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Therapeutics I - Spring 2017 > Anemia/Drug Induced Hematologic Disorders > Flashcards

Anemia/Drug Induced Hematologic Disorders Flashcards

1
Q

PO Iron Side Effects

A

Constipation and Dark Colored Feces
Abdominal cramping/Epigastric Distress
Nausea

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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)

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3
Q

Separate PO iron from what?

A

Milk and antacids

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4
Q

How to prevent constipation from PO iron

A

stool softener and adequate fluid intake

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5
Q

What PO Drug interaction will increase Iron absorption

A

Vitamin C/Ascorbic Acid

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6
Q

What PO Drug interactions will decrease Iron absorption

A
  • H2 blockers
  • PPI
  • Cholestyramine
  • Tea/Coffee/Coffee/Wine
  • Calcium
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7
Q

Iron decreases the absorption of what drugs

A

Fluoroquinolones; Tetracyclines

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8
Q

Indications for IV Iron

A
  • severe iron malabsorption
  • noncompliance w/ oral therapy
  • chronic uncorrectable bleeding
  • diminished erythropoiesis
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9
Q

Does IV iron work faster to correct anemia than oral iron?

A

No

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10
Q

MCV Normal Range

A

80 - 100 (Hct/RBC)

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11
Q

Anemia Value for Hgb

male and female

A

male: < 13.5 g/dL
female: < 12 g/dL

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12
Q

Anemia value for Hct

male and female

A

male: <41%
female: <36%

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13
Q

Anemia value for RBC

male and female

A

male: < 4.5
female: < 4.1
(units - million/mcL)

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14
Q

Common Causes for Normocytic Anemia

A

Acute Blood loss;
Mixed Anemias (look at RDW);
Chronic Illness

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15
Q

Common Causes for Microcytic Anemia

A

IRON DEFICIENCY ANEMIA
Copper/Zinc deficiency
Toxin poisoning
Inherited disorders

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16
Q

“Extreme” Symptoms/Consequences of Iron Deficiency Anemia

A

Pica
Angular Stomatitis (side of mouth is swollen)
Glossitis (swollen tongue)
Koilonychia (flat nails)

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17
Q

IDA treatment for Adults

A

200 mg of ELEMENTAL IRON PO/IV

especially for symptomatic IDA

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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

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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

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20
Q

Which PO Iron option is cheapest

A

Ferrous Sulfate

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21
Q

Name the PO iron options

A

Ferrous Sulfate; Ferrous Gluconate; Ferrous Fumarate; Polysaccharide-iron complex; Carbonyl iron

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22
Q

How much elemental iron is in ferrous sulfate

A

65 mg

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23
Q

How much elemental iron is in ferrous gluconate

A

35 mg

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24
Q

How much elemental iron is in ferrous fumarate

A

99 mg

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25
Q

How much elemental iron is in polysaccharide iron complex

A

150 mg

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26
Q

How much elemental iron is in carbonyl iron

A

50 mg

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27
Q

Common Risk Factors for Anemia:

3 main groups

A

Demographics, Social Factors, Dietary Factors

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28
Q

What Risk factors for anemia are social factor based

A
  • EtOH abuse
  • poverty
  • poor dentition
  • GI disease
  • depression
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29
Q

What Risk factors for anemia are demographic based

A

elderly
teenage
female
marital status

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30
Q

What Risk factors for anemia are dietary factor based

A
  • low iron
  • low fruit/veggies
  • phytates
  • tannins
  • fad diets
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31
Q

Special Considerations in determining Anemia - Acute Bleed

A

drop in Hgb and Hct may not show up until 36 - 48 hrs after acute bleed

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32
Q

Special Considerations in determining Anemia - Pregnancy

A

Volume is diluted - levels look low but they probably are just fine..

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33
Q

Special Considerations in determining Anemia - Volume Depletion

A

Won’t show anemia after rehydration

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34
Q

IV products for IDA and CKD

A

Injectafer and Triferic

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35
Q

For non-hemodialysis or hemodialysis patients?

injectafer

A

non-hemo

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36
Q

For non-hemodialysis or hemodialysis patients?

triferric

A

hemo pts

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37
Q

Which IV Iron product interferes with MRI

A

Ferraheme (Ferumoxytol)

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38
Q

IV Iron products

A

Iron Dextran; Iron Sucrose; Ferric Gluconate; Ferraheme;

Injectafer/ Triferic

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39
Q

Expect an increase in Hb __ g/dL every ______ weeks of therapy

A

1; 2 - 3

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40
Q

Monitor TSAT and Ferritin how often?

A

Every 3 months

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41
Q

KDIGO does not recommend iron supplementation if TSAT > ____ or ferrition is > _____

A

30%; 500 ng/mL

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42
Q

Issues that come from Iron Overload/Posioning

A

Gastric Ulcer; Metabolic acidosis; internal organ damage (brain and liver)

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43
Q

What is the criteria to get a blood transfusion?

A

Hgb < 8 g /dL
OR
Symptomatic Anemia

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44
Q

1 unit of PRBC (packed red blood cells) = _____ mL = Increase of Hb of _____ and Hct of _____

A

300 mL; 1 g/dL; 3%

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45
Q

Common Causes of Macrocytic Anemia

A 
Nutritional deficiency (B12 of Folic Acid)
EtOH abuse
Liver Disease
Hypothyroidism
Drugs (chemotherapy)
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46
Q

Possible transfusion complications

A

Iron overload; Acquired Infections; Hyperviscosity; Volume Overload; TRALI;
(TRALI - transfusion reaction acute lung injury)

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47
Q

B12 Deficiency is also known as _________ anemia

A

pernicious

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48
Q

RDA for B12

A

2 mcg daily

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49
Q

Body Stores for B12

A

2 - 5 mg found in the liver (V. LARGE STORE!!)

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50
Q

B12 is found in what kinds of food

A

meat and dairy and fruits and veggies

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51
Q

B12 is bound to what and released by what?

B12 combines with what for absorption?

A

bound to protein in food; release by HCl

intrinsic factor

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52
Q

Main Drug interactions with B12

A

H2 Blocker; PPI; Metformin

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53
Q

3 main ways to treat B12 Deficiency

A

Oral; Parenteral; Food

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54
Q

Oral B12 Treatment

A

1000 - 2000 mcg QD x 1 - 2 wks; then 1000 mcg QD for life

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55
Q

Parenteral B12 Treatment

A

1000 mcg IM or Deep SC inj QD x 1 week then weekly for 1 month then monthly for life

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56
Q

Causes of Folic Acid Deficiency Causes

A
  • Inadeqaute intake
  • Decreased Absorption
  • Inadequate utilization
  • Hyperutilizatoin
  • Drugs Altering Metabolism
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57
Q

Black Box Warning for ESAs

A

increase risk of death/serious life threatening CV events in pts with target Hb > 12 g/dL

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58
Q

2 ESAs

A

Epogen (Epoetin Alpha) and Aranesp (Darbepoetin Alpha)

59
Q

Should you give a pt ESA even if the iron is not at good levels?

A

NO

60
Q

Epogen Dosing

A

50 - 100 units/kg 3 x a week

61
Q

Aranesp Dosing

A

0.45 mcg/kg once weekly

62
Q

Folic Acid Deficiency Treatment

Oral Treatment for most patients

A

1 mg QD

63
Q

Folic Acid Deficiency Treatment

Oral Treatment for malabsorption patients

A

5 mg QD

64
Q

Folic Acid Deficiency Treatment

Oral Treatment for anticonvulsant medications

A

500 mcg QD

65
Q

SCA = Sickle Cell Anemia

Mutation ____ Chromosome that encodes for _________ on Hgb molecule

A

Mutation 11th Chromosome that encodes for Beta - 2 globulin on Hgb molecule

66
Q

What factors/conditions cause the precipitation/polymerization of the Beta-2 globulins in SCA

A
  • POOR O2
  • Low pH
  • Low temp
  • increase osmolarity
67
Q

Clinical Presentation of SCA

A
  • Arthralgia
  • Scleral Icterus
  • Enlarged liver, spleen, heart
  • Hematuria
  • Fever/pallor; weakness; anorexia; fatigue
68
Q

SCA Pts will have decreased levels of ?

A

hemoglobin

69
Q

SCA pts will have increase levels of ?

A
  • bilirubin
  • reticulocyte count
  • platelets
  • WBC count
  • sickled cells on smear
70
Q

SCA Acute Complications

A
  • Acute Chest Syndrome (ACS)
  • Sickle Cell Crises
  • Priapism
71
Q

What is Acute Chest Syndrome?

A

leading cause of death in SCA pts - pulmonary infiltrate present - can’t tell if infection or not. Will have cough/SOB/hypoxia

72
Q

What are some examples of Sickle Cell Crises

A

Vasoocclusive Pain Crises; Acute Splenic Sequestration Crises

73
Q

What is Vasoocclusive Pain Crises

A

Localized pain in the affected areas for Sickle cell patients

74
Q

How to treat vassocclusive pain crises

A

hydration and analgesia

75
Q

What is acute splenic sequestration crises

A

sudden enlargement of spleen/liver in sickle cell patients

happens bc spleen takes in a large blood volume

76
Q

What is priapism and how is it related to sickle cell

A

Sickling of sinusoids of the penis - results in prolonged/painful erection

77
Q

Chronic complications for SCA pts

A
  • pulmonary HTN
  • Bone/joint problems
  • Cholelithasis
  • CV problems
  • Depression
  • Ocular Problems
78
Q

Health Maintenance for SCA Pts

A
  • Immunizations (influenza and pneumococcal)
  • Penicillin (for kids)
  • Folic Acid
79
Q

Ways to “treat” SCA

A

Hydroxyurea
Butyrate
Pain management

80
Q

Dose for Hydroxyurea

A

10 - 15 mg/kg/day (max 35 mg/kg/day)

81
Q

Hydroxyurea is what type of agent

A

anti-neoplastic

82
Q

What does Hydroxyurea do

A

increase production of fetal Hgb

decrease need for transfusions/mortality/acute chest episodes

83
Q

Which is better - hydroxyurea or butyrate

A

hydroxyurea

84
Q

Butyrate is a naturally occurring what?

A

Fatty Acid

85
Q

Symptoms of Acute Anemia

A
  • tachycardia/tachypnea
  • orthostatic hypotension
  • light-headedness
  • angina
86
Q

Symptoms of Chronic Anemia

A
  • fatigue/weakness
  • headache/dizziness
  • dyspnea
  • Sensitivity to cold
  • pallor/loss of skin tone
  • Exacerbation of angina or CHF
87
Q

Causes of Anemia:
erythrocyte ______ - like bleeding
______ erythrocyte production
______ erythrocyte destruction

A

loss; decreased; increased

88
Q

Reasons for hypoproliferation/decreased production of erythropoeitin

A
  • low EPO

- deficiency of iron, B12, folic acid, –> decreased marrow response to erythropoeitin

89
Q

Normal Value for RDW (red cell distribution width)

A

11 - 15%

90
Q

Normal B12 levels

A

100 - 900 pg/mL

91
Q

Normal folate levels

A

2 - 20 ng/mL

92
Q

decrease in RBC, WBC, and platelets - what is that called

A

pancytopenia

93
Q

What are the drug-induced hematologic disorders

A 
Aplastic anemia
agranulocytosis
megaloblastic anemia
hemolytic anemia
thrombocytopenia
94
Q

What is Agranulocytosis

A

granulocytopenia and low granulocytes made in the bone marrow

95
Q

what is granulocytopenia

A

low neutrophil, basophil, and eosinophil count

96
Q

what is aplastic anemia

A

pancytopenia + lack of bone marrow production of WBC, RBC and platelets

97
Q

which drug-induced hematologic disorder has the highest mortality rate

A

aplastic anemia

98
Q

Symptoms of aplastic anemia

A

Anemia (Low RBCs): pallor, fatigue, weakness
Neutropenia (low WBCs): fever, chills, sx of infection
Thrombocytopenia (Low platelets): bruisability, petechiae, bleeding

99
Q

what is neutropenia

A

low WBC count

100
Q

possible DI causes of aplastic anemia

A
  • carbamzaepine
  • phenytoin
  • propylthiouracil
  • thiazide diuretics
  • sulfonamides
  • methimazole
101
Q

Aplastic Anemia:

Need ____ of the criteria to be diagnosed

A

2

102
Q 
What is the criteria to be considered of having aplastic anemia:
WBC: 
Platelets:
Hb:
Reticulocyte count:
A

WBC: < 3500 cells/mm^3
Platelets: < 55,000
Hb: < 10 g/dL
Reticulocyte count: < 30,000

103
Q

Diagnosing criteria for Agranulocytosis

Mature Myeloid cells (granulocytes/bands):

A

decrease in mature myeloid cells (granulocytes and bands) to < 500 cells/mm^3

104
Q

Who is at most risk for agranulocytosis

A

female and elderly

105
Q

Agranulocytosis is characterized by ___________ - onset occurs within _____ of drug exposure

A

neutropenia; 60 days

106
Q

Symptoms of Agranulocytosis

A

well its low WBCs…. so.. fever, malaise, weakness, chills, other Sx of infection

107
Q

Drug Classes known to cause Agranulocytosis

A
  • Antithyroid
  • Psychotropic
  • GI
  • Dermatologic
  • Abx
  • Antimalarials
  • Anticonvulsants
108
Q

what antithyroid drugs will induce agranulocytosis

A

methimazole, propylthiouracil

109
Q

what psychotropic drugs will induce agranulocytosis

A

clozapine, TCAs, cocaine/heroin

110
Q

what GI drugs drugs will induce agranulocytosis

A

sulfasalazine, H2 receptor antagonists

111
Q

what dermatologic drugs will induce agranulocytosis

A

dapsone, isotrentoin

112
Q

what Abx drugs will induce agranulocytosis

A

sulfonamides

113
Q

what antimalarial drugs will induce agranulocytosis

A

chloroquine, quinine

114
Q

what anticonvulsant drugs will induce agranulocytosis

A

phenytoin, valproic acid, carbamazepine

115
Q

Drug Induced Hemolytic Anemia will cause

(Micro,Normo,Macro) cytic anemia

A

Normocytic

116
Q

Drug Induced Hemolytic Anemia will cause an increase in what things?

A

reticulocyte count; LDH; bilirubin

117
Q

Hemolytic Anemia can be happen because of ________ or _______ factors

A

intrinsic/extrinsic

118
Q

INTRINSIC HEMOLYTIC ANEMIA:

What are some membrane defects

A

sphereocytosis

elliptocytosis

119
Q

INTRINSIC HEMOLYTIC ANEMIA:

What are some hemoglobin defects

A

Sickle cell anemia;

Thalassemia syndrome

120
Q

INTRINSIC HEMOLYTIC ANEMIA:

What are some metabolic defects

A

G6PD deficiency

other enzyme defciencies

121
Q

EXTRINSIC HEMOLYTIC ANEMIA:

What are some membrane defects

A

autoimmune hemolytic anemias

oxidants

122
Q

Extrinsic Hemolytic Anemia:

Autoimmune Hemolytics - 2 kinds

A

warm Ab mediated and Cold agglutinin disease

123
Q 
Extrinsic Hemolytic Anemia:
Autoimmune - Warm Ab mediated:
\_\_\_\_ binds to erythrocyte surface;
diagnosed by positive \_\_\_\_\_\_ test
is treated by: \_\_\_\_\_\_\_\_
A

IgG; coombs; corticosteroids or splenectomy

124
Q

Extrinsic Hemolytic Anemia:
Autoimmune - Cold Agglutinin Disease:
_____ Ab bind to erythrocyte surface

A

IgM;

125
Q

Possible drugs that could cause megaloblastic anemia (aka macrocytic anemia)

A

methotrexate; cotrimoxazole; phenytoin; phenobarbitol

126
Q

Drug Induced Thrombocytopenia:

has low _______ count

A

platelet

127
Q

Drug Induced Thrombocytopenia: Criteria to be diagnosed:
Platelet count < _________
OR
> ____ reduction from BASELINE values

A

100,000 cells/mm^3; 50%

128
Q

Most common incidence of Drug Induced Thrombocytopenia:

A

Heparin

129
Q

Non-Drug inducing causes of Drug Induced Thrombocytopenia

A

blood loss; infection; DIC

130
Q

4 main mechanisms of Drug Induced Thrombocytopenia

A
  • Direct toxicity
  • Immune reactions
  • Platelet-Reactive Abs
  • Drug- Dependent Abs
131
Q

Mechanisms of Drug Induced Thrombocytopenia:

Examples of Direct Toxicity

A
  • chemotherapy
  • organic solvents
  • pesticides
132
Q

Mechanisms of Drug Induced Thrombocytopenia:

Examples of immune reactions

A
  • quinine/quinidine
  • gold salts
  • sulfonamide
  • antibiotics
  • rifampin
  • glycoprotein (IIb/IIIa) inhibitors
  • heparin
133
Q

Mechanisms of Drug Induced Thrombocytopenia:

Examples of Platelet reactive Ab

A

procainamide

134
Q

Mechanisms of Drug Induced Thrombocytopenia:

Examples of drug-dependent Ab

A

heparin

135
Q

Normal amount of methemoglobin is _____

A

< 1%

136
Q

More methemoglobin is known as __________

A

methemoglobinemia

137
Q

Clinical Presentation for Methemoglobinemia:

A

cyanosis/hypoxia; shock; seizures; blue colored blood

138
Q

How treat methemoglobinemia

A
  • 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
Q

B12 Deficiency Sx

A

Neurologic: (peripheral neuropathy; paresthesias; depressed tendon reflexes)
Psychiatric: (irritability, mood changes, memory impairment, depression, psychosis)
Dysphagia
Glossitis
Muscle Weakness/Anorexia

140
Q

Drugs Altering Metabolism of Folic Acid

A

Folate Antagonists: Methotrexate, trimethoprim, phenytoin, phenobarbitol

Anti-metabolites: azathioprine, 6-mercaptopurine, 5-flurouracil

141
Q

How to treat an Vasoocclusive Pain Crises (Sickle cell crises)

A

Hydration and Analgesia

Adults: 3 - 4 L/day

142
Q

How to treat Acute Splenic Sequestration Crises

A
  • blood transfusion

- broad spectrum Abx

143
Q

How to treat Priaprism (a sickle cell crises)

A
  • analgesia
  • irrigation/aspiration
  • Vasoconstriction (Forces blood back into circulation - phenylephrine, epinephrine)
  • Vasodilation (relaxes smooth muscle - terbutaline, hydralazine)
144
Q

Side effects of Hydroxyurea

A

bone marrow suppression; skin ulcers

Therapeutics I - Spring 2017 (17 decks)

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