Anemia Flashcards

Question

What are the blood loss causes of iron deficiency?

Answer 1

Menstruation Trauma GI bleeding- ulcer, hemorrhoids, tumor, alcohol, steroids/NSAIDS

Answer 2

``` Decreased exercise tolerance Fatigue Dizziness Irritability Weakness Vertigo Shortness of breath Chest Pain PICA IF VERY SEVERE DEFICIENCY ```

Answer 3

``` ↓ Hgb ↓ Hct ↓ MCV ↑ RDW ↓ Iron ↓ Ferritin ↑ TIBC ↓ Fe: TIBC ratio ```

Answer 4

``` Treat underlying disease Correct iron deficiency Dietary Encourage intake of foods high in iron Heme iron is easiest to absorb May not be able to meet needs if Vegetarian/vegan Problems with iron absorption Oral Supplementation ```

Answer 5

``` Chicken liver Oysters Beef Turkey (dark>light meat) Chicken (dark>light meat) ```

Answer 6

``` Cereal/oatmeal, fortified Soybeans Other legumes Tofu Spinach ```

Answer 7

``` FERROUS SULFATE FERROUS GLUCONATE Ferrous Fumarate Polysaccharide iron complex Carbonyl Iron ```

Answer 8

Amounts of elemental iron

Answer 9

Can cause substantial GI intolerance Give in divided doses (2 – 3 times daily) Start with smaller doses to improve tolerance, then escalate Best absorbed without food Can take with food if GI intolerance occurs Try to make GI a little more acidic by taking with OJ Keep out of reach of children! Risk of toxicity

Answer 10

Nausea/vomiting Constipation- huge issue Dark stool- make sure they know this

Answer 11

- Antacids- often have calcium which chelate with iron and will make it a clump that comes right out - Tetracycline antibiotics - Histamine-2 antagonists - Proton pump inhibitors- change acidity - Cholestyramine- screws up absorption of all - Fiber

Answer 12

Normalize Hgb Responds in ~ 3 weeks Should rise 2 – 4 g/dL in this time Resolution within 1-2 months Replete iron stores Takes 3 - 6 months Supplement iron for 3 – 6 months

Answer 13

If Hgb rises < 2g/dL after 3 weeks of treatment ``` Reasons Poor patient compliance Inability to absorb iron Incorrect diagnosis Persistent bleeding ```

Answer 14

Evidence of iron malabsorption Intolerance of oral iron Long-term noncompliance Significant blood loss and refusal of transfusions

Answer 15

IRON SUCROSE IRON DEXTRAN Sodium Ferric Gluconate

Answer 16

``` Flushing Hypotension Fever/chills Myalgia ANAPHYLAXIS- BLACK BOX WARNING Iron overload ```

Answer 17

``` Weekly Hgb Hct Ferritin Transferrin saturation Monthly Serum iron (these take a long time to build up) ```

Answer 18

``` Vitamin B12 (cyanocobalamin) deficiency Folate deficiency Abnormal utilization of B12 or folate ```

Answer 19

Alcohol abuse

Answer 20

--Abnormal DNA synthesis in developing erythrocyte B12 & folate are required cofactors --Resulting RBC are macrocytic and immature --Hypercellular bone marrow, full of “–blast” progenitor cells Especially erythroid line

Answer 21

``` Azathioprine 6 – mercaptopurine Cytarabine Fluorouracil Methotrexate Pentamidine Trimethoprim Triamterene Hydroxyurea Zidovudine Phenytoin Phenobarbital ```

Answer 22

Women Elderly Those using gastric acid-suppressing therapy Alcoholics

Answer 23

DNA synthesis With folate Myelin synthesis - maintains integrity of neurologic system Fatty acid biosynthesis and conversion of some amino acids

Answer 24

Meat Fish Dairy Fortified cereals

Answer 25

- Bound to proteins in saliva - Released from salivary protein complexes in acidic environment of stomach, then binds to intrinsic factor released from parietal cells - B12 - intrinsic factor complex absorbed via mucosal receptors in distal ileum - Vitamin transported from ileal cells to portal circulation - A small amount of B12 is absorbed via passive diffusion

Answer 26

Intrinsic factor

Answer 27

-In portal blood, vitamin is transferred to transcobalamin transport proteins -Transcobalamin-II necessary for endocytosis into cells including bone marrow and liver -Liver converts vitamin to coenzyme B12, necessary for: Hematopoesis Myelin maintenance Epithelial cell production

Answer 28

Strict vegans | Chronic alcholics

Answer 29

``` Pernicious anemia Gastric atrophy Gastrectomy/ileectomy Acid-suppressing therapy Inflammatory bowel disease ```

Answer 30

When iron is taken into the body it doesn’t work how it should. Doesn’t get into the liver like it should or transported to the blood.

Answer 31

- Absence of intrinsic factor - Due to autoimmune parietal cell destruction, gastric atrophy, surgery - Most common in African-Americans and those of northern European descent - Higher risk of gastric cancer

Answer 32

``` Decreased exercise tolerance Fatigue Dizziness Irritability Weakness Vertigo Shortness of breath Chest Pain GLOSSITIS- TONGUE IS BIG, RED, BEEFY, SHINY, ALMOST LOOKS BLOODY NUMBNESS, PARETHESIAS IN EXTREMITIES ```

Answer 33

``` ↓ Hgb ↓ Hct ↑ MCV – difference from iron deficiency ↑ RDW ↓ B12- important ↑ Methylmalonic acid (MMA) ↑ Homocysteine Mild leuko- and thrombocytopenia May have intrinsic factor antibodies Not seen in everyone with Vit B12 def ```

Answer 34

Goals Reverse hematologic manifestations Prevention/reversal of neurologic manifestations Replace body stores Consider even if B12 levels are at low end of normal Supplementation usually necessary Can encourage dietary intake as well

Answer 35

``` Mollusks Beef liver Fortified cereal Salmon Beef Yogurt Tuna MIlk ```

Answer 36

Oral 1 – 2 mg/day for 1 month, then 125 – 500 micrograms/day IM/SC *Use this route if neurologic symptoms are present Cyanocobalamin 1 mg/day for 1 week, then 1 mg/week for 1 month, then monthly thereafter Hydroxycobalamin 1 mg/ month is alternative Intranasal Once weekly

Answer 37

Rebound thrombocytosis Fluid retention Anaphylaxis

Answer 38

``` Strength improves within days Glossitis improves in 24 hrs Bone marrow normoblastic in 24 hrs Hgb/Hct respond in week Leukocytes/platelets normal in 1 week ```

Answer 39

CBC in 10 - 14 days, again in 2 – 3 months | MMA/homocysteine in 2 -3 months

Answer 40

Adolescents/teens Elderly Pregnant women Alcoholics

Answer 41

Works with DNA synthesis Important for Protein, amino acid, purine & pyrimidine synthesis Important in fetal development

Answer 42

``` Green leafy vegetables Citrus Mushrooms Diary Organ meats Fortified cereals ```

Answer 43

In the small intestine | Converted to active form via B12-dependent reaction

Answer 44

Sprue/celiac disease | Alcoholism

Answer 45

Pregnancy Chronic hemolysis Myelofibrosis Autoimmune diseases

Answer 46

Alcoholism

Answer 47

Sulfa drugs Methotrexate Phenytoin

Answer 48

``` Decreased exercise tolerance Fatigue Dizziness Irritability Weakness Vertigo Shortness of breath Chest Pain ```

Answer 49

``` ↓ Hgb ↓ Hct ↑ MCV ↑ RDW ↓ Folate ↓ RBC Folate ↑ Homocysteine **You MUST rule out B12 deficiency** ```

Answer 50

Reverse hematologic manifestations Replace body stores Provide for healthy fetal development

Answer 51

``` Chicken liver Beef liver Cereal Lentils Other legumes Pasta Spinach ```

Answer 52

Supplementation can mask B12 deficiency* | 1 mg PO daily for at least 4 months

Answer 53

Strength improves within days | Hbg/Hct repsond in 2 days

Answer 54

CBC in 1 month

Answer 55

Due to increased blood loss – Trauma, GI bleed, malignancy | Reduced production

Answer 56

Marrow failure | Myeloproliferative disorder

Answer 57

Renal failure Endocrine Disorders Anemia of chronic disease

Answer 58

Hemolytic disorders

Answer 59

Source Injury Upper GI bleed (variceal, non-variceal [ulcer, Mallory-Weiss tear, malignancy, etc.]) Lower GI bleed (hemorrhoids, malignancy, etc.) Patient may be hypovolemic, tachycardic Especially with large-volume losses More likely if blood loss was rapid

Answer 60

``` -Surgical or medical management of injury GI bleed Proton pump inhibitor (upper) Banding of varices (upper) Injection of sclerosing agent ``` - Fluid resuscitation - Blood transfusion

Answer 61

1 “Unit of blood” is 300 cc of packed RBCs Raises Hgb by 1 mg/dL by and Hct by 3% Indications Hgb < 7 mg/dL (higher cutoff for patients with severe cardiovascular disease) > 30% blood loss

Answer 62

To prevent hemolysis of given RBCs Type Screen for blood type & antibodies (A-B-O) Rh (D) antigen Cross - Match units of blood to type that patient needs

Answer 63

Transmit disease Very small risk – blood is screened Iron overload Each unit of RBC contains 200 – 250 mg of iron

Answer 64

Anemia of chronic disease

Answer 65

Frequently occurs in elderly | Most common with diseases that last a few months

Answer 66

Not 100% understood Hypoproliferation of RBC due to Chronic inflammatory processes increase cytokines Interleukin-1 & Tumor necrosis factor (TNF) released Reduced response to EPO (erythropoetin) Reduced transferrin synthesis

Answer 67

Major abnormalities Limited release of iron from marrow – impaired iron mobilization Impaired marrow response to EPO Shortened survival of RBC

Answer 68

Tuberculosis HIV Subacute bacterial endocarditis Osteomyelitis

Answer 69

Rheumatoid arthritis SLE IBD GOut

Answer 70

Renal failure

Answer 71

Carcinoma Lymphoma Leukemia Multiple myeloma

Answer 72

Alcoholic liver disease CHF COPD

Answer 73

``` Decreased exercise tolerance Fatigue Dizziness Irritability Weakness Vertigo Shortness of breath Chest Pain CHRONIC, MILD TO MODERATE SX MAY NOT BE DISTINGUISHABLE FORM SX OF OVERLYING DISEASE CAN BE ACCOMPANIED BY IRON DEFICIENCY ANEMIA IN SOME PATIENTS ```

Answer 74

There is no definitive test This is a diagnosis of exclusion Anemia in someone who is chronically ill No other definite etiology

Answer 75

``` ↓ Hgb ↓ Hct Normal or Slightly ↓ MCV Normal RDW ↓ Iron ↑ or normal Ferritin ↓ TIBC ↓ Reticulocyte count ```

Answer 76

- *Treat underlying disease* - Replace iron IF deficient - Not for patients with high ferritin - Blood transfusion if severe anemia & symptomatic - Erythropoietic agents - Useful since these patients can have a deficiency of EPO

Answer 77

``` Epoetin Alfa (Procrit®, Epogen®) Darbopoetin Alfa (Aranesp®) ```

Answer 78

Stimulates RBC production & maturation, like endogenous EPO

Answer 79

Anemia associated with chronic renal failure Anemia due to chemotherapy for non-myeloid malignancies Anemia associated with HIV therapies causing myelosupression No consistent guidelines for EPO use in patients with anemia of chronic disease VERY EXPENSIVE

Answer 80

Do not begin in chemo patients with Hgb > 10 g/dL

Answer 81

Maintain Hgb sufficient to avoid RBC transfusions Chronic renal failure - Hgb 10 – 12 g/dL Hgb should NOT exceed 12 g/dL in any patient Hgb should not rise > 1 g/dL within 2 weeks

Answer 82

As goal Hgb is approached, dosing should be reduced If Hgb > 12 g/dL – withhold dosing, might resume at reduced dose after Hgb drops below 10 g/dL Can increase dose at 4 week intervals if Hgb increase < 1 g/dL **Discontinue therapy if inadequate response in 12 weeks

Answer 83

Bone marrow will utilize iron in Hgb production Patients may need iron supplementation during therapy If ferritin drops below 100 ng/mL If transferrin saturation drops below 20%

Answer 84

``` Monitoring Hgb/Hct weekly Resolution of symptoms Iron studies Side effects USE MINIMUM EFFECTIVE DOSE of EPO agent ```

Answer 85

Adverse effects Infusion reactions: fever, chest pain, N/V, back pain Edema Severe hypertension (renal failure patients) Seizures Allergic reactions Black Box Warnings Shortened time to tumor progession & increased mortality in breast, cervical, head & neck, lymphoid, & non-small cell lung cancer, especially when targeting Hgb >12 g/dL Increased risk of death and serious cardiovascular & thromboembolic events in renal failure patients targeting higher Hgb (≥ 13.5 vs. > 10)

Answer 86

Shortened time to tumor progession & increased mortality in breast, cervical, head & neck, lymphoid, & non-small cell lung cancer, especially when targeting Hgb >12 g/dL Increased risk of death and serious cardiovascular & thromboembolic events in renal failure patients targeting higher Hgb (≥ 13.5 vs. > 10)