Anaemia

Question 1

Treatment of iron deficiency anaemia with an iron preparation is only justified in the presence of a demonstrable iron-deficiency state. However, under which contexts is prophylaxis with an iron preparation suitable?

Answer 1

1. Malabsorption
2. Menorrhagia
3. Pregnancy
4. After subtotal or total gastrectomy
5. Haemodialysis patients
6. In the management of low birth-weight infants such as preterm neonates

Question 2

Name 4 preparations of iron that can be administered parenterally?

Answer 2

Iron dextran
Iron sucrose
Ferric carboxymaltose
Ferric derisomaltose

Question 3

What are the 5 indications to administer iron parenterally?

Answer 3

1. Patient cannot tolerate oral iron
2. Patient does not reliably take oral iron
3. Continuing blood loss
4. Malabsorption
5. Chronic renal failure receiving haemodialysis (and sometimes peritoneal dialysis)

Question 4

Generally, does parenteral iron produce a faster haemoglobin response than oral iron?

Answer 4

NO

Exception - severe renal failure

Question 5

In what context may parenteral iron produce a faster haemoglobin response than oral iron?

Answer 5

Severe renal failure receiving haemodialysis

Question 6

In pregnant women compound preparations containing iron and (?) can be used

Answer 6

Folic acid

In pregnant women who are at high risk of developing iron and folic acid deficiency

Question 7

Should women who are planning a pregnancy take the compound preparations of iron and folic acid to prevent neural tube defects?

Answer 7

NO

Preparations containing iron and folic acid are used during pregnancy in women who are at high risk of developing iron and folic acid deficiency; they should be distinguished from those used for the prevention of neural tube defects in women planning a pregnancy.

Question 8

In the compound preparations of iron and folic acid used in pregnancy, are the doses of folic acid sufficient to treat megaloblastic anaemia?

Answer 8

NO - the dose of folic acid is too small

Question 9

What is the cause of megaloblastic anaemia in patients with pernicious anaemia?

Answer 9

Lack of gastric intrinsic factor leading to malabsorption of vitamin B12

Question 10

Prolonged nitrous oxid anaesthesia inactivates (?) leading to megaloblastosis

Answer 10

Vitamin B12

Question 11

What is needed in the treatment of megaloblastosis in a patient with congenital transcobalamin II deficiency?

Answer 11

Vitamin B12

Question 12

What form of vitamin B12 is the first choice for therapy of vitamin B12 deficiency?

Answer 12

Hydroxocobalamin

Question 13

Why is hydroxocobalamin replaced cyanocobalamin as the choice therapy for vitamin B12 deficiency?

Answer 13

Retained in the body for longer

Maintenance therapy is given at intervals of up to 3 months

Question 14

For vitamin B12 deficiency treated with hydroxocobalamin, how often is maintenance therapy given?

Answer 14

Intervals of up to 3 months

Dose: 1 mg

Question 15

What is the mode of administration of hydroxocobalamin?

Answer 15

IM injection

- 1 mg

Question 16

Why should you not give folic acid alone if you do not know the cause of megaloblastic anaemia?

Answer 16

Neuropathy may be precipitated unless vitamin B12 is administered concurrently

Question 17

In folate-deficient megaloblastic anaemia, how long do you require daily folic acid supplementation to bring about haematological remission and replenish body stores?

Answer 17

4 months

Folic acid has few indications for long-term therapy since most causes of folate deficiency are self-limiting or will yield to a short course of treatment.

Question 18

Folic acid is used for the prevention of (drug?)-induced side-effects in Crohn’s disease, rheumatic disease, and severe psoriasis

Answer 18

Methotrexate

Question 19

What is the most common mode of administration of folic acid supplementation?

Answer 19

Oral

Can be given if patient is receiving parenteral nutrition

Question 20

What form of folic acid is used in association with cytotoxic drugs for the treatment of folate deficient megaloblastic anaemia?

Answer 20

Folinic acid (calcium folinate) (IM or IV)

E.g. used as an adjunct to fluorouracil in colorectal cancer

Question 21

Vitamin B12 should be given prophylactically after which surgeries? (3)

Answer 21

1. Total gastrectomy
2. Total ileal resection
3. Partial gastrectomy if vitamin B12 absorption test shows vitamin B12 malabsorption

Question 22

Folic acid is given for prophylaxis in which conditions?

Answer 22

1. Chronic haemolytic states
2. Malabsorption
3. Renal dialysis

Folic acid is given daily or sometimes weekly, depending on the diet and the rate of haemolysis

Question 23

What dose of folic acid is given to adults with folate-deficient megaloplastic anaemia?

Answer 23

5 mg daily for 4 months (oral)

Doses up to 15 mg daily may be required in malabsorption states

Question 24

What is given to patients with sickle-cell anaemia to reduce the risk of infection? (4)

Answer 24

1. Pneumococcal vaccine
2. Haemophilus influenzae type b vaccine
3. Annual influenza vaccine
4. Lifelong prophylactic penicillin

Question 25

Why is folic acid supplementation recommended in sickle-cell patients?

Answer 25

Haemolytic anaemia is often present accompanied by increased erythropoiesis which may increase folate requirements

Question 26

What drug can be used to prevent acute chest syndrome, reduce the frequency of painful crises and reduce transfusion requirements in sickle-cell disease patients?

Answer 26

Hydroxycarbamide - Xromi (trade name): Initially 15 mg/kg daily, increased in steps of 5 mg/kg daily, dose to be increased every 8 weeks according to response; usual maintenance 20–25 mg/kg daily; maximum 35 mg/kg per day. (adult; oral) - Siklos (trade name): Initially 15 mg/kg daily, increased in steps of 2.5–5 mg/kg daily, dose to be increased every 12 weeks according to response; usual dose 15–30 mg/kg daily; maximum 35 mg/kg per day. (adult; oral)

Question 27

Why is hydroxycarbamide used in the treatment of sickle-cell disease? (3)

Answer 27

1. Prevent acute chest syndrome 2. Reduce the frequency of painful crises 3. Reduce transfusion requirements The benefit may not become evident for several months

Question 28

At what eGFR should you not use hydroxycarbamide in patients with sickle-cell disease?

Answer 28

eGFR < 30 mL/minute/1.73m^2 Reduce dose by 50% if eGFR < 60 mL/minute/1.73m^2

Question 29

What needs to be monitored in patients taking hydroxycarbamide? (4)

Answer 29

1. Renal function 2. Hepatic function 3. Full blood count 4. Secondary malignancies (if receiving long-term therapy for malignant disease)

Question 30

What advice must you give patients receiving long-term therapy with hydroxycarbamide?

Answer 30

Protect skin from sun exposure

Question 31

Is G6PD deficiency more common in males or females?

Answer 31

Males

Question 32

In a patient with G6PD deficiency, what is favism?

Answer 32

Developing haemolytic anaemia when they eat fava beans (broad beans)

Question 33

Name 8 drugs that have DEFINITE risk of haemolysis in most G6PD deficient individuals

Answer 33

1. Dapsone with other sulfones 2. Fluoroquiolones (ciprofloxacin, moxifloxacin, norfloxacin, ofloxacin) 3. Methylthioninium chloride 4. Nitrofurantoin 5. Primaquine 6. Quinolones 7. Rasburicase 8. Sulfonamides (including co-trimoxazole) Two others which are not on UK market: - Niridazole - Pamaquin

Question 34

Name 5 drugs with a POSSIBLE risk of haemolysis in some G6PD-deficient individuals

Answer 34

1. Aspirin 2. Chloroquine 3. Menadione, water-soluble derivatives (e.g. menadiol sodium phosphate) 4. Quinine (may be acceptable in acute malaria) 5. Sulfonylureas

Question 35

What drugs are used as immunosuppressive treatment for aplastic anaemia? (2)

Answer 35

IV horse antithymocyte globulin in combination with ciclosporin

Question 36

When IV horse antithymocyte globulin in combination with cyclosporin is given as immunosuppressive treatment for aplastic anaemia, what drug is also given to prevent adverse effects associated with antithymocyte globulin?

Answer 36

Prednisolone Early adverse effects include: fever, rash, fluid retention, rigors, acute respiratory distress syndrome, anaphylaxis Serum sickness may occur 7-14 days later

Question 37

Which drug is licensed for the treatment of idiopathic sideroblastic anaemia?

Answer 37

Pyridoxine hydrochloride - 100-400 mg daily in divided doses (oral) (the dose required is usually high)

Question 38

What is used to treat anaemia associated with erythropoietin deficiency in chronic renal failure?

Answer 38

Epoetins (recombinant human erythropoietins) They increase the yield of autologous blood in normal individuals and to shorten the period of symptomatic anaemia in patients receiving cytotoxic chemotherapy.

Question 39

Which drug is licensed for the prevention of anaemia in preterm neonates of low birth weight?

Answer 39

Epoetin beta

Question 40

(Drug?) is a hyperglycosylated derivative of epoetin which has a longer half-life and can be administered less frequently than epoetin

Answer 40

Darbepoetin alfa Used to treat anaemia associated with erythropoetin deficiency in chronic renal failure

Question 41

What drug is a continuous erythropoietin receptor activator that is licensed for the treatment of symptomatic anaemia associated with chronic kidney disease?

Answer 41

Methoxy polyethylene glycol-epoetin beta It has a longer duration of action than epoetin.

Question 42

When treating iron deficiency anaemia with oral iron supplements, What should you monitor to determine the therapeutic response?

Answer 42

Haemoglobin concentration Should rise by about 100-200 mg/100mL (1-2 g/L) per day or 2g/100 mL (20 g/L) over 3-4 weeks

Question 43

When treating iron deficiency anaemia with oral iron supplements, what rise in haemoglobin concentration would you expect per day?

Answer 43

100-200 mg/100 mL (1-2 g/L) 3-4 weeks: 2 g/100 mL (20 g/L)

Question 44

When treating iron deficiency anaemia with oral iron supplements, how long after the haemoglobin is within normal range should you continue the treatment?

Answer 44

3 months To replenish the iron stores