Anemia

Question 1

Lab values for iron deficiency anemia?

Answer 1

LOW:
Serum iron, transferrin saturation, ferritin, MCV
(Ferritin stores iron, transferrin binds iron, MCV is mean corpuscle volume)

HIGH:
TIBC (This is binding capacity - body can bind lots of iron when there isn’t much around!)

HgB and Hct are normal at first then get low over time (chronic)

Question 2

What’s better - immediate or extended release iron?

Answer 2

Immediate release. Extended release results in less absorption

Question 3

Should iron be given with food?

Answer 3

No, it decreases absorption

Question 4

Adverse effects of iron admin?

Answer 4

Dark discoloration of feces
Constipation or diarrhea
N/V
Upset stomach

(All of these are dose relatd)

Question 5

What options do we have for oral iron supplementation?

Answer 5

Ferrous sulfate
Ferrous sulfate excsiccated (30% absorption - highest)
Ferrous gluconate (13% absorption - lowest)
Ferrous fumarate

Question 6

Drug interactions for oral iron therapy?

Answer 6

Antacids, tetracycline antibiotics, H2 blockers/proton pump inhibitors, levothyroxine, mycophenolate, and cholestyramine impair absorption

Levodopa and penicillamine chelate iron to reduce levels

Question 7

Dosing for oral iron therapy?

Answer 7

150-200 mg daily divided into 2-3 doses

Take with an empty stomach, start low and titrate upwards

Question 8

How long should oral iron therapy last?

Answer 8

3-6 months AFTER anemia has resolved, this allows for replenishment of the stores (not just increasing to normal levels)

Question 9

When do we give parenteral iron therapy?

Answer 9

Inadequate response to oral therapy
Chronic kidney disease
Chemotherapy patients receiving erythropoiesis stimulating agents
Refusal of blood product administration (wut?)

Question 10

Options for parenteral iron therapy?

Answer 10

Iron dextran
Sodium ferric gluconate
Iron sucrose
Ferumoxytol

Question 11

How is parenteral iron therapy dosed?

Answer 11

Hgb deficit = target Hgb - observed
multiply by weight in pounds!!!
then
Add 600 for women, 1000 for men to get dose

Question 12

Iron dextran - dosing? Adverse effects? Limitations?

Answer 12

100 mg daily until total dose is reached
Can give as a single IV infusion also

Adverse effects - anaphylaxis (black box warning)
MUST do test dose of 25 mg followed by 1 hour observation

Also worry about painful injection, flushing, hypotension, fever, chills, myalgia

Question 13

Sodium ferric gluconate - dosing? adverse effects? limitations?

Answer 13

Indicated when pt is undergoing hemodialysis

125 mg IV daily (IV infusion only)

Adverse effects: Less risk for rash but still monitor for 30 mins post dose just in case
Cramps, nausea, vomiting, flushing, hypotension, gastric pain, rash, pruritis

Question 14

Iron sucrose - dosing? Adverse effects? Limitations?

Answer 14

Indication is pts with CKD with or without hemodialysis

Dosing: 100 mg IV daily

adverse effects: Leg cramps, hypotension

Don’t give oral iron with this

Question 15

Ferumoxytol - dosing? Adverse effects? Limitations?

Answer 15

Indicated in pts with CKD

Dosed 510 mg IV followed by 510 mg 3-8 days later
30 mg/s

Adverse effects: No test dose required, observe for 30 mins after dose
Diarrhea, constipation, nausea, dizziness, hypotension, peripheral edema

Question 16

How do we monitor response to iron therapy?

Answer 16

Hgb and Hct weekly until stabilized
Serum iron/ferritin monthly (wait 48 hours after IV iron)
Iron toxicity: serum ferritin over 800 or transferrin saturation over 50%
Check 1 week after doses 100-200 mg, 2 weeks after larger doses

Question 17

Lab values for VB12 deficiency?

Answer 17

MCV over 100 fL, vitamin B12 less than 150 pg/mL

LOW:
Hct

HIGH:
Homocysteine (converted to cysteine by B12, low B12 = low conversion = too much homocysteine)
MMA (Same as above)

Question 18

Signs/symptoms of VB12 deficiency?

Answer 18

Late stage can cause psychosis, dementia

Can have paresthesia

Question 19

What is the DRA of VB12?

Answer 19

2 mcg in adults
2.6 mcg in pregnancy or breast feeding
Typical western diet provided 5-15

Question 20

What is the DRA of iron?

Answer 20

Men and postmenopausal women it’s 8
Women it’s 18 mg
Western diet provides between 12-15 mg

Question 21

When do we treat VB12 deficiency?

Answer 21

Megaloblastic anemia
Neurologic disease from deficiency
Marginally low VB12 levels with high MMA/homocysteine levels

Question 22

How to treat VB12 deficiency?

Answer 22

1-2 mg orally once daily, avoid times release

IM admin: 1000 mcg daily x 1 week, then weekly for 1 month, then monthly thereafter

If you want to go from IM to oral, just give 1 mg orally daily starting on the due date of the next injection

Question 23

Monitoring for VB12 deficiency?

Answer 23

Rapid response (usually within a few days, with response to anemia in 1-2 months)

Question 24

Folic acid deficiency - how much folic acid do we need daily?

Answer 24

400 mcg in adults
600 mcg in pregnancy
500 mcg in lactating women

Question 25

How to treat folic acid deficiency?

Answer 25

1 mg folic acid

Treat for 4 months, ongoing may be required for chronic disease

Question 26

Monitoring for folic acid deficiency?

Answer 26

Response should be seen within 2 weeks (increased Hgb/Hct, normalizing within 2 months)

Question 27

Which populations see folic acid deficiency?

Answer 27

Pregnancy, alcoholics

Question 28

Lab values in folic acid deficiency?

Answer 28

MCV over 100 fL
Serum folate less than 3 ng/mL
RBC folate less than 150 ng/mL
Hct low
Homocysteine high
MMA normal!

Question 29

Pediatric patients with microcytic anemia - tratment?

Answer 29

Oral iron

Question 30

Pediatric patients with macrocytic anemia - treatment?

Answer 30

Folate

Question 31

Treatment for congenital pernicious anemia?

Answer 31

Vitamin B12