Anemia Flashcards
s/s of anemia
- exertional dyspnea
- angina
- tachycardia
- fatigue
- pallor
- May be asymptomatic, especially if develops slowly
BLOODWORK
Hgb
___ -18 (male)
___ -16 (female)
Oxygen carrying capacity
- 13.5
- 12
BLOODWORK
MCV - Mean Corpuscular Volume
- ___ - ___ mm3
- Average volume of RBCs
microcytic - MCV < ___
macrocytic - MCV > ___
80-100
60
100
BLOODWORK
RDW - RBC Distribution Width
- ___ - ___ %
- variation in size of RBCs
11.5-14.5%
3) 74 year old male with Hgb 12.5g/dL
CAUSES
Decreased RBC ___
* Chronic diseases ( ___ , Cancer, CHF)
* Nutritional deficiencies (Iron, Folic Acid, Vitamin B12)
Increased RBC ___
* Drugs
* ___ ___ Anemia/Thalassemia
Increased RBC ___
* Acute blood loss
* Chronic ___ /ASA
- production
- CKD
- destruction
- Sickle Cell
- loss
- NSAIDs
CLASSIFICATION
Size of RBC
1. Microcytic
- MCV < __
- ___ deficiency, ___ ___, Thalassemia
- Normocytic
- MCV ___ - ___
- Anemia of ___ disease, blood ___ , hemolysis - Macrocytic
- MCV > ___
- ___ and or ___ deficiency
- 80
- iro, sickle cell
- 80-100
- chronic, loss
- 100
- folic acid, B12
CONSEQUENCES
- Impaired cognitive function
- Falls
- Heart failure
- Atrial fibrillation
- Cardiovascular events
- Mortality
GOALS
1) Increase ___
2) Relieve symptoms (decrease ___)
3) Reduce morbidity (HF, cognitive impairment)
4) Improve quality of life
5) Reduce mortality
NOT JUST NORMALIZE LAB VALUES!
- Hgb
- fatigue
IRON DEFICIENCY ANEMIA
- Hgb ___
- MCV ___
- RDW __ / —
- Ferritin ___
- TIBC/transferrin __
- Serum iron — / ___
- Transferrin saturation (TSAT) ___
- ↓
- ↓
- ↑
- ↓
- ↑
- ↓
- ↓
IRON STUDIES
Ferritin
- ___ - ___ ng/mL
- iron deficiency is still likely for ferritin
< ___ ng/mL
- Iron stores
- acute phase reactant- ___ in acute inflammation or chronic disease
- ___ in Fe deficiency
- 15-200
- 45
- elevated
- ↓
IRON STUDIES
Iron
- ___ - ___ mcg/dL
- Concentration of iron
bound to ___
- ___ in Fe deficiency
- 40-160
- transferrin
- ↓
IRON STUDIES
Transferrin
- ___ - ___ mg/dL
- ___ that delivers iron
throughout the body
- ___ in Fe deficiency
- 200-360
- protein
- ↑
IRON STUDIES
TSAT (transferrin saturation)
- ___ - ___ %
- amount of iron ready for ___
- ___ in Fe deficiency
- 20-50%
- erythropoiesis
- decreased
CAUSES OF IRON DEFICIENCY
Blood ___
* Menstruation, blood donation
Decreased ___
* Maximal absorption in the
___
* Examples: celiac disease,
gastric bypass
___ diet
increased consumption ( ___ )
- loss
- absorption
- duodenum
- vegetarian
- pregnancy
T or F: Drug causes are unlikely for iron deficiency anemia
True
ADDITIONAL SIGNS AND SYMPTOMS
(ONLY FOR IRON DEFICIENCY)
- spoon shaped nails
- inflamed tongue
- pica
HOW DO I TREAT IRON DEFICIENCY ANEMIA?
Oral or IV iron?
* ___ is preferred
Exceptions:
* Cannot tolerate (side effects)
* Cannot absorb
* End stage renal disease (ESRD)
* Heart failure
Need to address the underlying cause
oral
ORAL IRON- HOW MUCH?
- ___ mg of elemental iron every other day
- ___ - ___ mg of elemental iron per day (often divided BID or TID)
- Variations in practice
- Often takes __ - __ months to replete stores
- 65
- 120-200
- 3-6
Oral Fe
Why might every other day dosing be better?
Hepcidin
* Iron-regulating peptide hormone produced in the liver
* ___ dietary iron absorption and iron transfer to the plasma
* Hepcidin is increased after a dose of oral iron for ~24 hours and normalizes within __ hours
* Hepcidin is also elevated during inflammation
- Decreases
- 48
ORAL IRON
Ferrous fumarate 300mg
- elemental: ___ mg
Ferrous sulfate 325mg
- elemental: ___ mg
Ferrous gluconate 300mg
- elemental: ___ mg
Polysaccharide iron complex
- Varies 100%
- 100
- 65
- 30
COUNSELLING POINTS - oral iron
- Taken once daily to three times daily
- Increased absorption on ___ stomach
- Causes stomach upset
- Can take with food or split up doses
- Absorption increased by ___ acid (vitamin C)
- Causes ___ (Increase fluids, activity and fiber)
- Causes dark stools (May be mistaken for GI bleed)
- empty
- ascorbic
- constipation
IV IRON
Indications
* ___ , heart failure, failed oral
iron, malabsorption
Side effects
* ___ during infusion (common)
* Skin ___ (rare)
Products available
* Sodium Ferric Gluconate
* Iron Sucrose
* Ferumoxytol
* Ferric Carboxymaltose
* Iron Dextran (risk of anaphylaxis)
- ESRD
- hypotension
- tattooing
4) Ferrous sulfate 325mg every other day
VITAMIN B12 DEFICIENCY ANEMIA
- Hgb ___
- MCV ___
- RDW ___
- Ferritin/TIBC/transferrin —
- Serum iron/ Transferrin
saturation (TSAT) — - Serum B12 __ (< ___ pg/mL)
- Homocysteine/Methylmalonic
Acid __
- ↓
- ↑
- ↑
- ↓, 200
- ↑
VITAMIN B12 DEFICIENCY
Vitamin B12 = cobalamin
Causes of deficiency
Diet
* Vegan/vegetarian
* ___
Lack of intrinsic factor -> pernicious anemia
* ↓ ___ (ex: Crohn’s)
* Medication (PPI’s, ___ )
- alcoholism
- Absorption
- metformin
VITAMIN B12 DEFICIENCY
Our bodies cannot make vitamin B12
* Must absorb it from ___
Consequences of B12 deficiency
* Neurologic
* Weakness, ___ , ___ dysfunction
- diet
- numbness, cognitive
B12 anemia treatment
Vitamin B12 Replacement
* IM or deep SC
* ___ - ___ mcg (daily, weekly, monthly- regimens vary)
* Often daily for 1-2 weeks,
then weekly or monthly as
maintenance
- 100- 1000
B12 anemia treatment
Vitamin B12 Replacement
* Oral
* ___ - ___mcg/day
* Oral is as effective as parenteral
May not be as effective in
pernicious anemia
* Can check for intrinsic factor antibodies
- ___ soluble vitamin
- 1000 - 2000
- water
2) A 22 year old female with asthma
FOLIC ACID DEFICIENCY ANEMIA
- Hgb ___
- MCV ___
- RDW ___
- Ferritin/TIBC/transferrin —
- Serum iron/ transferrin
saturation (TSAT) — - Serum folate ___ (<5 ng/mL)
- Homocysteine ___
- ↓
- ↑
- ↑
- ↓
- ↑
FOLIC ACID DEFICIENCY
Causes of deficiency
* ___
* ___- found in green vegetables, orange juice, cereal, flour, milk
* ___
* Medications ( ___ , phenytoin, sulfasalazine, SMZ-TMP)
- malabsorption
- malnutrition
- alcoholism
- methotrexate
FOLIC ACID DEFICIENCY
Treatment
* ___ folic acid supplement
* __ - __ mg daily until ___ normalizes
* Well absorbed, rarely need IV
* Treat the underlying cause or continue to supplement
* ___ soluble vitamin
- oral
- 1-5, Hgb
- water
FOLIC ACID DEFICIENCY
In 1998 the FDA mandated that all
enriched wheat flour was to be fortified with folic acid
- To prevent ___ defects in
pregnancy
Never replace folic acid without checking vitamin ___*
- Folic acid supplements will correct anemia but ___ deficits of vitamin ___deficiency remain
- neural tube
- neurologic, B12, B12
2) Folic acid 1mg orally daily
4) Check vitamin B12 level before starting treatment
ANEMIA OF CHRONIC DISEASE
One of the most ___ causes of anemia
- Patients with chronic diseases lasting months to years. Common in inflammatory or infectious diseases
* ___
* CHF
* Cancer
* HIV/AIDS
common
CKD
ANEMIA OF CHRONIC KIDNEY DISEASE
___ is produced in the kidneys and stimulates production of RBC’s
Anemia occurs because of:
1. Decreased ___ production
2. Chronic ___ state which causes anemia of chronic disease
3. Nutritional deficiencies (iron, folate, vitamin B12)
- erythropoietin
- erythropoietin
- inflammatory
ANEMIA OF CHRONIC KIDNEY DISEASE
___ blood transfusions
- Especially for patients eligible for kidney transplantation (risk of allosensitization)
Correct ___ deficiencies
* Folate/B12
* Iron
* Use ___ iron in stage 3-5 CKD if possible (may require IV)
* Use ___ iron in hemodialysis (HD) patients
* Target transferrin saturation (TSAT) above __ %
- avoid
- nutritional
- PO
- IV
- 30
ANEMIA OF CHRONIC KIDNEY DISEASE
Erythropoiesis Stimulating Agents (ESA)
- Help prevent blood transfusions
- DO NOT target normal Hgb levels
- Use minimum dose to maintain Hgb > ___
- ↑ risk of ____ events, stroke and death
Only start ESA after replenishing ___ stores
- Do not titrate dose up for at least __ weeks after initiating or increasing dose
- 10
- cardiovascular
- iron
- 4
HEART FAILURE
Patients that may benefit from ___ iron
* NYHA class ___ and ___ HF and
* Iron deficiency (ferritin < ___ or 100 to 300 if TSAT < ___ %)
Evidence
* FAIR-HF trial (2009) - Improvements in 6-minute walk test and quality of life
* CONFIRM-HF trial (2014) - Improvements in 6-minute walk test
* AFFIRM-AHF trial (2020) - Decreased HF hospitalizations, did not decrease cardiovascular death
- IV
- II, III
- 100, 20
HEART FAILURE
- ___ iron supplementation has not showed benefit
- ___ should not be used
- Increased risk of ___ events
- oral
- ESA
- thromboembolic
1) Increase ferrous sulfate to 325mg bid
3) Change ferrous sulfate to 325mg every other day
3) IV iron decreases hospitalization in certain patient with heart failure, but
there is no evidence that it will improve survival
BLOOD LOSS ANEMIA
Stop the bleeding
- Transfuse packed red blood cells
(PRBC) when Hgb < ___
* Each unit of PRBC contains
~ ___mg iron
Medications may be indicated for
specific indications
* Example: pantoprazole infusion
for non-variceal upper GI bleed
- 7
- 250
HEMOLYTIC ANEMIA
RBC are destroyed before 120 days
(normal lifespan)
* Types of hemolytic anemia
* Intertied: ___ ___ anemia,
___ deficiency
* Acquired: ___ induced
- sickle, G6PD
- drug
SICKLE CELL ANEMIA
RBC’s are irregular shape (sickles)
* RBC’s collect in the ___ and are
___ faster than they can be
produced
Inherited
* Sickle cell trait- asymptomatic
(patients have one normal cell and
one sickle cell hemoglobin gene)
* Sickle cell anemia- both genes are
sickle cell hemoglobin ( ___ )
- spleen
- destroyed
- homozygous
SICKLE CELL TREATMENT
Folic acid
* 1mg/day
* Increased need for folic acid due to
accelerated erythropoiesis
* Blood transfusions
* Symptomatic episodes of acute or chronic
anemia
* *Iron overload from frequent transfusions
* Hydroxyurea
* Fetal hemoglobin inducer
* Decreases sickling
* 10-15mg/kg/day (titrated to max
35mg/kg/day)
TREATMENT
Immunizations
* Impaired ___ function
* Risk of infection from ___ organisms
* Influenza, pneumococcal, and
meningococcal vaccinations
Pain control
* Acetaminophen/NSAIDS
* Opioids in pain crisis
* May use ____
- splenic
- encapsulated
- PCA
DRUG INDUCED ANEMIA
Drug induced ___ anemia
Drug induced ___ hemolytic anemia
Drug induced ___ hemolytic anemia
- Affects patients with G6PD enzyme deficiency
Drug induced ___ anemia
- aplastic
- hemolytic
- oxidative
- megaloblastic
DRUG INDUCED ANEMIA
Aplastic Anemia
- ___ failure that causes body to stop producing enough new blood cells
- Carbamazepine, phenytoin, sulfonamides, chloramphenicol, phenylbutazone, indomethacin, methimazole, propylthiouracil,
gold
These examples will not be tested
Bone marrow
DRUG INDUCED ANEMIA
Immune hemolytic anemia
* ___ form against body’s own red blood cells and destroy them
* Cefotetan, ceftriaxone, levodopa,
nitrofurantoin, NSAIDS, piperacillin
Antibodies
DRUG INDUCED ANEMIA
Oxidative hemolytic anemia
- medications trigger ___ breakdown of red blood cells in patients with genetic
deficiency of G6PD enzyme
* Dapsone, doxorubicin, moxifloxacin, nitrofurantoin, phenazopyridine, primaquine,
rasburicase
These examples will not be tested
premature
