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Thera II > Anemia / Nutrition Module 6 > Flashcards

Anemia / Nutrition Module 6 Flashcards

1
Q

microcytic anemia

Ferritin <20

What are potential causes ?

A

IDA

Blood loss

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2
Q

Microcytic anemia

Ferritin >20

What are potential causes ?

A

Anemia or chronic disease

Thallassemia

Lead overload

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3
Q

You have a patient with IDA, what do you look for ?

A

Causes of bleeding

Review meds like NSAIDS, anticoagulant, antiplatelet

Review menstruation

Regular blood donor?

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4
Q

Nonpharm approaches for iron deficiency anemia

A

1 is removing offending agent and supportive care

Dietary iron sources, especially from foods rich in heme (liver, lean red meat, seafood such as oysters, clams, tuna, salmon, sardine and shrimp)

Typically not sufficient if severe anemia

Nonheme sources has low bioavailability consists of whole grains, nuts, seeds, legumes and leafy greens

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5
Q

Pharm treatment for IDA

A

FGS

Ferrous fumarate
100mg elemental iron/ 300mg

Ferrous gluconate
35 elemental iron/ 300mg

Ferrous surface
60 mg of elemental iron/ 300 mg

Polysaccharides heme complex 150mg elemental iron/ capsule

Heme iron polypeptide 11mg of elemental iron / tablet

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6
Q

What is the goal dosing for IDA?

A

2 to 3 mg/kg/day of elemental iron or 60 to 300 mg of elemental iron per day as tolerated

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7
Q

What is the expected increase of haemoglobin with IDA on treatment

A

10g/L per week

Reticulocyte response should be evident within 1 week of beginning iron therapy

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8
Q

What should you recommend to increase absorption of nonheme iron

A

Ascorbic acid 250-500mg BID given with iron prep may enhance iron absorption

Or acidic foods like oranges should be recommended to increase absorption of non heme iron

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9
Q

What are the main side effects of oral iron salts?

A

Nausea, dyspepsia, constipation, and/or diarrhoea

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10
Q

What iron preparations should you avoid?

A

Enteric coated preparations. It’s poorly absorbed.

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11
Q

Which medication’s decrease absorption of iron/ what should you do about it?

A

NSAIDs
ASA
PPI

  • antacids
  • calcium carbonate
    -cholestyramine
    -levodopa
    -methyldopa
    -penicillamine
    -quinolones
    -sodium bicarb
    -tetracyclines
  • separate the med admins by 2 hours
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12
Q

How much elemental iron can elderly manage

A

15-50 mg for IDA

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13
Q

When do you consider parenteral iron?

A

Reserved for a patients with malabsorption who are intolerant to iron therapy or in situations where large doses of iron needed in short time

Admin is hospital or out-pt clinic

Can replace full iron stores in 1-2 infusions

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14
Q

If the haemoglobin fails to respond as anticipated, what do you consider?

A
  • ongoing blood loss
  • use of other meds that impair absorption
    -a different or concurrent cause of anemia and/or impaired erythropoietin response
    -adherence issues
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15
Q

Iron deficiency and pregnancy what is first line

A

Best to meet the needs through diet and supplement to prevent development of iron deficiency and pregnancy, but most often in pregnancy requirement is increased

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16
Q

Treatment for iron deficiency and pregnancy what is first line

A

Oral iron salts, same as nonpregnant patients.

FGS
Ferrous fumarate
100mg of elemental iron/ 300mg

ferrous gluconate
35mg of elemental iron/ 300mg

Ferrous sulfate
60mg of elemental iron/ 300mg

Polysaccharide iron complex
150mg of elemental iron/ capsule

Heme iron polypeptide
11mg of elemental iron/ tab

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17
Q

What if the pregnant person cannot tolerate the G.I. effects of iron supplement?

A

Can do intermittent iron supplementation once, twice or three times weekly or on non-consecutive days

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18
Q

What is second line for pregnancy IDA treatment

A

Parenteral iron for malabsorption or true intolerance to oral therapy

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19
Q

If there is no blood loss, what disorders do you screen for IDA?

A

Celiac
Autoimmune atrophic gastritis
Undergone gastric bypass surgery

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20
Q

When do you treat infants with iron supplementation?

A

If they are premature less than 37 weeks gestation

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21
Q

What is first line treatment for less than 37 week gestation who is breastfed?

BW >1000g ?

BW <1000g ?

A

> 1000g : 2-3mg of elemental iron/kg/day (same calculation as adults)
Max 15mg/ day

<1000g: 3-4mg elemental iron/kg/day
Max 15mg/day

higher dose in smaller infants

FS (no G)
Ferrous fumarate suspension
20mg of elemental iron/60mg =1 ml

Ferrous sulphate drops
15mg of elemental iron/ 75 mg =1 ml

Ferrous sulphate syrup
6mg of elemental iron/30mg=1 ml

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22
Q

What is first line treatment for formula fed preterm <37 gestation babies ?

A

Iron fortified formulas (all of them)

Higher dose may be considered if iron deficiency develops between 4-8 months

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23
Q

Do you need iron supplementation for breast-fed infants that are term?

A

No, in theory their iron stores should be ok!

Consider iron supplement if required at 1mg of elemental iron/kg/day starting at 4 months until appropriate iron containing foods have been introduced

You want to consider vitamin D supplement for all breast fed babies until diet provides source of vitamin D

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24
Q

Do you need iron supplementation for formula fed or breast-fed +/- term infants

A

Iron fortified formula iron fortified infant cereal should be sufficient

In those four months of age not receiving iron containing foods, consider iron supplement of 0.5 to 2 mg elemental iron/kg/day (max 15mg/day)

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25
Q

Infants >6-12 months that are having complementary foods and breastfeeding and/or formula ? Do you give them an iron supplement?

A

No.

Introduced complementary foods containing iron after six months plus iron fortified formula or infant cereal and or breast-feeding

Delay, introduction of cows milk until 9 to 12 months

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26
Q

Toddlers >1 ? And Ida ?

A

Supplement not required unless diet is lacking iron rich foods

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27
Q

So now you have an infant over four months and has iron deficiency anemia. What is the prescription?

A

Reinforced need for appropriate iron rich diet and continue iron treatment for 2 to 3 months

Mild to moderate:
3mg of elemental iron/kg/day in 1-2 divided doses

Severe anemia:
4-6 mg elemental iron/ kg/day in 2-3 divided doses

Max 60mg elemental iron/ dose

FS (no G)
Ferrous fumarate
20mg of elemental iron/ 60 mg =1 ml

Ferrous sulphate drops
15mg of elemental iron/ 75mg= 1 ml

Ferrous sulphate syrup
6mg of elemental iron/30mg =1 ml

Polysaccharide iron complex
1/4 tsp powder =15 mg elemental iron
- can stain teeth / mix with water or fruit juice (not milk) and drink through straw followed by a drink of water or juice
-stains can be removed by rubbing teeth with baking soda

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28
Q

When do you repeat screening in infants and adolescence with IDA?

A

Repeat CBC in 4 weeks

Reassess CBC again 6 months after treatment completed

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29
Q

Treatment for adolescence 12 to 18 with IDA

A

Same as adults

60-120 mg of elemental iron/ day

FGS
Ferrous fumarate
100mg of elemental iron/ 300

Ferrous gluconate
35 mg of elemental iron / 300

Ferrous sulphate
60mg of elemental iron/ 300

Polysaccharides iron complex
1/4 tsp powder= 15 mg elemental iron

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30
Q

Length of treatment for 4months and older children and adolescents ?

A

2-3 months

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31
Q

Megaloblastic anaemia is caused by what deficiency

A

B12
Folate
Liver disease
Alcoholism
Myelodysplasia
Hemolytic anemia

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32
Q

Nonfarm approaches for B12 and folate deficiency

A

-Normal diet intake of B12 and folate
-if neurological complications of B12 -> treat pharmacologically

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33
Q

Pharm for B12 deficiency (poor nutrition or malabsorption)

A

Treat etiology of vitamin B12 deficiency followed by:

Cyanocobalamin or methylcobalamin
100-200 mcq daily

Doses exceeding >100mcq / day exceeds binding capacity but excess B12 is not toxic and is readily excreted by kidneys
- > tendency to give more if neuro deficits

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34
Q

What is first line for the treatment of pernicious vitamin B 12 deficiency

A

Oral cyanocolabalim or methylcobalamin
1000-2000mcg/ day

Or

IV
1000mcq daily x1-2 weeks then 1000mcq weekly until Hgb normal and then 1000mcq monthly to maintain erythrocyte count

Duration: lifelong

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35
Q

If your client presents with neurological symptoms and vitamin B 12 deficiency, what is the suggested approach?

A

Administer parenteral B12 until all neurological symptoms and haematological abnormalities resolve

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36
Q

When is PO adequate for B12?

A

If dietary deficiencies is clearly the cause and patient has known neurological deficits

37
Q

Important that B12 deficiency are NOT treated with folic acid alone because this improves haematologic perimeters, but worsens neurologic symptoms which may become permanent

A
38
Q

Folic acid deficiency treatment

A

Prior to starting folate therapy, it is important to exclude anemia secondary to vitamin B12 deficiency. Since the anemia, but not the neurological deficits of vitamin B12 deficiency will be reversed

Folate does not treat neurological manifestation of B12 **

RO vitamin B12 deficiency first

Adults: 1mg daily of folic acid x until it’s corrected for approx 4 months

39
Q

Recommended daily allowance for folate is (for men and women)

A

Recommend daily allowance for folate is 400mcq daily for male and females

(Folate is abundant in fresh green leady vegetables, fruits (citrus), yeast and animal protein // prolonged cooking in water destroys the percentage of folate

40
Q

Causes of folic acid deficiency

A

-inadequate intake
-decreased absorption ( celiac, Crohns, alcoholism )
-hyper utilization (pregnancy, malignancy)
-growth spurts
-drug induced

41
Q

Folate stores are relatively small compared to vitamin B 12 and subsequent megaloblastic anaemia may result within 3 to 4 weeks of decreased folate intake

A
42
Q

Folate prescription for pregnancy what is it?

A

Folic acid 1 mg daily three months prior

43
Q

What do you watch for with vitamin B12 deficiency and that start of treatment?? Who are at risk?

A

Rapid production of new hematopoetic cells lead to potentially a dramatic shift of potassium which can cause profound hypokalaemia

Serum potassium should be monitored and managed appropriately if hypokalemia develops

At risk patients (diuretic therapy for HF)
-obtain baseline K+ , monitor in first few days of therapy and adjust accordinglyz

44
Q

When do neurological symptoms resolve with vitamin B12 deficiency?

A

Six months

45
Q

How many milligrams of folic acid do you give to high-risk patients or first-degree relatives with neural tube defects or those that are on valproic acid?

A

Folic acid 5 mg daily

46
Q

When should you expect improvement to be seen with B12 deficiency ? Deficiency should resolve when?

A

5-7 days improvement

Deficiency should resolve after 3-4 weeks of treatment

6 months for neurological manifestations improvement.

47
Q

How long folate deficiency treatment ?

A

Treatment is continued until the deficiency is corrected

Therapy must be continued for approx 4 months in order for all folate deficient RBC be cleared

Maintenance therapy is rarely needed if poor diet is corrected or if celiac diet is effectively treated with gluten free diet

48
Q

It takes approximately 2 to 5 years to deplete B12 stores

Time release preparations should be avoided

B12 is best absorbed on an empty stomach

A
49
Q

B12 absorption is reduced by which medication’s

A

MEN cause problems

Metformin
Ethanol
Neomycin

Colchicine
PPI/ H2RA

Colchicine
Metformin
Neomycin
PPI
Ethanol

50
Q

Risk factors for B12 macrocytic anemia

A

Alcoholism
chronic hemolytic anemia
Malabsorption states
Malaria
Pregnancy
Renal dialysis

51
Q

Normocytic anemias in CKD treatment

A

As a result of inadequate production of erythropoietin by the kidneys

Treat immediate correction so red blood cells, if Hgb <80

If immediate correction is not required. Factors to consider iron and or ESAa are:
Hgb <100
Ferritin >100
Symptoms
Blood pressure control

Treatment in that case would be oral or IV iron or ESA



52
Q

When is pharm stimulation of RBC using erythropoiesis stimulating agents beneficial?

A

-anemia secondary to chronic kidney disease
-chemo induced anemia in pt with nonhemalogic cancers
-symptomatic anemia in pt with low risk myelodysplastic syndrome
-anemia due to antiretrovirals with HIV infections
-anemia in pt with chronic hepatitis C receiving ribavarin

53
Q

In order to qualify for ESA
– haemoglobin less than 100
– baseline erythropoeitin levels should be approximately 330 and healthy.
– important to ensure adequate iron supply conjunction with erythropoietin in use

A
54
Q

ESA pharm for CKD

A

Epoitin Alfa IV or SC 50-100 units/kg 3 times daily

Or

Darbapoietin 0.45mcq/kg IV weekly

You continue until HGB target <120
Increase dose by 25% if no response Monthly
Decrease dose by 25% if approaching 120

55
Q

What is the risk with using ESA agents?

A

-Increase risk of cardiovascular events
-Haemoglobin target should be less than 120 depending on indication.
-possibility of pure red cell aplasia
-rapid/ excessive correction may provoke HTN and seizures and thrombotic complications
- monitor BP 3 times weekly and after each dose thereafter

56
Q

Nonfarm for obesity

A

Decrease calorie (~500)
Increase physical activity
Behavioral / strategy

57
Q

What are the macros that should be attained for obesity ?

A

CHO greater or equal to 100/ day

Protein > 1g/kg/day

Fat should only be 30-35% of total calories consumed and less than 10% from trans and saturated fats

58
Q

Diet to try for obesity

A

Low carb, low fat or Mediterranean

Programs like Jenny craving or WW will help

Regular 3meals 3 snacks

Discouraged prolonged fasting and skipping meals

59
Q

Physical activity guidelines

A
  • assess treadmill test for or with elevated CVS risk
  • > 30 min of doing continuous or intermittent x5 days / week

-walking 10 K steps

Resistance training

Goal to burn 100-130kcal/day
700-1000kcal/ week

60
Q

When is bariatric surgery considered?

A

BMI 35 with comorbidities:
Coronary heart disease
Type II Diabetes mellitus
Hypertension
Diagnosed sleep apnea
Gastroesophageal Reflux Disease (GERD)

Or > 40 BMI

61
Q

What are complete CI to bariatric surgery?

A

Severe HF
Unstable CAD
End stage lung disease
Active cancer diagnosis/ tx
Cirrhosis
Crohns
Drug or alcohol dependency
Severely impaired intellectual capacity

62
Q

Pharm for obesity

A

Lifestyle and drug therapy is superior to Lifestyle alone

Discontinue of drugs may cause regain, should be continued for as long as necessary

1) appetite suppressants

Bupropion 300-400mg for 24 weeks (usually plateaus at 24 weeks)
AE= dry mouth, constipation, agitation, insomnia, seizures (rare)

Bupropion/ naltrexone (contrave)
-for BMI >30 or >27 with 1 comorbidity (DM, HTN, dyslipidemia)
AE= nausea, vomiting, constipation, headache, dizziness, insomnia, dry mouth
^* minimize / avoid alcohol consumption**

** avoid consumption with a high fat meal **

2) incretins
Liraglutide SC (Saxenda)
-slows gastric emptying and reduces appetite
AE= nausea, vomiting, constipation and diarrhea

CI = pregnancy, breastfeeding, personal or family history of thyroid carcinoma or medullary endocrine neoplasia syndrome type 2

Discontinue after 12 weeks if weight loss <5%

3) lipase inhibitors
orlistat 120 mg daily TID with meals containing fat

AE= oily spotting, flatus with discharge, fecal urgency

  • pancreatic and gastric lipase inhibitor that decrease dietary fat absorption by 30% resulting in a calorie reduction of around 180 cal a day on a diet containing 60 g of fat.
    – less effective in patients on a low-fat diet
    should take multivitamin >2 hours before or after orlistat or at bedtime
63
Q

Can you have bariatric surgery and want a baby ? What are the guidelines

A

Women who have undergone bariatric surgery advice to delay pregnancy by one to two years

64
Q

Risk for obesity and pregnancy

A

Increase risk of gestational, diabetes, hypertension, preeclampsia, birth defects, C-section, foetal macrosomnia, perinatal death, anaemia

65
Q

Management for obesity and pregnancy

A

Form of awaking targets no more than 11 to 20 pounds during pregnancy.
– healthy eating and staying active line.
–orlistat not recommended
-bupropion information is conflicting

66
Q

Breastfeeding and obesity management

A

-Encourage BF( obesity can affect lactation / mechanical difficulties)
-exercise
-can maybe cause seizure in babe if bupropion use and orlistat not recommended

67
Q

Fat soluble vitamins

A

KADE

68
Q

Water soluble vitamins

A

Thiamine (B1), riboflavin (B2), niacin B3, panthothenic acid (B5), biotin B7, folic acid B9, cyanocobalamin (B12), ascorbic acid (vitamin C)

69
Q

Do you encourage vitamins or supplementation through food?

A

Encourage consumption of food such as fruits, vegetables, whole grains, legumes, nuts, and fish, as these may contain other important nutrients

70
Q

Vitamin B 12 deficiencies what’s the recommendation for those that are taking drugs known to deplete B12 stores

A

Consume food high in vitamin B 12
– consider 1000 µg per day for persons taking drugs known to deplete B12 store

71
Q

Vitamin D dosing for Canadian in general

A

800 to 1000 units per day

72
Q

What is the adequate levels for vitamin D

A

Greater than 50
Consider deficiency less than 25

73
Q

Paediatric Society dosing for vitamin D levels in pregnancy and breast-feeding

A

400 units daily

Or

800 units daily in northern communities

74
Q

Osteoporosis vitamin D recommendation for 19 to 50-year-olds and >50

A

1000 units per day all year (19-50)

800-2000 units / day all year (>50)

Healthy adults between 19-50 years of age, including pregnant or breast feeding women, require 400 – 1,000 IU daily. Those over 50 or those younger adults at high risk (with osteoporosis, multiple fractures, or conditions affecting vitamin D absorption) should receive 800 – 2,000 IU daily.

75
Q

Calcium dosing recommendation

A

Total intake (from diet and supplements):
<50 y: 1000 mg daily PO (divided to maximize absorption)
>50 y: 1200 mg daily PO (divided to maximize absorption)

76
Q

Do you supplement for iron?

A

No supplementation for adults unless evaluated/needed

Vegan/vegetarians that eat non-heme sources of food should have food high in vitamin C

77
Q

Non pharm for anorexia nervosa

A

Body fat must be normalized for psychological treatment to be effective and restore normal psychological and physical function

  1. develop and maintain a rapport
  2. Consider need and roll of family intervention and treatment.
  3. Step wise nutritional goals by registered dietitian.
  4. Recommend boost, ensure to achieve weight gain, if not possible with food.
  5. Feeding necessary if PO fails.
  6. Exercise should be limited a supervised graded exercise plan like non-movement yoga can decreasing anxiety while not interfering with weight gain.
  7. Warming can Improve recovery.
  8. Monitor, binge purge, and set goals for normalization (gradual tapering of laxatives)
  9. One’s body fight is normalized psychotherapy can begin.
78
Q

Outpatient program weight gain target for anorexia nervosa?

A

0.2- 0.5 kg/ week
Until normal BMI is reached >18.5

79
Q

Pharm interventions for anorexia nervosa, which agents to decrease feeling full caused by decreased intestinal motility during early stages of feeding?

A
  1. Domperidone 10-20mg q30min before meals
  2. Metoclopramide 5-20mg Q30min before meals (helps with nausea)

Can add erythromycin 125mcq BID or Azithromycin 250mg daily if above ineffective

80
Q

Prokinetic agents can cause QTC prolongation what should you do before initiating the dose of domperidone?

A

ECG prior to and one week after the start of therapy

If QTC greater than 50 msec - d/c domperidone

81
Q

What medication can help with constipation and colonic function for anorexia nervosa?

A

Prucolapride 2mg daily

82
Q

What are other vitamins for an anorexic universal that is necessary

A
  1. Zinc gluconate 100mg daily x2 months (with meals)
  2. Thiamine 100mg daily IM x 5 days
83
Q

Other non-vitamin medication’s to help with anorexia nervosa

A
  1. Olanzapine 2.5-5mg x 3-4 months until no longer needed
    - decreases delusional thinking and anorexia rumination
  2. Cyproheptadine
    - causes modest weight gain
  3. Benzo (clonazepam) 0.25-0.5mg BID
    Can be used to treat severe anxiety
  4. Seroquel 12.5-50mg before meals and HS
  5. Fluoxetine
    - only with coexisting depression, purge behaviors or OCD
84
Q

What do you monitor for anorexias while you are refeeding

A

Hypoglycaemic can occur when patient starts to eat-> monitor blood sugar 2 hours after meals for first 1-2 days if confusion occurs

Treat chronic lax abuse by slow taper

Refeeding syndrome = hypophosphatemia

Pregnancy can still occur when amenorrheic

If SI, worsening depression - refer to eating disorder specialist

85
Q

What are labs to monitor for anorexia and bulimia?

A

Anorexia;
Lytes
Ext lytes
Cr
B12
Ferritin
ECG
Urinalysis
Folate
BG
Bicarb
Zinc

Bulimia:
All excess no ecg, urinalysis, folate or BG

86
Q

Non pharm for bulimia

A

-assess for SI and depression and treat
– CBT and interpersonal therapy, helpful and addressing emotional issues and reinforcing normal eating behaviors.
– psychoed groups addressing nutritional and psychological issues can enhance individual therapy
-internet CBT also helpful

87
Q

Pharm for bulimia

A

Antidepressant
- minimum 6 months, best 1 year

Fluoxetine - supported by most evidence

Also:
Venlafaxine
Trazodone - helpful for insomnia

Do not combine two antidepressants

88
Q

What do you monitor for bulimia?

A

Purging can prevent drug absorption as patient about timing of purging behaviours in dose admin

Temporary worsening of binge purge occurs during therapy = not indicative of worsening condition

If med effective continue for 6 to 12 month before considering tapering

Treatment of psycho morbidities essential for recovery

89
Q

Eating disorders and pregnancy what is the management?

A

Eating disorder symptoms usually improved during pregnancy

-Assess for depression/SI
-Reassess all meds and risk of pregnancy, discontinue or change drug therapy as needed
non pharm is always first line
-labs must be monitored
-RD should be referred

Thera II (12 decks)

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