Anemia Flashcards
What’s hemoglobin?
Protein in RBC that carries oxygen
What’s the normal lifespan of RBC?
About 120 days
List the main causes of anemia
Impaired RBC production
Increased RBC destruction (hemolysis)
Blood loss
What’s the main cause behind sx experienced in anemia?
Tissue hypoxia (tissues not getting enough oxygen-rich blood)
List the sx of anemia.
Fatigue
Malaise
Weakness
SOB
Headache
Dizziness
And/or
Pallor
When does a pt typically NOT experience sx of anemia (asymptomatic)?
In mild anemia or in beginning stages
What’s sx are experienced in acute blood loss?
Chest pain
Angina
Fainting
Palpitations
Tachycardia
List the unique sx that may develop in iron deficiency anemia
Glossitis
Koilonychias
Pica
What’s Glossitis?
An inflamed, sore tongue
What’s Koilonychias?
Thin, concave, spoon-shaped nails
What’s Pica?
Craving and eating non-foods such as chalk or clay
How is anemia xterized?
Low hemoglobin (Hgb) and low hematocrit (Hct) levels
What’s the most common way to classify the type of anemia?
Mean corpuscular volume (MCV)
Or
Average volume of RBCs
While the sx of both microcytic and macrocytic anemia are similar, how can they be differentiated?
MCV
Define microcytic anemia
MCV is small (< 80um3) dis to small cell size from a lack of iron
Define macrocytic anemia
MCV is large (> 80um3) due to folate or Vit b12 deficiency
Also called Megaloblastic anemia
What’s normocytic anemia? How does it normally occur?
Anemia with normal MCV (80-100 um3)
From acute blood loss (surgery or trauma)
What’s the normal range of MCV?
80 - 100 um3
What’s erythropoietin?
Hormone secreted by the kidneys that INCREASES the rate of pdt of RBCs in response to falling levels of oxygen in the tissue
What’s essential for hemoglobin formation?
Iron
What should be done b4 initiation of erythropoietin therapy? Why?
Iron levels need to be checked
If iron stores are low, erythropoietin-stimulating agents (ESAs) will NOT work
What’s the mainstay of anemia tx?
Iron therapy
ESAs
What does majority of pts needing iron replacement use?
Oral iron supplement
Why would a pt need iron by injection as replacement?
Usually are CKD pts on hemodialysis
What’s the normal adult range for hemoglobin (hgb)?
Males: 13.5 - 18 g/dL
Females: 12-16 g/dL
What’s the normal adult range for hematocrit (Hct)?
Males: 38-50%
Females: 36-46%
What’s the normal adult range for mean corpuscular volume (MCV)?
80-100 um3
What’s the normal adult range for total iron binding capacity (TIBC)?
250-400 mcg/dL
What’s the normal adult range for serum ferritin?
Males: 30-300 ng/mL
Females: 10-200 ng/mL
What’s the normal adult range for transferrin saturation (TSAT)?
Males: 15-50%
Females: 12-45%
What’s the list common type of anemia?
Iron-deficiency anemia
Which is more easily absorbed? Heme or non-heme iron?
Heme iron is minimally affected by dietary factors
How is microcytic anemia diagnosed?
Low hemoglobin and low MCV (<80 um3)
Why may vegetarians still need iron supplement even if they are consuming enough iron?
Becuz their iron is non-heme, which is less available than heme iron (from meat)
What’s the first-line tx of iron deficiency anemia? Exception?
Ferrous sulfate
Patients on hemodialysis (start with injectable iron)
Which is more readily absorbed, ferrous iron (Fe2+) or ferric (Fe3+)?
Ferrous iron (Fe2+)
Duration of iron replacement?
3-6 months AFTER anemia has resolved (to allow for iron stores to return to normal and prevent relapse)
What formulations of iron replacement is NOT recommended as initial therapy? Why?
Sustained-release formulations or Enteric coated formulation
They reduce amt of iron present for absorption in the duodenum
In what gastric environment is absorption of iron enhanced?
Acidic
What may be used with iron to enhance absorption, to a minimal extent?
Ascorbic acid (Vit C 200mg)
Should iron be taken with food? Why or why not?
Food will DECREASE iron absorption
Take iron at least 1 hr before meals (take iron with meals if GI upset occurs when taking iron on an empty stomach)
What’s the dosing of ferrous sulfate (1st line therapy)?
325 mg PO daily to TID (65 mg elemental iron)
What’s the brand name of ferrous sulfate, dried (exsiccated) controlled release? Dose?
Slow Fe, Feosol
160mg PO daily to TID
What’s the leaving cause of fatal poisoning in children under 6?
Accident overdose of iron-containing pdts
Side effects of oral iron replacement therapy?
Nausea
Stomach upset
Constipation (dose related)
Dark and tarry stools
Why are enteric-coated and delayed-release pdts not recommended?
Decresaes iron absorption
What’s recommended for iron-induced constipation?
Docusate
Although, fiber is 1st line tx for constipation, Docusate is 1st line here
What’s unique about carbonyl iron (Feosol with carbonyl iron, ferracap, ferralet 90)?
Highest amt of iron (100% elemental iron)
Effects of antacids and agents that raise pH on iron absorption?
They decrease iron absorption (remember, iron needs acidic gastric environment)
Effects of antibiotics on iron absorption?
Primarily Tetracyclines (less concern with Doxycycline and Minocycline) and Quinolones DECREASE iron absorption through chelation
Which tetracyclines are of less concern wrt reducing iron absorption?
Doxycycline
Minocycline
How to take iron if pt is also on Tetracycline?
Take iron 1-2 hrs BEFORE tetracycline
OR
4 hrs AFTER tetracycline
How to take iron if pt is also on Ciprofloxacin?
Take iron 2hrs BEFORE
OR
6hrs AFTER Cipro
How to take iron if pt is also on Levofloxacin?
Take iron 2 hrs BEFORE
OR
2hrs AFTER Levofloxacin
How to take iron if pt is also on Moxifloxacin?
Take iron 4 hrs BEFORE
OR
8hrs AFTER Moxifloxacin
How much Vit c is needed to increase gastric acidicity t4 enhance iron absorption?
About 200mg or Ascorbic acid
By how much does food decrease iron absorption?
About 50%
List the drugs that iron interacts with and DECREASES their levels. How should they be separated?
Levothyroxine
Levodopa
Methyldopa
Cefdinir
Bisphosphonates
Mycophenolate
Seperate doses by 2-4 hrs
T/F? If a parent finds that their kid has swallowed iron tablet, they should be directed to the ER?
True
How much iron do kids need to overdose on iron?
As little as 5 tablets of iron can lead to over dose
What’s the antidote for oral iron overdose?
Deferoxamine
What’s the antidote for transfusional iron overdose?
Deferiprone (Ferriprox)
What conditions may require Parenteral iron therapy?
Hemodialysis (most common use of IV iron)
Unable to tolerate oral iron OR losing iron too fast for oral replacement
Intestinal malabsorption, such as Crohn’s
Pts donating large amts of blood for autoinfusion
List IV (Parenteral) iron supplements
Iron dextran
Sodium ferric gluconate
Iron sucrose
Ferumoxytol
Ferric carboxymaltose
What’s the brand name of iron dextran?
INFeD
Dexferrum
What’s the brand name of Sodium Ferric Gluconate?
Ferriecit
Nulecit
What’s the brand name of iron Sucrose?
Venofer
Which IV iron supplement has a black box warning?
Iron Dextran (INFeD, Dexferrum)
What’s the black box warning ass with iron dextran? How is it prevented?
Risk of anaphylactic rxns
A test dose should be given to ALL pts prior to 1st therapeutic dose
What factors may be of concern, even if the test dose was tolerated by a pt?
Hx of drug allergy
And/or
Concomitant use of ACE-I
How should IV iron be given? Why?
By slow IV injection
To reduce risk of hypotension
What type of anemia is iron replacement therapy used for?
Microcytic anemia
What’s macrocytic anemia?
Is due to either Vit B12 or Folate deficiency OR both
What’s the concern with long-term untreated macrocytic anemia?
Pt is at risk of NEUROLOGICAL consequences including
Cognitive dysfunction (dementia)
AND
Peripheral nerve damage
What’s Pernicious anemia?
Type of macrocytic anemia that results in LOW B12 levels due to a lack of intrinsic factor, which is req for adequate B12 absorption on small intestine
What’s the tx duration for those with pernicious anemia?
Forever!
They req lifelong Vit B12 replacement therapy
Which dosage form of Vit B12 is preferred? Why?
Vit B12 injections
Becuz macrocytic anemia can lead to neurological complications
List the other causes of macrocytic anemia.
Alcoholism
Crohn’s dx
Celiac dx
Howz macrocytic anemia diagnosed?
LOW hemoglobin and HIGH mean corpuscular volume (MCV) >100mm3
What other values are considered in diagnosing macrocytic anemia?
Vit B12 and/or serum folate levels will be LOW
What’s used to diagnosed Vit B12 deficiency specifically?
Schilling test
Can pick up lack of intrinsic factor (needed for absorption of Vit B12 in the small intestine )
What’s the tx of macrocytic anemia?
Tx usually starts with Vit B12 injections and follow with oral supplements
List drugs used to treat macrocytic anemia
Cyanocobalamin (Vit B12)
Folic acid (folate)
What’s contraindication to use of cyanocobalamin?
Cobalt allergy
What’s formulation of b12 isn’t used?
Sustained-release B12 supplements as the absorption is not adequate
What’s tne dose of Folic acid (folate) used in macrocytic anemia?
0.4-1mg daily
1mg (Rx)
0.4, 0.8mg (OTC)
What’s the SE of Folic acid (folate)?
Bronchospasm
Flushing
Rash
Pruritus
What’s the monitoring for both Vit B12 and Folic acid (folate)?
Hgb
Hct
Folate
Vit B12
Iron
List drugs that may reduce the absorption of Vit B12
Chloramphenicol
Colchicine
Ethanol
Long-term tx with Metformin
List drugs that Folic acid may reduce absorption of?
Raltitrexed (avoid concurrent use)
What’s the effect of CKD on iron?
CKD causes anemia due to deficiency in erythropoietin, a hormone produced by healthy kidneys
How should ESAs be used in chronic renal failure?
At lowest possible dose that reduces need for blood transfusion
When should ESA be started and stopped (or reduced)?
Start - when hgb < 10 g/dL
Reduce or Stop - when hgb is near 11 g/dL
What values should transferrin saturation and ferritin be b4 ESA is started?
Transferrin saturation - At least 20%
Ferritin - At least 100 ng/mL
What other values need to be assessed before ESA is started?
Folate and Vit B12, especially if there’s a poor response to ESA
List agents that fall under ESA
Epoetin alfa (Epogen, Procrit)
Darbepoetin (Aranesp)
Whats the brand name of Epoetin alfa (ESA)?
Epoetin
Procrit
Whats the brand name of Darbepoetin (ESA)?
Aranesp
What’s the black box warning on ESAs (Epoetin and Darbepoetin)? When is this a concern?
ESAs increase the risk of serious cardiovascular events, thromboembolic events, strokes and mortality.
When ESA is admin to target hgb > 11g/dL
What’s the hgb target in CKD pts?
11… Black box warning comes in
Effect of ESA on cancer survival?
ESA shortens overall survival and/or increased risk of tumor progression or recurrence in pts with breast, head and neck, non-small cell lung, lymphoid and cervical cancer
What’s ESA APPRISE?
Oncology program to prescribe and/or dispense agents (Epoetin and Darbepoetin) to cancer pts
When should ESA be used in cancer pts?
Anemia from myelosuppressive chemotherapy
T/F? In cancer pts, ESA (Epoetin, Darbepoetin) is not recommended when the outcome is cure?
True
T/F? D/c ESA following chemotherapy course?
True
ESA and perisurgergy?
Increases risk of DVT, t/4 DVT prophylaxis is recommended
List contradictions to ESA (Epoetin and Darbepoetin) use
Uncontrolled HTN
Pure red cell aplasia (PRCA) that begins after tx
SE of ESA
Hypertension
Thrombosis
Fever Headache Arthralgia/ bone pain Pruritus/ rash Nausea Cough Injection site pain Edema Chills Dizziness
What’s the monitoring parameters of ESA?
Hgb
Hct
Transferrin saturation
Serum ferritin
BP
What’s the preferred route of ESA for pts on hemodialysis?
IV route
Wheee should ESA be stored?
In the refrigerator
What’s the cut-off for admin ESA in CKD pts and cancer pts?
CKD - stop if hgb is > 11.5
Cancer - stop if Hg. Is 11
How will ESA work faster?
If taken on empty stomach
List nutrients from food that should be limited when on ESA? Their effect on iron absorption?
Tannins
Calcium
Polyphenols
Phytates
(Found in legumes and whole grains)
They decrease iron absorption
List serious life-threatening conditions that may occur, the longer one is on ESA?
Heart or circulation problems including heart attack and stroke
Seek emergency medical help immediately if u feel sx of stroke or heart attack
Effect of ESA on cancer remission time?
ESA may shorten remission time in pts with breast, non-small lung, head and neck, cervical or lymphoid cancer
How does the dr make sure pt is getting best results from medication?
By occasionally changing the dose of ESA
Should the ESA bottle (vial) be shaken?
No
List sites of injections of ESA
Outer area of upper arms
Abdomen (except 2inches around navel)
Front of the middle thighs
Upper outer area of buttocks
What’s anemia?
Common blood disorder xterized by a DECREASE in EITHER
hemoglobin
OR
Volume of RBC
