Anemia Flashcards
Anemia
-Decrease in RBCs, Hgb, and/or Hct
(Reticulocytes are immature RBCs formed in BM)
Sx: fatigue, weak, SOB, HA, dizzy, pallor, exercise intolerance
Iron vs B12 Deficiency SX
IRON = glossitis (inflamed, sore tongue), koilonychia (spoon-shaped nails), pica (eating non-foods)
B12 = also glossitis, neurologic sx (peripheral neuropathy, visual disturbances, psych sx)
Types of Anemia
Low Hgb/Hct —> Check MCV:
MCV < 80 (micro): iron def
-Also low RET
MCV 80-100 (norm): acute blood loss, malignancy, CKD, bone marrow failure, hemolysis
-RET high in acute blood loss and hemolysis
MCV > 100 (macro): B12 or folate def
-Also low RET
Pregnancy and Iron Deficiency
CDC rec:
-low-dose iron supplementation (30 mg/day) for all, usually in prenatal vitamin
Causes of Iron Deficiency
-Low iron intake (vegan diet, malnutrition)
-Blood loss (hemorrhage, heavy menses, PUD, drug use - AC/AP/NSAID)
-High gastric pH, GI disorders, gastric bypass
-Pregnancy, lactation, infants (higher iron requirements)
Elemental Iron in Oral Products
Ferrous gluconate - 12%
Ferrous sulfate - 20%
Ferrous sulfate dried - 30%
Ferrous fumarate - 33%
Caronyl iron, polysaccharide iron, ferric maltol - 100%
Ferrous sulfate: Dosing
325 mg (65 mg elemental iron)
Assessing and Treating Iron Deficiency
Assess
-LOW: Hgb, MCV, RET, iron, TSAT, ferritin
-HIGH: TIBC
Tx (HAP EE)
-Common dosing: 1 tab QD or EOD (no difference in efficacy or AE in products)
-Take on EMPTY STOMACH (1 hr before or 2 hr after meals) for best absorption
-Avoid H2RAs and PPIs, separate from antacids
-SR or EC forms cause less GI irritation (BUT are not rec due to poor absorption)
Goal
-Increase Hgb after 1-2 weeks, continue 3-6 months or until iron studies normalize
Ferrous products: BBW/AE
BBW
-OD (leading cause of poisoning in children)
*go to ED or call poison control ASAP even in asx
-ANTIDOTE: deferoxamine (DESFERAL)
AE
-GI (nausea, stomach upset)
-Constipation (dose-related)
-Dark/tarry stools
*liquid preparations may stain teeth
*can take with food if GI upset occurs (no milk)
(ferri in STOC GF)
Iron: DDIs
-Antacids (take iron 2 hr prior or 4 hr after aa)
-H2RAs (no use)
-PPIs (no use)
-Vitamin C (may inc abs)
Separate:
-Quinolones, tetracyclines (take iron 2 hr prior or 4-8 hr after abx)
-Bisphosphonates
-Levothyroxine
-INSTIs
QT LIVs PHAB
IV (Parenteral) Iron
Risk of more severe AE and cost, restricted for:
-CKD on hemodialysis or receiving ESAs (erythropoiesis-stimulating agents)
-Unable to tolerate oral iron (GI or fail tx)
-Severe anemia (Hgb < 7)
-Who will not accept RBC transfusions (which is first line for acute blood loss/life threatening anemia)
IV Iron: BBW/AE
Iron sucrose (Venofer), Ferumoxytol (Feraheme), Iron dextran
BBW:
-Dextran/Ferumoxytol: fatal anaphylactic rxns
-Dextran only: MUST be given test dose prior to full therapeutic dose (fatal rxns can still occur even if tolerate test)
W:
-Hypersensitivity (can pre-medicate)
AE: NVD, dizzy, chest pain, edema, dyspnea
Give IV SLOWLY to reduce hypotension
All NS stable (Feraheme is stable in NS or DSW)
dex moxy and ana, dex tests NHS
Most common cause of B12 deficiency
Pernicious anemia
-developed antibodies to intrinsic factor
-requires lifelong parenteral VB12 replacement
Other
-AUD, low B12/folate intake, long term use of metformin/H2RA/PPIs (PMH)
Assessing and Treating B12 Deficiency
Assess
-LOW: Hgb, RET, B12, folate
-HIGH: MCV, methylmalonic acid (B12), homocysteine (both B12/folate)
-NEURO SX
Treatment
-B12 injections first-line if severe or with neuro sx
-Oral folic acid usually sufficient
Cyanocobalamin (B12): Dosing
IM or DEEP SC
1000 mcg daily/weekly/monthly depending on severity
Oral
1000-2000 mcg daily
Nascobal
500 mcg in one nostril once weekly
CI: allergy to cobalt/B12
Folic acid (Folate, B9)
0.4-5 mg daily
AE: bronchospasm, flushing, rash, malaise (all rare)
Folic acid can decrease concentration of PPP
-Fosphenytoin, phenytoin
-Primidone
-Phenobarbital
Anemia of Chronic Disease
Deficiency of EPO
-Iron therapy and ESAs
ESAs initiated when Hgb < 10
-DC when Hgb near or exceeds 11
-Iron store required for ESAs to work so iron replacement therapy is often needed
KDIGO: CKD and Anemia
-Iron therapy is all CKD anemia pts if TSAT < 30% and ferritin is < 500
-IV iron preferred (oral can be trialed if not on hemodialysis)
-If all anemia causes is corrected and Hgb < 10 still then use ESAs
-Daprodustat (Jesduvroq) is an oral ESA indicated in CKD pts who have been receiving dialysis for at least 4 months
Epoetin alfa (Epogen, Procrit): Dosing
50-100 u/kg IV or SC 3x a week
Darbepoetin alfa (Aranesp): Dosing
HD
-0.45 mcg/kg IV/SC weekly
-0.75 mcg/kg IV/SC q 2 weeks
Non-HD
-0.45 mcg/kg IV/SC q 4 weeks
darbepoetin half-life is 3 times that of epo alfa (allows weekly admin)
ESA (Epoetin, Darbepoetin): BBW/AE
BBW
-Risk of death, MI, stroke, VTE, thrombosis
-CKD: risk of death/CV when > 11 Hgb
-Cancer: shortened survival (not indicated when anticipated outcome is cure)
AE:
-HTN, seizures, allergic rxn, SJS/TEN
-Arthralgia, bone pain, edema
+ the usual (HA, fever, NV, dizzy, rash)
IV ROUTE FOR HEMODIALYSIS
STORE IN FRIDGE, NO SHAKE
MD got a SASH for saving SVT
Drug-Induced Hemolytic Anemia
+ Coombs test (CPS RID)
-PCN, cephalosporins, sulfonamides
-Isoniazid
-Levodopa, methyldopa
-Rifampin
-Quinidine, quinine
G6PD (MD PR on QBS)
-Dapsone
-Methylene blue
-Nitrofurantoin, sulfonamides
-Pegloticase, rasburicase
-Primaquine, quinidine, quinine
Agent should be d/c
