Anemia

Question 1

MCV

Answer 1

mean corpuscular volume, low MCV means smaller than normal RBC, and high means larger than normal RBC

MCV <80 fl= microcytic likely iron deficiency
MCV 80-200 fl= likely cause acute blood loss, malignancy, CKD, bone marrow failure, hemolysis
MCV>100 fl= most likey vitamin b12 or floate deficiency

Question 2

Iron studies

Answer 2

further evaluate microcytic anemia
serum iron, serum ferritin, TIBIC, TSAT

Question 3

Vitamin B12 and folate levels

Answer 3

further evaluate macrocytic anemia
folate, B12, homocysteine, methylmalonic acid

Question 4

reticulocyte count

Answer 4

measures the production of RBCs. a low count is low in untreated anemia is due to iron, folate, b12 deficiency and with bone marrow suppression.

Hemoglobin, hematocrit, RBC count reticulocyte count

Question 5

lab finding that indicate anemia

Answer 5

• decreased Hgb, MCV< 80, decreased RBC production (low reticulocyte count)
• decreased serum iron, ferritin, and TSAT
• increased TIBC

Question 6

anemia tx oral therapy

Answer 6

• 100-200mg elemental iron per day
• avoid H2RA and PPIs; separate from antacids
• sustained-release or enteric-coated formation cause less GI irritation but are not recommended due to poor absorption

Question 7

anemia tx goal

Answer 7

increase serum Hgb by 1g/dl every 2-3 weeks, continue tx for 3-6 months after anemia has resolved until iron stores return to normal

Question 8

% elemental iron in oral products

Answer 8

ferrous gluconate 12%
ferrous sulfate 20%
ferrous sulfate, dried 30%
ferrous fumarate 33%
carbonyl iron, polysaccharide iron complex, ferric maltol 100%

Question 9

Ferrous sulfate

Answer 9

FeroSul, Fer-In-Sol, OTC
325mg (65mg elemental) TID
20% elemental

Question 10

Ferrous sulfate, dried

Answer 10

Slow Fe, Slow Iron
160mg (50mg elemental) TID
30% elemental

Question 11

Ferrous fumarate

Answer 11

Ferrets, ferrimin 150, hemocyte
324mg (106mg elemental) TID
33% elemental

Question 12

Ferrous gluconate

Answer 12

Ferate
324mg (38mg elemental) TID
12% elemental

Question 13

carbonyl iron

Answer 13

FerraPlus 90, Ferralet 90, Iron chews
90mg (90mg elemental) PO daily
100% elemental

Question 14

Polysaccharide iron complex

Answer 14

Ferrex 150
150mg (150mg elemental) dail
100% elemental y

Question 15

Feerric maltol

Answer 15

Accrufer
30mg (30mg elemental) PO BID
100% elemental

Question 16

oral iron info

Answer 16

• accidental overdose can occur!!!…. go to ED or call the poison center- antidote: deferoxamine (Desferal)
• SE: constipation dose-related, docusate can be recommended often w/supplement
• need acidic gut, avoid antacids, PPI and H2RAs (they increase gastric pH)
• Iron is a polyvalent cation (decrease other drugs absorption by binding to them)
  —-> quinolone and tetracycline- take iron 2 hrs before or 4-8 hrs after
  —-> bisphosphonates: 60min after ibandronate or 30 min after alendronate/risedronate
  —-> cefdinir, dolutegravir, levothyroxine, levodopa, methyldopa: separate by 2-4 hrs
• Vitamin C increases absorption of iron…acidic gut

Question 17

IV parental iron

Answer 17

generally restricted for:
CKD on hemodialysis
CKD receiving erythropoiesis-stimulating agent (ESAs)
unable to tolerate oral Iron… or failure of oral therapy (IBD, celiac disease, H. pylori, etc.)

Question 18

IV parental iron products
Iron Sucrose
Ferumoxytol
Iron dextran complex

Answer 18

Iron Sucrose (Venofer)
Ferumoxytol (Feraheme)
iron dextran (INFeD)

all pt receiving dextran should be tested before. dextran or ferumoxytol warning for fetal anaphylactic reactions.
all carry a risk for hypersensitivity reaction

Ferric pyrophosphate citrate (Triferic)- is only indicated for iron replacement in hemodialysis-dependent CKD. should be added to bicarbonate concentration.

Question 19

Macrocytic anemia

Answer 19

low Hgb and high MCV

cyanocobalamin vitamin b12- IM/Sc daily/weekly/monthly
oral/sublingual- 1,000-2,000mcg
nascobal: 500mcg nasal- weekly one nostril

folic acid, folate, vitamin B9 0.4-1mg daily

Question 20

epoetin alfa

Answer 20

Epogen, Procrit
CKD
3x weekly, initiate when Hgb <10g/dL
stop or decrease therapy when HgB approaches or exceeds 11g/dL

Chemo
initiate when Hgb <10g/dL when at least 2 additional months of chemo

for all indications titrate dose up or down but do not increase dose more frequently than once every 4 weeks

• ESA

Question 21

Darbepoetin

Answer 21

Aranesp
CKD
IV or Sc weekly
chemo
2.25 mcg weekly IV or 500mcg Sc every 3 weeks
t1/2 is 3 for longer than epoetin alfa… give weekly

for all indications titrate dose up or down but do not increase dose more frequently than once every 4 weeks

• ESA

Question 22

ESA info

Answer 22

generally last last last line for all
do not use in curable cancer cause it does increase there is of tumor progression!
increased risk of death, MI, stroke, VTE, thrombosis!
CKD: increased risk of death when Hgb>11
cancer: shortened overall survival… not indicated when the anticipated outcome is cure

refrigerate, protect from light. Do not shake

Question 23

G6PD

Answer 23

glucose-6-phosphate dehydrogenase deficiency, is X-linked inherited disorder commonly affects African, Asia, middle eastern

G6PD protects RBCs from harmful substances.

Question 24

G6PD
select drugs that can cause hemolysis

Answer 24

hemolytic anemia select drugs to monitor in G6PD
- cephalosporins
- Dapsone (AVOID in G6PD)
- Isoniazid
- Methyldopa
- Methylene blue (AVOID in G6PD)
- Nitrofurantoin (AVOID in G6PD)
- Pegloticase (AVOID in G6PD)
- penicillins
- primaquine (AVOID in G6PD)
- quindine
- quinine
- Rasburicase (AVOID in G6PD)
- Rifampin
- Sulfonamide* (AVOID in G6PD)