Anemia

Question 1

What are abnormal Hgb & hct levels?

Answer 1

Male: <13 Hgb, <38 Hct
Female: <12 Hgb, <36 Hct

Question 2

What defines microcytic anemia?

Answer 2

• Low hgb, MCV <80, low RBC production (low reticulocyte), low iron/ferritin/TSAT, high TIBC
• Iron deficiency

Question 3

What defines macrocytic anemia?

Answer 3

Low hgb, MCV >80
Folate or vit b12 deficiency

Question 4

Treatment for iron deficiency anemia

Answer 4

• 100-200 mg elemental iron per day

Question 5

Admin instructions for iron

Answer 5

• Take on empty stomach, may take WF if GI upset
• avoid H2RA/PPI ; separate from antacids
• Separate with quinolone/tetracyclines, bisphosphonate, cefdinier, dolutegravir, levothyroxine, levodopa/methyldopa
• Vit C 200 mg may enhance absorption

Question 6

Ferosul, Fer-In-Sol

Answer 6

• 325 mg (65 elemental iron) - 20%
• daily to TID

Question 7

Slow Fe, Slow iron

Answer 7

Ferrous sulfate, dried
ER tab
160 (50 mg elemental) - 30%
daily to TID

Question 8

Ferretts, Ferrimin 150, Hemocyte

Answer 8

Ferrous fumarate
324 mg (106 mg elemental) - 33%
daily to TID

Question 9

Ferate

Answer 9

Ferrous gluconate
324 mg (38 mg elemental iron) - 10%
daily to TID

Question 10

Safety/SE/Notes for iron

Answer 10

BW: accidental OD of iron-containing products/fatal poisoning in children <6, keep away
CI: hemochromatosis, hemolytic anemia, hemosiderosis
SE: constipation (dose-related), dark/tarry stools, nausea, stomach upset
Notes: use stool softener
Antidote for iron OD: deferoxamine (Desferal)

Question 11

Who should use IV iron?

Answer 11

• CKD on HD, ESA
• unable to tolerate PO iron (ex: IBD, celiac, gastric bypass, achlorhydria, H.pylori)
• losing iron too fast for PO
• alt for blood transfusions

Question 12

Safety/SE/Notes for IV iron

Answer 12

• BW for iron dextran/ferumoxytol: analyphylactic rxns (fatal) occurred; need test dose prior to full dose. Careful w/pts with hx of drug allergy or multiple drug allergies
• ADE: muscle aches, fatgue, hypo/hypertension, tachcardia, CP, peripheral edema
• Notes: give by slow IV injection or infusion to decrease hypotension
• Stable in NS; Feraheme stable in NS/D5W

Question 13

Triferic

Answer 13

ferric pyrophosphate citrate
* indicated only for HD dependent CKD
* added to the bicarb concentrate of hemodialysate in HD

Question 14

Venofer

Answer 14

Iron sucrose

Question 15

Feraheme

Answer 15

ferumoxytol
stable in NS/D5W

Question 16

InFeD

Answer 16

Iron dextran complex

Question 17

Ferrlecit

Answer 17

sodium ferric gluconate

Question 18

Injectafer

Answer 18

Ferric carboxymaltose

Question 19

Monoferric

Answer 19

ferric derisomaltose

Question 20

Causes of macrocytic anemia

Answer 20

• alcoholism
• poor nutrition
• GI disorders (Crohns, celiac)
• Pregnancy
• Vit B12 deficiency: long term use of metformin, PPI/H2RA –> serious neurologic dysfunction (CI, peripheral neuropathy)
• Folic acid deficiency –> ulceration of the tongue/mouth, changes to skin/hair/nail pigmentation

Question 21

Treatment of macrocytic anemia

Answer 21

Vit B12 - first parenteral
Folic acid

Question 22

Nascobal

Answer 22

Nasal vitamin b12
500 mcg in 1 nostril once weekly

Question 23

Cyanocobalamin

Answer 23

IM or deep SC: 100-1000 mcg daily/weekly/monthly
PO/SL: 1000-2000 mcg daily

Question 24

Vit B12 Safety/SE/

Answer 24

• CI: allergy to cobalt or vit B12
• Warning: parenteral products may contain aluminum (cns/bone tox in renal dysfxn) or benzyl alcohol (fatal tox & “gasping syndrone” in neonates
• SE: pain with injection; rash, polycythemia vera, pulmonary edema (all rare)

Question 25

FA-8

Answer 25

Folic acid
0.4-1 mg daily
SE: bronchospasm, flushing, rash, pruritis, malaise (all rare)

Question 26

What can decrease vit B12 efficacy?

Drug interactions

Answer 26

Chloramphenicol (abx)
Colchicine (gout)

Question 27

Which meds can folic acid decrease the concentrations of?

Answer 27

Raltitrexed (chemo)
fosphenytoin, phenytoin, primidone, phenobarb

Question 28

What can decrease concentrations of folic acid?

Answer 28

Green tea, sulfasalazine

Question 29

Which meds cause G6PD deficiency (hemolytic anemia risk)?

Answer 29

• Abx: cephs, PCN, dapsone, isoniazid, nitrofurantoin, primaquine (malaria), rifampin, sulfonamides
• Gout: rasburicase, pegloticase
• Levodopa, methyldopa, methylene blue, quinidine, quinine

Question 30

When to supplement iron before ESA in CKD?

Answer 30

• TSAT <30% FERRITIN <500

Question 31

Epogen, Procrit, Retacrit

Answer 31

Epoetin alfa
* CKD: 50-100 units/kg IV or SC 3x/week
Initiate when hgb <10, decrease or d/c when Hgb approaches or exceeds 11 (due to stroke risk) in HD, or >10 in non-HD

*Cancer (taking chemo): 150 units/kg SC 3x/week or 40,000 units weekly
Initiate when Hgb <10 & at least 2 more months of chemo

Question 32

Aranesp

Answer 32

Darbepoetin
* CKD: weekly or every 2 weeks (longer half-life)
* Cancer: weekly or every 3 weeks

Question 33

ESA boxed warnings, SE, CI, warnings

Answer 33

• BW: increased risk of DEATH, MI, STROKE, VTE, THROMBOSIS
• CKD: incr risk of DEATH & stroke when hgb >11
• Cancer: not indicated when CURE is goal
• Perisurgery (epogen only): DVT prophy rec

CI: uncontrolled HTN, pure red cell aplasia after tx; epogen: multidose vials contain benzyl ETOH (not for pregnant, lactating, infants/neonates)

Warnings: HTN, seizure, allergic rxn, SJS/TENS

ADE: arthralgia/bone pain, fever, HA, pruritis/rash, N/V, cough, dyspnea, edema, dizziness, inj site pain

Store in fridge, protect from light. Discard MDV in 21 days. Don’t shake