Anemia/Drug Induced Hematologic Disorders Flashcards
1
Q
PO Iron Side Effects
A
Constipation and Dark Colored Feces
Abdominal cramping/Epigastric Distress
Nausea
2
Q
Iron is best absorbed in what conditions?
A
Empty Stomach/Acidic environments
Aka separate iron from milk or antacids by 2 hours (before and after)
3
Q
Separate PO iron from what?
A
Milk and antacids
4
Q
How to prevent constipation from PO iron
A
stool softener and adequate fluid intake
5
Q
What PO Drug interaction will increase Iron absorption
A
Vitamin C/Ascorbic Acid
6
Q
What PO Drug interactions will decrease Iron absorption
A
- H2 blockers
- PPI
- Cholestyramine
- Tea/Coffee/Coffee/Wine
- Calcium
7
Q
Iron decreases the absorption of what drugs
A
Fluoroquinolones; Tetracyclines
8
Q
Indications for IV Iron
A
- severe iron malabsorption
- noncompliance w/ oral therapy
- chronic uncorrectable bleeding
- diminished erythropoiesis
9
Q
Does IV iron work faster to correct anemia than oral iron?
A
No
10
Q
MCV Normal Range
A
80 - 100 (Hct/RBC)
11
Q
Anemia Value for Hgb
male and female
A
male: < 13.5 g/dL
female: < 12 g/dL
12
Q
Anemia value for Hct
male and female
A
male: <41%
female: <36%
13
Q
Anemia value for RBC
male and female
A
male: < 4.5
female: < 4.1
(units - million/mcL)
14
Q
Common Causes for Normocytic Anemia
A
Acute Blood loss;
Mixed Anemias (look at RDW);
Chronic Illness
15
Q
Common Causes for Microcytic Anemia
A
IRON DEFICIENCY ANEMIA
Copper/Zinc deficiency
Toxin poisoning
Inherited disorders
16
Q
“Extreme” Symptoms/Consequences of Iron Deficiency Anemia
A
Pica
Angular Stomatitis (side of mouth is swollen)
Glossitis (swollen tongue)
Koilonychia (flat nails)
17
Q
IDA treatment for Adults
A
200 mg of ELEMENTAL IRON PO/IV
especially for symptomatic IDA
18
Q
IDA treatment for Peds
A
9 - 12 months: 3 mg/kg of elemental iron qd or BID for 2 -3 months after corrected
Older Kids: 6 mg/kg split into BID or TID dosing
19
Q
Is it best to have low or high TIBC
A
Low! if it isn’t “hungry” for Iron/not binding a lot - that means ferritin has a good amount of stores of iron available
20
Q
Which PO Iron option is cheapest
A
Ferrous Sulfate
21
Q
Name the PO iron options
A
Ferrous Sulfate; Ferrous Gluconate; Ferrous Fumarate; Polysaccharide-iron complex; Carbonyl iron
22
Q
How much elemental iron is in ferrous sulfate
A
65 mg
23
Q
How much elemental iron is in ferrous gluconate
A
35 mg
24
Q
How much elemental iron is in ferrous fumarate
A
99 mg
25
How much elemental iron is in polysaccharide iron complex
150 mg
26
How much elemental iron is in carbonyl iron
50 mg
27
Common Risk Factors for Anemia:
| 3 main groups
Demographics, Social Factors, Dietary Factors
28
What Risk factors for anemia are social factor based
- EtOH abuse
- poverty
- poor dentition
- GI disease
- depression
29
What Risk factors for anemia are demographic based
elderly
teenage
female
marital status
30
What Risk factors for anemia are dietary factor based
- low iron
- low fruit/veggies
- phytates
- tannins
- fad diets
31
Special Considerations in determining Anemia - Acute Bleed
drop in Hgb and Hct may not show up until 36 - 48 hrs after acute bleed
32
Special Considerations in determining Anemia - Pregnancy
Volume is diluted - levels look low but they probably are just fine..
33
Special Considerations in determining Anemia - Volume Depletion
Won't show anemia after rehydration
34
IV products for IDA and CKD
Injectafer and Triferic
35
For non-hemodialysis or hemodialysis patients?
| injectafer
non-hemo
36
For non-hemodialysis or hemodialysis patients?
| triferric
hemo pts
37
Which IV Iron product interferes with MRI
Ferraheme (Ferumoxytol)
38
IV Iron products
Iron Dextran; Iron Sucrose; Ferric Gluconate; Ferraheme;
| Injectafer/ Triferic
39
Expect an increase in Hb __ g/dL every ______ weeks of therapy
1; 2 - 3
40
Monitor TSAT and Ferritin how often?
Every 3 months
41
KDIGO does not recommend iron supplementation if TSAT > ____ or ferrition is > _____
30%; 500 ng/mL
42
Issues that come from Iron Overload/Posioning
Gastric Ulcer; Metabolic acidosis; internal organ damage (brain and liver)
43
What is the criteria to get a blood transfusion?
Hgb < 8 g /dL
OR
Symptomatic Anemia
44
1 unit of PRBC (packed red blood cells) = _____ mL = Increase of Hb of _____ and Hct of _____
300 mL; 1 g/dL; 3%
45
Common Causes of Macrocytic Anemia
```
Nutritional deficiency (B12 of Folic Acid)
EtOH abuse
Liver Disease
Hypothyroidism
Drugs (chemotherapy)
```
46
Possible transfusion complications
Iron overload; Acquired Infections; Hyperviscosity; Volume Overload; TRALI;
(TRALI - transfusion reaction acute lung injury)
47
B12 Deficiency is also known as _________ anemia
pernicious
48
RDA for B12
2 mcg daily
49
Body Stores for B12
2 - 5 mg found in the liver (V. LARGE STORE!!)
50
B12 is found in what kinds of food
meat and dairy and fruits and veggies
51
B12 is bound to what and released by what?
| B12 combines with what for absorption?
bound to protein in food; release by HCl
| intrinsic factor
52
Main Drug interactions with B12
H2 Blocker; PPI; Metformin
53
3 main ways to treat B12 Deficiency
Oral; Parenteral; Food
54
Oral B12 Treatment
1000 - 2000 mcg QD x 1 - 2 wks; then 1000 mcg QD for life
55
Parenteral B12 Treatment
1000 mcg IM or Deep SC inj QD x 1 week then weekly for 1 month then monthly for life
56
Causes of Folic Acid Deficiency Causes
- Inadeqaute intake
- Decreased Absorption
- Inadequate utilization
- Hyperutilizatoin
- Drugs Altering Metabolism
57
Black Box Warning for ESAs
increase risk of death/serious life threatening CV events in pts with target Hb > 12 g/dL
58
2 ESAs
Epogen (Epoetin Alpha) and Aranesp (Darbepoetin Alpha)
59
Should you give a pt ESA even if the iron is not at good levels?
NO
60
Epogen Dosing
50 - 100 units/kg 3 x a week
61
Aranesp Dosing
0.45 mcg/kg once weekly
62
Folic Acid Deficiency Treatment
| Oral Treatment for most patients
1 mg QD
63
Folic Acid Deficiency Treatment
| Oral Treatment for malabsorption patients
5 mg QD
64
Folic Acid Deficiency Treatment
| Oral Treatment for anticonvulsant medications
500 mcg QD
65
SCA = Sickle Cell Anemia
| Mutation ____ Chromosome that encodes for _________ on Hgb molecule
Mutation 11th Chromosome that encodes for Beta - 2 globulin on Hgb molecule
66
What factors/conditions cause the precipitation/polymerization of the Beta-2 globulins in SCA
- POOR O2
- Low pH
- Low temp
- increase osmolarity
67
Clinical Presentation of SCA
- Arthralgia
- Scleral Icterus
- Enlarged liver, spleen, heart
- Hematuria
- Fever/pallor; weakness; anorexia; fatigue
68
SCA Pts will have decreased levels of ?
hemoglobin
69
SCA pts will have increase levels of ?
- bilirubin
- reticulocyte count
- platelets
- WBC count
- sickled cells on smear
70
SCA Acute Complications
- Acute Chest Syndrome (ACS)
- Sickle Cell Crises
- Priapism
71
What is Acute Chest Syndrome?
leading cause of death in SCA pts - pulmonary infiltrate present - can't tell if infection or not. Will have cough/SOB/hypoxia
72
What are some examples of Sickle Cell Crises
Vasoocclusive Pain Crises; Acute Splenic Sequestration Crises
73
What is Vasoocclusive Pain Crises
Localized pain in the affected areas for Sickle cell patients
74
How to treat vassocclusive pain crises
hydration and analgesia
75
What is acute splenic sequestration crises
sudden enlargement of spleen/liver in sickle cell patients
| happens bc spleen takes in a large blood volume
76
What is priapism and how is it related to sickle cell
Sickling of sinusoids of the penis - results in prolonged/painful erection
77
Chronic complications for SCA pts
- pulmonary HTN
- Bone/joint problems
- Cholelithasis
- CV problems
- Depression
- Ocular Problems
78
Health Maintenance for SCA Pts
- Immunizations (influenza and pneumococcal)
- Penicillin (for kids)
- Folic Acid
79
Ways to "treat" SCA
Hydroxyurea
Butyrate
Pain management
80
Dose for Hydroxyurea
10 - 15 mg/kg/day (max 35 mg/kg/day)
81
Hydroxyurea is what type of agent
anti-neoplastic
82
What does Hydroxyurea do
increase production of fetal Hgb
| decrease need for transfusions/mortality/acute chest episodes
83
Which is better - hydroxyurea or butyrate
hydroxyurea
84
Butyrate is a naturally occurring what?
Fatty Acid
85
Symptoms of Acute Anemia
- tachycardia/tachypnea
- orthostatic hypotension
- light-headedness
- angina
86
Symptoms of Chronic Anemia
- fatigue/weakness
- headache/dizziness
- dyspnea
- Sensitivity to cold
- pallor/loss of skin tone
- Exacerbation of angina or CHF
87
Causes of Anemia:
erythrocyte ______ - like bleeding
______ erythrocyte production
______ erythrocyte destruction
loss; decreased; increased
88
Reasons for hypoproliferation/decreased production of erythropoeitin
- low EPO
| - deficiency of iron, B12, folic acid, --> decreased marrow response to erythropoeitin
89
Normal Value for RDW (red cell distribution width)
11 - 15%
90
Normal B12 levels
100 - 900 pg/mL
91
Normal folate levels
2 - 20 ng/mL
92
decrease in RBC, WBC, and platelets - what is that called
pancytopenia
93
What are the drug-induced hematologic disorders
```
Aplastic anemia
agranulocytosis
megaloblastic anemia
hemolytic anemia
thrombocytopenia
```
94
What is Agranulocytosis
granulocytopenia and low granulocytes made in the bone marrow
95
what is granulocytopenia
low neutrophil, basophil, and eosinophil count
96
what is aplastic anemia
pancytopenia + lack of bone marrow production of WBC, RBC and platelets
97
which drug-induced hematologic disorder has the highest mortality rate
aplastic anemia
98
Symptoms of aplastic anemia
Anemia (Low RBCs): pallor, fatigue, weakness
Neutropenia (low WBCs): fever, chills, sx of infection
Thrombocytopenia (Low platelets): bruisability, petechiae, bleeding
99
what is neutropenia
low WBC count
100
possible DI causes of aplastic anemia
- carbamzaepine
- phenytoin
- propylthiouracil
- thiazide diuretics
- sulfonamides
- methimazole
101
Aplastic Anemia:
| Need ____ of the criteria to be diagnosed
2
102
```
What is the criteria to be considered of having aplastic anemia:
WBC:
Platelets:
Hb:
Reticulocyte count:
```
WBC: < 3500 cells/mm^3
Platelets: < 55,000
Hb: < 10 g/dL
Reticulocyte count: < 30,000
103
Diagnosing criteria for Agranulocytosis
| Mature Myeloid cells (granulocytes/bands):
decrease in mature myeloid cells (granulocytes and bands) to < 500 cells/mm^3
104
Who is at most risk for agranulocytosis
female and elderly
105
Agranulocytosis is characterized by ___________ - onset occurs within _____ of drug exposure
neutropenia; 60 days
106
Symptoms of Agranulocytosis
well its low WBCs.... so.. fever, malaise, weakness, chills, other Sx of infection
107
Drug Classes known to cause Agranulocytosis
- Antithyroid
- Psychotropic
- GI
- Dermatologic
- Abx
- Antimalarials
- Anticonvulsants
108
what antithyroid drugs will induce agranulocytosis
methimazole, propylthiouracil
109
what psychotropic drugs will induce agranulocytosis
clozapine, TCAs, cocaine/heroin
110
what GI drugs drugs will induce agranulocytosis
sulfasalazine, H2 receptor antagonists
111
what dermatologic drugs will induce agranulocytosis
dapsone, isotrentoin
112
what Abx drugs will induce agranulocytosis
sulfonamides
113
what antimalarial drugs will induce agranulocytosis
chloroquine, quinine
114
what anticonvulsant drugs will induce agranulocytosis
phenytoin, valproic acid, carbamazepine
115
Drug Induced Hemolytic Anemia will cause
| (Micro,Normo,Macro) cytic anemia
Normocytic
116
Drug Induced Hemolytic Anemia will cause an increase in what things?
reticulocyte count; LDH; bilirubin
117
Hemolytic Anemia can be happen because of ________ or _______ factors
intrinsic/extrinsic
118
INTRINSIC HEMOLYTIC ANEMIA:
| What are some membrane defects
sphereocytosis
| elliptocytosis
119
INTRINSIC HEMOLYTIC ANEMIA:
| What are some hemoglobin defects
Sickle cell anemia;
| Thalassemia syndrome
120
INTRINSIC HEMOLYTIC ANEMIA:
| What are some metabolic defects
G6PD deficiency
| other enzyme defciencies
121
EXTRINSIC HEMOLYTIC ANEMIA:
| What are some membrane defects
autoimmune hemolytic anemias
| oxidants
122
Extrinsic Hemolytic Anemia:
| Autoimmune Hemolytics - 2 kinds
warm Ab mediated and Cold agglutinin disease
123
```
Extrinsic Hemolytic Anemia:
Autoimmune - Warm Ab mediated:
____ binds to erythrocyte surface;
diagnosed by positive ______ test
is treated by: ________
```
IgG; coombs; corticosteroids or splenectomy
124
Extrinsic Hemolytic Anemia:
Autoimmune - Cold Agglutinin Disease:
_____ Ab bind to erythrocyte surface
IgM;
125
Possible drugs that could cause megaloblastic anemia (aka macrocytic anemia)
methotrexate; cotrimoxazole; phenytoin; phenobarbitol
126
Drug Induced Thrombocytopenia:
| has low _______ count
platelet
127
Drug Induced Thrombocytopenia: Criteria to be diagnosed:
Platelet count < _________
OR
> ____ reduction from BASELINE values
100,000 cells/mm^3; 50%
128
Most common incidence of Drug Induced Thrombocytopenia:
Heparin
129
Non-Drug inducing causes of Drug Induced Thrombocytopenia
blood loss; infection; DIC
130
4 main mechanisms of Drug Induced Thrombocytopenia
- Direct toxicity
- Immune reactions
- Platelet-Reactive Abs
- Drug- Dependent Abs
131
Mechanisms of Drug Induced Thrombocytopenia:
| Examples of Direct Toxicity
- chemotherapy
- organic solvents
- pesticides
132
Mechanisms of Drug Induced Thrombocytopenia:
| Examples of immune reactions
- quinine/quinidine
- gold salts
- sulfonamide
- antibiotics
- rifampin
- glycoprotein (IIb/IIIa) inhibitors
- heparin
133
Mechanisms of Drug Induced Thrombocytopenia:
| Examples of Platelet reactive Ab
procainamide
134
Mechanisms of Drug Induced Thrombocytopenia:
| Examples of drug-dependent Ab
heparin
135
Normal amount of methemoglobin is _____
< 1%
136
More methemoglobin is known as __________
methemoglobinemia
137
Clinical Presentation for Methemoglobinemia:
cyanosis/hypoxia; shock; seizures; blue colored blood
138
How treat methemoglobinemia
- D/c agent causing it
- if levels < 20% /asymptomatic - do not treat
- if levels > 20% /symptomatic - treat methylene blue 1 - 2 mg/kg IV over 5 minutes
139
B12 Deficiency Sx
Neurologic: (peripheral neuropathy; paresthesias; depressed tendon reflexes)
Psychiatric: (irritability, mood changes, memory impairment, depression, psychosis)
Dysphagia
Glossitis
Muscle Weakness/Anorexia
140
Drugs Altering Metabolism of Folic Acid
Folate Antagonists: Methotrexate, trimethoprim, phenytoin, phenobarbitol
Anti-metabolites: azathioprine, 6-mercaptopurine, 5-flurouracil
141
How to treat an Vasoocclusive Pain Crises (Sickle cell crises)
Hydration and Analgesia
| Adults: 3 - 4 L/day
142
How to treat Acute Splenic Sequestration Crises
- blood transfusion
| - broad spectrum Abx
143
How to treat Priaprism (a sickle cell crises)
- analgesia
- irrigation/aspiration
- Vasoconstriction (Forces blood back into circulation - phenylephrine, epinephrine)
- Vasodilation (relaxes smooth muscle - terbutaline, hydralazine)
144
Side effects of Hydroxyurea
bone marrow suppression; skin ulcers
