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864 > Anemia > Flashcards

Anemia Flashcards

1
Q

s/s of anemia

A
  • exertional dyspnea
  • angina
  • tachycardia
  • fatigue
  • pallor
  • May be asymptomatic, especially if develops slowly
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2
Q

BLOODWORK

Hgb
___ -18 (male)
___ -16 (female)
Oxygen carrying capacity

A
  • 13.5
  • 12
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3
Q

BLOODWORK

MCV - Mean Corpuscular Volume
- ___ - ___ mm3
- Average volume of RBCs

microcytic - MCV < ___
macrocytic - MCV > ___

A

80-100
60
100

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4
Q

BLOODWORK

RDW - RBC Distribution Width
- ___ - ___ %
- variation in size of RBCs

A

11.5-14.5%

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5
Q
A

3) 74 year old male with Hgb 12.5g/dL

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6
Q

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

A
  • production
  • CKD
  • destruction
  • Sickle Cell
  • loss
  • NSAIDs
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7
Q

CLASSIFICATION

Size of RBC
1. Microcytic
- MCV < __
- ___ deficiency, ___ ___, Thalassemia

  1. Normocytic
    - MCV ___ - ___
    - Anemia of ___ disease, blood ___ , hemolysis
  2. Macrocytic
    - MCV > ___
    - ___ and or ___ deficiency
A
  • 80
  • iro, sickle cell
  • 80-100
  • chronic, loss
  • 100
  • folic acid, B12
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8
Q

CONSEQUENCES

A
  • Impaired cognitive function
  • Falls
  • Heart failure
  • Atrial fibrillation
  • Cardiovascular events
  • Mortality
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9
Q

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!

A
  • Hgb
  • fatigue
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10
Q

IRON DEFICIENCY ANEMIA

  • Hgb ___
  • MCV ___
  • RDW __ / —
  • Ferritin ___
  • TIBC/transferrin __
  • Serum iron — / ___
  • Transferrin saturation (TSAT) ___
A
  • ↓
  • ↓
  • ↑
  • ↓
  • ↑
  • ↓
  • ↓
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11
Q

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

A
  • 15-200
  • 45
  • elevated
  • ↓
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12
Q

IRON STUDIES

Iron
- ___ - ___ mcg/dL
- Concentration of iron
bound to ___
- ___ in Fe deficiency

A
  • 40-160
  • transferrin
  • ↓
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13
Q

IRON STUDIES

Transferrin
- ___ - ___ mg/dL
- ___ that delivers iron
throughout the body
- ___ in Fe deficiency

A
  • 200-360
  • protein
  • ↑
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14
Q

IRON STUDIES

TSAT (transferrin saturation)
- ___ - ___ %
- amount of iron ready for ___
- ___ in Fe deficiency

A
  • 20-50%
  • erythropoiesis
  • decreased
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15
Q

CAUSES OF IRON DEFICIENCY

Blood ___
* Menstruation, blood donation

Decreased ___
* Maximal absorption in the
___
* Examples: celiac disease,
gastric bypass

___ diet

increased consumption ( ___ )

A
  • loss
  • absorption
  • duodenum
  • vegetarian
  • pregnancy
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16
Q

T or F: Drug causes are unlikely for iron deficiency anemia

A

True

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17
Q

ADDITIONAL SIGNS AND SYMPTOMS
(ONLY FOR IRON DEFICIENCY)

A
  • spoon shaped nails
  • inflamed tongue
  • pica
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18
Q

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

A

oral

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19
Q

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
A
  • 65
  • 120-200
  • 3-6
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20
Q

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

A
  • Decreases
  • 48
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21
Q

ORAL IRON

Ferrous fumarate 300mg
- elemental: ___ mg

Ferrous sulfate 325mg
- elemental: ___ mg

Ferrous gluconate 300mg
- elemental: ___ mg

Polysaccharide iron complex
- Varies 100%

22
Q

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)
A
  • empty
  • ascorbic
  • constipation
23
Q

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)

A
  • ESRD
  • hypotension
  • tattooing
24
Q
A

4) Ferrous sulfate 325mg every other day

25
# VITAMIN B12 DEFICIENCY ANEMIA - Hgb ___ - MCV ___ - RDW ___ - Ferritin/TIBC/transferrin --- - Serum iron/ Transferrin saturation (TSAT) --- - Serum B12 __ (< ___ pg/mL) - Homocysteine/Methylmalonic Acid __
- ↓ - ↑ - ↑ - ↓, 200 - ↑
26
# 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
27
# VITAMIN B12 DEFICIENCY **Our bodies cannot make vitamin B12** * Must absorb it from ___ Consequences of B12 deficiency * Neurologic * Weakness, ___ , ___ dysfunction
- diet - numbness, cognitive
28
# 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
29
# 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
30
2) A 22 year old female with asthma
31
# FOLIC ACID DEFICIENCY ANEMIA - Hgb ___ - MCV ___ - RDW ___ - Ferritin/TIBC/transferrin --- - Serum iron/ transferrin saturation (TSAT) --- - Serum folate ___ (<5 ng/mL) - Homocysteine ___
- ↓ - ↑ - ↑ - ↓ - ↑
32
# FOLIC ACID DEFICIENCY Causes of deficiency * ___ * ___- found in green vegetables, orange juice, cereal, flour, milk * ___ * Medications ( ___ , phenytoin, sulfasalazine, SMZ-TMP)
- malabsorption - malnutrition - alcoholism - methotrexate
33
# 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
34
# 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
35
2) Folic acid 1mg orally daily 4) Check vitamin B12 level before starting treatment
36
# 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
37
# 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
38
# 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
39
# 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
40
# 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
41
# HEART FAILURE - ___ iron supplementation has not showed benefit - ___ should not be used - Increased risk of ___ events
- oral - ESA - thromboembolic
42
1) Increase ferrous sulfate to 325mg bid 3) Change ferrous sulfate to 325mg every other day
43
3) IV iron decreases hospitalization in certain patient with heart failure, but there is no evidence that it will improve survival
44
# 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
45
# HEMOLYTIC ANEMIA RBC are destroyed before 120 days (normal lifespan) * Types of hemolytic anemia * Intertied: ___ ___ anemia, ___ deficiency * Acquired: ___ induced
- sickle, G6PD - drug
46
# 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
47
# 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)
48
# 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
49
# 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
50
# 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
51
# DRUG INDUCED ANEMIA Immune hemolytic anemia * ___ form against body’s own red blood cells and destroy them * Cefotetan, ceftriaxone, levodopa, nitrofurantoin, NSAIDS, piperacillin
Antibodies
52
# 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

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