doctor complaining of weakness. He had pallor and was tachycardic. The CBC had the following values: WBC 4.5 cells/mm³, Hgb 10.2 g/dL, PLT 350/mm³ and MCV 76 µm³. A peripheral smear showed hypochromic, microcytic RBCs. The patient had no history of GI symptoms, and endoscopic exams were unremarkable. He was diagnosed with iron-deficiency anemia and given oral iron supplementation. Gustavo went to the pharmacy and asked for a recommendation for an iron supplement. What should the pharmacist recommend for this patient?
A. Ferumoxytol
B. Ferrous sulfate
C. Iron sucrose
D. Fer-In-Sol
E. Poly-Vi-Sol
B. Ferrous sulfate is the usual recommendation for oral iron replacement. There is no particular advantage over other (generally more expensive) formulations, although ferrous bisglycinate might cause less nausea in some patients and carbonyl iron is more concentrated. Fer-In-Sol are iron-only drops for infants. Poly-Vi-Sol are infant drops with iron and vitamin D–both of which are required by breast-fed babies. Ferumoxytol and iron sucrose are injectable iron formulations.
Intravenous iron administration commonly causes this side effect:
A. QT-prolongation
B. Hypertension
C. Hypotension
D. Migraine headache
E. Petechiae
C. Slowing the rate of infusion and spreading out the doses may help reduce hypotension.
IV iron can cause anaphylaxis. Which of the following IV iron preparations has the highest risk for anaphylaxis and requires a test dose prior to administration?
A. Iron sucrose (Venofer)
B. Sodium ferric gluconate complex (Ferrlecit)
C. Ferumoxytol (Feraheme)
D. Iron dextran (INFeD, Dexferrum)
E. Ferric carboxymaltose (Injectafer)
D. Iron dextran requires a test dose, due to the potential for anaphylaxis. The patient is given a small dose and monitored for adverse reactions for 15-20 minutes. IV iron can cause delayed reactions (arthralgias, myalgias, fever, dizziness, nausea). Some patients receive prophylaxis for these reactions with NSAIDs or steroids. All the IV iron preparations have a boxed warning for anaphylaxis risk; iron dextran has the highest risk.
Keith has severe anemia. In addition to the classic symptoms of anemia, what symptoms might be present in a patient with a severe case? (Select ALL that apply.)
A. Fainting
B. Chest pain, angina, heart attack
C. Glossitis
D. Koilonychias
E. Tachycardia
A, B, C, D, E. More severe symptoms include chest pain, angina, heart attack, fainting, and tachycardia. Pallor, or pale skin, and glossitis (an inflamed tongue) may be noticeable. Koilonychias, or thin, concave, spoon-shaped nails, brittle nails and restless leg syndrome may be present.
Mary has a low hemoglobin and hematocrit. The physician needs to determine the anemia type. What lab value is used to distinguish between microcytic and macrocytic anemia?
A. Mean corpuscular volume (MCV)
B. Mean Corpuscular Hemoglobin Concentration (MCHC)
C. Total Iron-Binding Capacity (TIBC)
D. Serum ferritin
E. Total Reticulocyte count
A. The symptoms may be similar for both macrocytic or microcytic, but the mean corpuscular volume, or MCV, will differ. The MCV is small (less than 80) in microcytic anemia due to a small cell size from a lack of iron. The MCV is large (greater than 100) in macrocytic anemia, due to folate and/or vitamin B12 deficiency.
Parenteral iron therapy is as effective but can be more dangerous and is much more expensive than oral therapy. All of the following clinical situations may warrant IV iron administration except:
A. Patients donating large amounts of blood for autoinfusion
B. GI tract absorption condition (such as Crohn’s) that is causing poor oral absorption
C. Anyone unable to tolerate iron orally, or if losing the iron too rapidly
D. A patient who wants to get her iron levels up rapidly in order to enter a marathon in a few weeks
E. Hemodialysis patients
D. Hemodialysis patients are the most common users of intravenous iron. The National Kidney Foundation (NKF) guidelines state that to achieve and maintain a hemoglobin level of 11 to 12 g/dL, most hemodialysis patients will require IV iron on a regular basis.
