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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%

A
  • 100
  • 65
  • 30
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
Q

VITAMIN B12 DEFICIENCY ANEMIA

  • Hgb ___
  • MCV ___
  • RDW ___
  • Ferritin/TIBC/transferrin —
  • Serum iron/ Transferrin
    saturation (TSAT) —
  • Serum B12 __ (< ___ pg/mL)
  • Homocysteine/Methylmalonic
    Acid __
A
  • ↓
  • ↑
  • ↑
  • ↓, 200
  • ↑
26
Q

VITAMIN B12 DEFICIENCY

Vitamin B12 = cobalamin

Causes of deficiency

Diet
* Vegan/vegetarian
* ___

Lack of intrinsic factor -> pernicious anemia
* ↓ ___ (ex: Crohn’s)
* Medication (PPI’s, ___ )

A
  • alcoholism
  • Absorption
  • metformin
27
Q

VITAMIN B12 DEFICIENCY

Our bodies cannot make vitamin B12
* Must absorb it from ___

Consequences of B12 deficiency
* Neurologic
* Weakness, ___ , ___ dysfunction

A
  • diet
  • numbness, cognitive
28
Q

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

A
  • 100- 1000
29
Q

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
A
  • 1000 - 2000
  • water
30
Q
A

2) A 22 year old female with asthma

31
Q

FOLIC ACID DEFICIENCY ANEMIA

  • Hgb ___
  • MCV ___
  • RDW ___
  • Ferritin/TIBC/transferrin —
  • Serum iron/ transferrin
    saturation (TSAT) —
  • Serum folate ___ (<5 ng/mL)
  • Homocysteine ___
A
  • ↓
  • ↑
  • ↑
  • ↓
  • ↑
32
Q

FOLIC ACID DEFICIENCY

Causes of deficiency
* ___
* ___- found in green vegetables, orange juice, cereal, flour, milk
* ___
* Medications ( ___ , phenytoin, sulfasalazine, SMZ-TMP)

A
  • malabsorption
  • malnutrition
  • alcoholism
  • methotrexate
33
Q

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

A
  • oral
  • 1-5, Hgb
  • water
34
Q

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

A
  • neural tube
  • neurologic, B12, B12
35
Q
A

2) Folic acid 1mg orally daily
4) Check vitamin B12 level before starting treatment

36
Q

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

A

common
CKD

37
Q

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)

A
  • erythropoietin
  • erythropoietin
  • inflammatory
38
Q

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 __ %

A
  • avoid
  • nutritional
  • PO
  • IV
  • 30
39
Q

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

A
  • 10
  • cardiovascular
  • iron
  • 4
40
Q

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

A
  • IV
  • II, III
  • 100, 20
41
Q

HEART FAILURE

  • ___ iron supplementation has not showed benefit
  • ___ should not be used
  • Increased risk of ___ events
A
  • oral
  • ESA
  • thromboembolic
42
Q
A

1) Increase ferrous sulfate to 325mg bid
3) Change ferrous sulfate to 325mg every other day

43
Q
A

3) IV iron decreases hospitalization in certain patient with heart failure, but
there is no evidence that it will improve survival

44
Q

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

A
  • 7
  • 250
45
Q

HEMOLYTIC ANEMIA

RBC are destroyed before 120 days
(normal lifespan)
* Types of hemolytic anemia
* Intertied: ___ ___ anemia,
___ deficiency
* Acquired: ___ induced

A
  • sickle, G6PD
  • drug
46
Q

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 ( ___ )

A
  • spleen
  • destroyed
  • homozygous
47
Q

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)

A
48
Q

TREATMENT

Immunizations
* Impaired ___ function
* Risk of infection from ___ organisms
* Influenza, pneumococcal, and
meningococcal vaccinations

Pain control
* Acetaminophen/NSAIDS
* Opioids in pain crisis
* May use ____

A
  • splenic
  • encapsulated
  • PCA
49
Q

DRUG INDUCED ANEMIA

Drug induced ___ anemia

Drug induced ___ hemolytic anemia

Drug induced ___ hemolytic anemia
- Affects patients with G6PD enzyme deficiency

Drug induced ___ anemia

A
  • aplastic
  • hemolytic
  • oxidative
  • megaloblastic
50
Q

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

A

Bone marrow

51
Q

DRUG INDUCED ANEMIA

Immune hemolytic anemia
* ___ form against body’s own red blood cells and destroy them
* Cefotetan, ceftriaxone, levodopa,
nitrofurantoin, NSAIDS, piperacillin

A

Antibodies

52
Q

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

A

premature

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