Anemias Flashcards
What level of hemoglobin is anemia in men?
< 13
What level of hemoglobin is anemia in women?
< 12
What do anemias result from?
Inadequate RBC production
Increased RBC destruction
Blood loss
What stimulate RBC production?
Erythropoietin (EPO)
Where is EPO produced?
Kidneys
What is needed for DNA and RNA?
Folic acid
Vitamin B12
What is the lifespan of a RBC?
120 days
What is transferrin?
Transports iron into cell via transferrin receptor
Delivers to bone marrow or storage (liver, spleen)
What element binds O2?
Iron
What is TIBC?
Blood capacity to bind iron with transferrin
What is ferritin?
Storage form of iron
What are the s/sx of chronic development?
Fatigue HA Malaise Exertional dyspnea Pale Angina
What are the s/sx of acute development?
Palpitations Angina SOB Lightheaded Tachycardic Hypotensive
What are Microcytic anemias?
< 80
Iron deficiency anemia (IDA)
Sickle cell
Thalassemias
What are macrocytic anemias?
> 100 B12 deficiency (pernicious anemia) Folic acid deficiency
What are normocytic anemias?
80-100 Blood loss Bone marrow failure Chronic inflammation (malignancy) Hemolysis (DI)
What are the roles of iron in microcytic anemias?
Binds O2
Cell function
What is the recommended intake of iron?
8-18 mg
Where does heme iron come from?
Beef
Fish
Poultry
Where does non-heme iron come from?
Vegetables Fruits Beans Nuts Grains
What causes microcytic anemias?
Inadequate intake
Inadequate absorption
Increased demands
What causes increased demands for iron?
Pregnancy, rapid growth in children
Blood loss
Menstruation, ulcers, trauma, blood donation, arteriovenous malformations
What are the s/sx of IDA?
Glossal pain
Pica
Pagophagia
Koilonychias
What extra labs are looked at for IDA?
Serum iron (decreased)
TIBC (Increased)
Transferrin (Decreased)
Ferritin (Decreased)
What is the treatment of IDA?
Oral supplementation
IV supplementation
What is the dose of oral iron?
150-200mg elemental iron in divided doses
How should iron be administered?
W/o food
What kind of environment should iron be administered?
Acidic
Absorbed in the duodenum
What are the AEs of iron?
GI
Black stools
What drugs decreased iron absorption?
Al Mg Ca Histamine antagonists PPIs Tetracyclines Cholestyramine
What drugs are affected by iron?
Levadopa Methyldopa Levothyroxine Penicillins FQs Tetracycline, doxycycline Mycophenolate
What is the % iron in the available oral products?
Ferrous sulfate 20%
Ferrous gluconate 12%
Ferrous Fumarate 33%
Polysaccharide iron complex 100%
When is IV iron supplementation considered?
Oral intolerance
Non-adherence
Malabsorption
Refusing transfusions
What is IV iron FDA approved for?
IDA in CKD
Iron dextran only one approved for non-CKD IDA
What is the test dose for iron dextran?
25 mg
Which IV forms of iron have a BBW for anaphylactic reaction?
Iron dextran
Iron sucrose
Which IV forms of iron have an increased risk of hypersensitivity?
Ferumoxytol
Ferric carboxymaltose
Sodium Ferric gluconate
How do we monitor oral iron therapy?
Reticulocyte increase w/in days
Hgb rises in 2-3 weeks
Hgb normal in 2 months or less
Total duration often 6-12 months
How do we monitor IV iron therapy?
Monitored w/in 1 week: ferritin, transferrin, hgb, hct
Monitored monthly: iron, ferritin
From what foods does B12 come from?
Meat Fish Poultry Dairy Fortified cereals
From what foods does Folic Acid come from?
Enriched foods Green leafy Vegetables Citrus fruits Yeast Mushrooms Dairy products Animal organs
What two vitamins are reduced in macrocytic anemias?
B12
Folic acid
What drugs reduce B12 absorption?
PPIs
H2RAs
Metformin
What drugs reduce folic acid?
AZA 6-MP 5-FU Hydroxyurea Zidovudine MTX Pentamidine Trimethoprim Triamterene Phenytoin Phenobarb Primidone
What are the initial s/sx of neurologic B12 deficiency?
Bilateral paraesthesia in extremities
Loss of perception to surrounding objects
Loss of vibratory sensation
What are the severe s/sx of neurologic B12 deficiency?
Lack of muscle control
Dementia
Psychosis
Vision loss
What are the s/sx of folic acid deficiency?
No additional s/sx beyond general s/sx of anemia
What labs are observed for macrocytic anemias?
Folic acid B12 \+/- Homocysteine \+/- Methylmalonic acid (MMA) \+/- Schillings test
How is B12 deficiency diagnosed?
Decreased retic’s
Increased MMA
Increased Homocysteine
+ Schilling’s
What is the treatment for B12 deficiency?
Oral preferred
IV
Nasal
When are higher doses of B12 considered?
Pernicious anemia or lack of ilium
When is IV B12 considered?
Non-compliant
Unable to take oral
Neurologic involvement
What drugs interact with B12?
PPIs
H2RAs
Metformin
What is the monitoring of B12 treatment?
Sx improvement w/in days Increased retic w/in 5 days Hgb rises increase 1 week Hgb normalizes w/in 2 months or less B12 1-2 months
What is the diagnosis of Folic acid deficiency?
Rule out B12
Increased MCV
Decreased folate
Increased homocysteine
What is monitoring used in folic acid therapy?
Reticulocytes increase w/in 5-7 days
Hgb rises within 2 weeks
Hgb normalizes w/in 2 months
What are the types of anemia of inflammation?
Anemia of chronic disease
Anemia of critical illness
Hemolysis
Blood loss
What causes chronic disease in normocytic anemias?
Chronic infection Inflammatory disorders CHF ESRD HIV
What causes critical illness in normocytic anemias?
Frequent blood samples Sepsis Active bleeding Immune mediated iron deficiency Increased metabolic demands
What is the pathophysiology of normocytic anemias?
Pro-inflammatory cytokines released Blunted EPO response Impaired erythroid proliferation Disturbance of iron homeostasis Shorted RBC life span
What labs are taken in normocytic anemias?
LDH Coombs Haptoglobin Fractionated bilirubin Stool guiac Folic acid B12 Iron studies
How are normocytic anemias tested for?
Colonoscopy
Esophagogastroduodenoscopy
What diseases must be ruled out?
Rule out blood loss
Rule out iron deficiency
Rule out B12 deficiency
Rule out folic acid deficiency
How are labs altered in normocytic anemia?
Decreased hgb Decreased iron TIBC decreased Ferritin increased/normal Transferrin saturation decreased Transferrin decreased/normal
What is the main treatment of normocytic anemia?
Treat the underlying cause
What is an alternative treatment to normocytic anemia?
Blood transfusions Vitamins Iron B12 Folic acid ESA?
When do we give blood transfusions?
Hgb < 7
What is considered in elderly treatment as an alteration to therapy in anemias?
Lower dose iron d/t GI effects
