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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
Infants >6-12 months that are having complementary foods and breastfeeding and/or formula ? Do you give them an iron supplement?
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
26
Toddlers >1 ? And Ida ?
Supplement not required unless diet is lacking iron rich foods
27
So now you have an infant over four months and has iron deficiency anemia. What is the prescription?
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
28
When do you repeat screening in infants and adolescence with IDA?
Repeat CBC in 4 weeks Reassess CBC again 6 months after treatment completed
29
Treatment for adolescence 12 to 18 with IDA
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
30
Length of treatment for 4months and older children and adolescents ?
2-3 months
31
Megaloblastic anaemia is caused by what deficiency
B12 Folate Liver disease Alcoholism Myelodysplasia Hemolytic anemia
32
Nonfarm approaches for B12 and folate deficiency
-Normal diet intake of B12 and folate -if neurological complications of B12 -> treat pharmacologically
33
Pharm for B12 deficiency (poor nutrition or malabsorption)
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
34
What is first line for the treatment of pernicious vitamin B 12 deficiency
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
35
If your client presents with neurological symptoms and vitamin B 12 deficiency, what is the suggested approach?
Administer parenteral B12 until all neurological symptoms and haematological abnormalities resolve
36
When is PO adequate for B12?
If dietary deficiencies is clearly the cause and patient has known neurological deficits
37
Important that B12 deficiency are NOT treated with folic acid alone because this improves haematologic perimeters, but worsens neurologic symptoms which may become permanent
38
Folic acid deficiency treatment
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
Recommended daily allowance for folate is (for men and women)
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
Causes of folic acid deficiency
-inadequate intake -decreased absorption ( celiac, Crohns, alcoholism ) -hyper utilization (pregnancy, malignancy) -growth spurts -drug induced
41
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
42
Folate prescription for pregnancy what is it?
Folic acid 1 mg daily three months prior
43
What do you watch for with vitamin B12 deficiency and that start of treatment?? Who are at risk?
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
When do neurological symptoms resolve with vitamin B12 deficiency?
Six months
45
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?
Folic acid 5 mg daily
46
When should you expect improvement to be seen with B12 deficiency ? Deficiency should resolve when?
5-7 days improvement Deficiency should resolve after 3-4 weeks of treatment 6 months for neurological manifestations improvement.
47
How long folate deficiency treatment ?
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
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
49
B12 absorption is reduced by which medication’s
MEN cause problems Metformin Ethanol Neomycin Colchicine PPI/ H2RA Colchicine Metformin Neomycin PPI Ethanol
50
Risk factors for B12 macrocytic anemia
Alcoholism chronic hemolytic anemia Malabsorption states Malaria Pregnancy Renal dialysis
51
Normocytic anemias in CKD treatment
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
When is pharm stimulation of RBC using erythropoiesis stimulating agents beneficial?
-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
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
54
ESA pharm for CKD
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
What is the risk with using ESA agents?
-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
Nonfarm for obesity
Decrease calorie (~500) Increase physical activity Behavioral / strategy
57
What are the macros that should be attained for obesity ?
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
Diet to try for obesity
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
Physical activity guidelines
- 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
When is bariatric surgery considered?
BMI 35 with comorbidities: Coronary heart disease Type II Diabetes mellitus Hypertension Diagnosed sleep apnea Gastroesophageal Reflux Disease (GERD) Or > 40 BMI
61
What are complete CI to bariatric surgery?
Severe HF Unstable CAD End stage lung disease Active cancer diagnosis/ tx Cirrhosis Crohns Drug or alcohol dependency Severely impaired intellectual capacity
62
Pharm for obesity
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
Can you have bariatric surgery and want a baby ? What are the guidelines
Women who have undergone bariatric surgery advice to delay pregnancy by one to two years
64
Risk for obesity and pregnancy
Increase risk of gestational, diabetes, hypertension, preeclampsia, birth defects, C-section, foetal macrosomnia, perinatal death, anaemia
65
Management for obesity and pregnancy
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
Breastfeeding and obesity management
-Encourage BF( obesity can affect lactation / mechanical difficulties) -exercise -can maybe cause seizure in babe if bupropion use and orlistat not recommended
67
Fat soluble vitamins
KADE
68
Water soluble vitamins
Thiamine (B1), riboflavin (B2), niacin B3, panthothenic acid (B5), biotin B7, folic acid B9, cyanocobalamin (B12), ascorbic acid (vitamin C)
69
Do you encourage vitamins or supplementation through food?
Encourage consumption of food such as fruits, vegetables, whole grains, legumes, nuts, and fish, as these may contain other important nutrients
70
Vitamin B 12 deficiencies what’s the recommendation for those that are taking drugs known to deplete B12 stores
Consume food high in vitamin B 12 – consider 1000 µg per day for persons taking drugs known to deplete B12 store
71
Vitamin D dosing for Canadian in general
800 to 1000 units per day
72
What is the adequate levels for vitamin D
Greater than 50 Consider deficiency less than 25
73
Paediatric Society dosing for vitamin D levels in pregnancy and breast-feeding
400 units daily Or 800 units daily in northern communities
74
Osteoporosis vitamin D recommendation for 19 to 50-year-olds and >50
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
Calcium dosing recommendation
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
Do you supplement for iron?
No supplementation for adults unless evaluated/needed Vegan/vegetarians that eat non-heme sources of food should have food high in vitamin C
77
Non pharm for anorexia nervosa
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
Outpatient program weight gain target for anorexia nervosa?
0.2- 0.5 kg/ week Until normal BMI is reached >18.5
79
Pharm interventions for anorexia nervosa, which agents to decrease feeling full caused by decreased intestinal motility during early stages of feeding?
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
Prokinetic agents can cause QTC prolongation what should you do before initiating the dose of domperidone?
ECG prior to and one week after the start of therapy If QTC greater than 50 msec - d/c domperidone
81
What medication can help with constipation and colonic function for anorexia nervosa?
Prucolapride 2mg daily
82
What are other vitamins for an anorexic universal that is necessary
1. Zinc gluconate 100mg daily x2 months (with meals) 2. Thiamine 100mg daily IM x 5 days
83
Other non-vitamin medication’s to help with anorexia nervosa
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
What do you monitor for anorexias while you are refeeding
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
What are labs to monitor for anorexia and bulimia?
Anorexia; Lytes Ext lytes Cr B12 Ferritin ECG Urinalysis Folate BG Bicarb Zinc Bulimia: All excess no ecg, urinalysis, folate or BG
86
Non pharm for bulimia
-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
Pharm for bulimia
Antidepressant - minimum 6 months, best 1 year Fluoxetine - supported by most evidence Also: Venlafaxine Trazodone - helpful for insomnia Do not combine two antidepressants
88
What do you monitor for bulimia?
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
Eating disorders and pregnancy what is the management?
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

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