Anemias

Question 1

Acute Anemia SX

Answer 1

• Palpitations
• Angina
• Orthostatic hypotension
• Shortness of breath

SOAP

Question 2

Chronic Anemia SX

Answer 2

• Fatigue
• Dizziness

With exertion/exercise:
* Shortness of breath
* Headache
* Arrhythmias
* Difficulty concentrating
* Pale/cold skin

Question 2

Objective Signs of Anemia

Answer 2

• Tachycardia, angina pectoris, high output CHF
• Pale
• Decrease mental acuity
• Increase intensity of cardiac valvular murmurs
• Vit B12 def: diminished vibratory sense or gait due to neurotoxicity

Question 3

IDA LABS

Answer 3

• ↓ MCV (norm is 82-98), ↓ MCH, ↓ MCHC
• ↓ Serum iron
• ↓ Serum ferritin (earliest seen)
• ↑ TIBC (norm 250-450)**
• ↓ Transferrin saturation index

everything LOW, except high TIBC

mainly due to blood loss

Question 4

Unique Effects of IDA

Answer 4

• Glossitis (smooth, waxy tongue)
• Angular cheilitis (ulcerations on corner of mouth)
• Koilonychia (spoon shaped nails)
• Blue sclera
• Pica

IDA and PG call a KAB

Question 5

Treatment of IDA

Answer 5

1. Oral iron: tx of choice
2. IV iron: $$$, becoming more common
3. Blood transfusions

Question 6

Oral Iron

Answer 6

• Empty stomach
• 6 mo (or until Hgb and iron studies are normal)
• Many drug/food interactions

Most common are ferrous salts, all once daily or every other day
- Sulfate (FerInSol): 325, GOLD standard
- Gluconate (Ferate): 300
- Fumarate (Ferretts): 300

Question 7

Oral Iron Monitoring (Response, AE, DI)

Answer 7

• Reticulocyte count up by day 14, Hgb up in 3-4 wks
• Monitor serum ferritin monthly

AE: GI
- constipation, diarrhea, dark stools, epigastric pain, nausea

DI:
- Decrease abs: Tetracycline, cholestyramine, antacids, PPIs/H2RAs
- Increase abs: ascorbic acid

Question 7

Separate Iron and Levodopa/Methyldopa

Answer 7

By >= 2 hrs

Question 8

Separate Iron and Levothyroxine

Answer 8

By >= 4 hrs

Question 9

Separate Iron and Moxifloxacin

Answer 9

Give moxi 4 hr before, 8 hr after

Question 10

Separate Iron and Ciprofloxacin

Answer 10

Give cipro 2 hr before, 6 hr after

Question 11

Separate Iron and Levofloxacin

Answer 11

Give levofloxacin 2 hr before, 2 hr after

Question 12

Separate Iron and Mycophenolate

Answer 12

By >= 4 hrs

Question 13

Separate Iron and Tetracyclines

Answer 13

• Avoid if possible
• Give iron 2 hr before, 4 hr after tetra

Question 14

Separate Iron and Food

Answer 14

Give iron 1 hr before or 2 hr after meal

Question 15

Iron and H2RAs/PPIs

Answer 15

Monitor for reduced efficacy of iron

Question 16

Separate Iron and Antacids

Answer 16

Give iron 2 hours before or 4 hours after antacids

Question 17

Iron and Dietary considerations

Answer 17

• Avoid concurrent tea, coffee
• Calcium and fiber decrease abs.
• Iron with meat protein can increase abs.

Question 18

Parenteral Iron Indications

Answer 18

• Inadequate response to oral iron
• Non-compliance
• Malabsorption syndromes
• Continued blood loss
• Dialysis patients
• Most products dosed to 1000 mg

Question 19

Parenteral Iron Products and Hypersensitivity

Answer 19

• Ferric Gluconate: 125 mg per session
• Iron Sucrose: 100 mg per HD, or 200 mg times 5 over 14 days for non-HD

Question 20

Parenteral Iron Products and Anaphylaxis

Answer 20

• Ferumoxytol: 510 mg then another 510 3-8 days later
• Iron dextran: 100 mg (max)

Question 21

Vitamin B12 Deficiency Anemia

Answer 21

• MCV OVER 100
• Most common cause is decreased absorption
• SX: general anemia sx, PLUS neuropsychiatric sx and gastric mucosal atrophy/glossitis

Question 22

Vitamin B12 Deficiency Anemia Labs

Answer 22

• ↓ Serum B12 levels (< 100) (Norm: 211)
• ↓ Reticulocyte count
• ↑ MCV (normal is 82-98)
• ↑ methylmalonic acid (0.4+) & homocysteine levels

homo: norm is <15 so 15+ is high

Question 23

**Vitamin B12 TX**

Answer 23

With SX - 1000 mcg IM 1-3x week OR - 1000 mcg daily for 1 week then weekly for 4 weeks and maintenance of 1000 mcg monthly IM or 1000 mcg PO/SL daily W/O SX - 1000 mcg IM weekly for 4 weeks followed by cyanocobalamin monthly OR - 1000 or 2000 mcg PO/SL daily IRR: IM REV: oral

Question 24

**Folic Acid Deficiency Labs**

Answer 24

- ↓ Serum folate (< 3.1) - ↓ Reticulocyte count - ↑ MCV (norm is 82-98) - ↑ serum homocysteine levels only (15+) difference for B12: folate down instead of B12 and ONLY homo up

Question 25

**Folic Acid Deficiency SX**

Answer 25

NO neurological sx, similar to B12/anemia sx

Question 26

**Folic Acid Deficiency TX**

Answer 26

Oral folic acid 1-5 mg daily for >= 4 mo

Question 27

**Prophylactic folic acid should be used in**

Answer 27

- Pregnant and lactating - Patients with ↑ erythropoiesis due to: * Chronic hemolysis * Myeloproliferative syndromes

Question 28

Anemia of Chronic Disease (ACD) Labs

Answer 28

- ↓ Hgb < 10 - ↓ Serum iron (hypoferremia) - Normal or ↑ serum ferritin - ↓ TIBC (difference) < 250 - Normal iron stores, defect is release

Question 29

ACD Signs/SX

Answer 29

- Fatigue, SOB, edema, mental - Generally ELDERLY with many medical problems - Cardiac pts can tip over due to increased cardiac demands

Question 30

ACD TX

Answer 30

- TX underlying disease - Blood transfusions - Erythropoietic agents (not FDA indication)

Question 31

Side effects of erythropoietic agents

Answer 31

* Hypertension * Headache, fevers, hypersensitivity * ↑ risk of seizure * ↑ risk of thromboembolic events

Question 32

ACD Evaluation of Clinical Outcomes

Answer 32

- Maintain Hgb between 10-11 - Assess QOL - Monitor BP

Question 33

Hemolytic Anemias: G6PD Clinical Presentation

Answer 33

* Dark urine (↑ hemoglobinuria) * ↓ Hgb * ↑ Indirect bilirubin * ↑ Reticulocyte count * ⊕ Heinz bodies (bite cells) - Jaundice, pallor, ↑ RR, splenomegaly - Weakness, abd/back pain, fever, chills, tachy

Question 34

Medications/Foods to Avoid with Mod/Sever G6PD Deficiency

Answer 34

- DAPSONE - Chlorpropamide - Dabrafenib - Fava beans, henna, naphthalene, phenyl hydrazine

Question 35

G6PD Treatment

Answer 35

- Avoid or D/C offending drug - Transfuse RBCs - Hydration and urinary output maintenance