Chapter 35 - Anemia Flashcards
1
Q
what 2 lab tests are low in anemia
A
low hgb & hct
2
Q
Hgb is …
it is found in …
its main purpose is to …
A
- an iron-rich protein
- found in red blood cells (RBCs)
- carry oxygen from the lungs to the tissues.
3
Q
RBC life cycle:
- RBC are formed in:
- An immature RBC is known as:
- When do RBC get released into circulation?
- How long do they need to mature
- What is the lifespan of a mature RBC?
- How are erythrocytes removed from circulation?
A
- RBCs are formed in the bone marrow,
- where they take up Hgb and iron before being released into the circulation as immature RBCs, known as reticulocytes.
- After 1 - 2 days, the reticulocytes mature into erythrocytes, which have a lifespan of about 120 days.
- Erythrocytes are removed from circulation by macrophages, mainly in the spleen.
4
Q
Anemia can occur due to:
A
- impaired RBC production
- increased RBC destruction (hemolysis)
- blood loss
5
Q
Diagnosis of the underlying cause is essential.
Anemia can result from:
A
- nutritional deficiencies (e.g., iron, folate, vitamin B12)
- or it can occur as a complication of another medical disorder, such as chronic kidney disease (CKD) or a malignancy.
6
Q
Sx of anemia in:
1) Mild or early stage of anemia
2) Severe/ Prolonged
3) Sudden blood loss:
4) Iron Def anemia
5) Vit B12 def
A
1) Mild or early stage anemia:
- Asymptomatic.
2) Severe and/or prolonged:
1- Fatigue
2- Weakness
3- Dizziness
4- Exercise intolerance,
5- Shortness of breath
6- headache
7- anorexia and/or
8- pallor
3) Sudden blood loss:
Acute symptoms, such as
- chest pain
- fainting
- palpitations and
- tachycardia.
4) Iron deficiency anemia:
- Glossitis (an inflamed, sore tongue)
- Koilonychias (thin, concave, spoon-shaped nails)
- Pica (craving and eating non-foods: chalk/ clay)
5) Vitamin Bl2 (cobalamin) deficiency
Neurologic symptoms, including
- Peripheral neuropathies
- Visual disturbances and/or
- Psychiatric symptoms
7
Q
Chronic anemia could lead to HF, How?
2 main things:
A
1) In chronic anemia, the heart tries to compensate for low oxygen levels by pumping faster (tachycardia).
This can increase the mass of the ventricular wall (hypertrophy) and lead to heart failure .
8
Q
What is the likely cause of Microcytic?
MCV?
A
Likely cause:
iron deficiency
MCV < 80 fl
9
Q
Likely Causes of Normocytic anemia?
MCV value?
A
1) MCV 80-100 fl I
2) Likely causes:
1- Acute blood loss
2- Malignancy
3- CKD
4- Bone marrow failure (aplastic anemia),
5- hemolysis
10
Q
Likely causes of Macrocytic
MCV value?
A
Likely causes:
- Vitamin B 12 deficiency
- Folate deficiency
MCV > 100fL
11
Q
What are the 4 Iron studies that further evaluates microcytic anemia:
A
1) serum iron: bound to transferrin (Transferrin binds and transfers iron to blood serum)
2) serum ferritin: iron stores (Ferritin stores iron in tissue)
3) transferrin saturation: amount of transferrin binding sites occupied by iron
4) total iron binding capacity: amount of transferrin binding sites available to bind iron or unbound sites
12
Q
What tests are used to evaluate macrocytic anemia?
A
Vitamin Bl2 and folate levels
Vitamin Bl2 is required for enzyme reactions involving:
1) methylmalonic acid and
2) homocysteine,
making these tests potentially useful in confirming a diagnosis. (increased)
13
Q
Reticulocyte count:
1) What does the reticulocyte count measures?
2) It is low in:
3) It is high in:
A
- A reticulocyte count measures production of RBCs.
- The reticulocyte count is low in untreated anemia due to iron, folate or Bl2 deficiency and with bone marrow suppression.
- The reticulocyte count is high in acute blood loss or hemolysis.
14
Q
What are ALL the common lab tests in anemia:
1)
a)
b)
c)
d)
2)
a)
b)
c)
d)
3)
a)
b)
c)
d)
4)
a)
b)
c)
d)
A
Relevant CBC Components:
- Hemoglobin (Hgb)
- Hematocrit (Hct)
- Red Blood Cell (RBC)
- Reticulocyte Count
RBC lndices
- Mean Corpuscular Volume (MCV)
- Mean Corpuscular Hemoglobin (MCH)
- Mean Corpuscular Hemoglobin Concentration (MCHC)
- Red Blood Cell Distribution Width (RDW)
Iron Studies
- Serum Iron
- Serum Ferritin
- Total Iron Binding Capacity (TIBC)
- Transferrin Saturation (TSAT)
Additional Tests
- Serum Folate
- Serum Vitamin B12
- Methylmalonic Acid
- Homocysteine
15
Q
heme iron and non heme iron:
1) Heme iron is found in: (what food?)
2) Non heme iron is found in:
3) Is heme or non-heme iron more readily absorbed? And why?
4) What foods can increase the absorption of …?
5) What food can decrease its absorption?
6) Type of diet that makes person at risk of decreased absorption of iron? Counseling?
A
- heme iron (found in meat and seafood)
- non-heme iron (found in nuts, beans, vegetables and fortified grains, such as cereals).
- Heme iron is more readily absorbed than non-heme iron, which is affected by gastric pH and other foods being consumed.
- Meat, seafood, poultry and ascorbic acid increase the absorption of non-heme iron,
- while foods that contain phytate and polyphenols (e.g., grains, beans, cereals and legumes) can decrease non-heme iron absorption.
- This is particularly important for patients who follow a vegetarian diet, since they are more likely to consume foods with a less absorbable form of iron along with foods that decrease the absorption of iron.
Vegetarians may require iron supplementation, even if dietary intake of iron seems adequate.
16
Q
What are the 4 main causes of iron deficiency anemia?
A
1) Inadequate Dietary Intake
- Iron-poor diets (e.g.,vegetarian, vegan)
- Malnutrition
- Disease-related (e.g.,dementia, psychosis)
2) Blood Loss:
- Acute (e.g., GI hemorrhage)
- Chronic (e.g., heavy menses, blood donations, peptic ulcer disease, inflammatory bowel disease)
- Drug-induced (e.g., NSAIDs, steroids, anti-platelets, anticoagulants)
Decreased Iron Absorption
- High gastric pH (e.g., PPls) (more basic)
- GI diseases (e.g.,celiac disease, inflammatory bowel disease, gastrectomy, gastric bypass)
Increased Iron Requirements
- Pregnancy
- Lactation
- Infants
- Rapid growth (e.g., adolescence)
17
Q
The CDC recommends low-dose iron supplementation (—) for all pregnant women,
When should it be given?
A
30 mg/day
beginning at the first prenatal visit
18
Q
What are the LABORATORY FINDINGS to asses iron def anemia and are they low or high?
A
1- Dec Hgb
2- MCV < 80 fl
3- Dec RBC production (low reticulocyte count)
4- Dec serum iron
5- Dec ferritin
6- Dec TSAT
7- Inc TIBC
19
Q
What is the treatment of iron def anemia?
What is the recommended dose?
Are all formulations equally good?
Should you take it on an empty stomach or with food?
What should you avoid with it? (DDI)
What formulations cause less GI irritation? Are they recommended?
A
ORAL IRON THERAPY
- Recommended dose: 100-200 mg elemental iron per day
(One oral formulation is not better than another if dosed appropriately based on elemental iron needs.)
- Take iron on an empty stomach
(1 hr before or 2 hrs after meals; can be taken with food if GI upset occurs.) - Avoid H2RAs and PPls; separate from antacids
- Sustained-release or enteric-coated formulations cause less GI irritation but are not recommended due to poor absorption
20
Q
What are the Goals of ttmt of iron def anemia?
After Anemia has resolved, should you stop ttmt?
A
- Inc in serum Hgb by 1 g/dl every 2-3 weeks;
- Continue treatment for 3-6 months after anemia has resolved until iron stores return to normal
21
Q
% ELEMENTAL IRON IN ORAL PRODUCTS
Ferrous gluconate
A
12%
(Person 1 and 2 are glued together –12)
22
Q
Ferrous sulfate % elemental iron
A
20 %
(My fate is in person 2’s hands)
23
Q
Ferrous sulfate, dried
A
30 %
(my fate is dried so sar in God’s (trinity) hands)
24
Q
Ferrous fumarate
A
33 %
fumarate = furious so badde bas GOD 3 w 3
25
What iron supplements have 100% elemental iron in them?
1) Carbonyl iron (A car gives 100%)
2) Polysaccharide iron complex (Poly w complex of iron so 100%)
3) Ferric maltol (Rony gave his 100% in Malta)
26
most IDA you treat with:
oral iron supplements
27
In what specific condition do you use parenteral iron supplements?
in dialysis
28
which oral iron supplement is most commonly prescribes and least expensive
Ferrous sulfate
(fate in person 2's hands is least expensive)
29
Ferrous sulfate brand/ dose/ Elemental iron %
- FeroSul
- Fer-In-Sol
325 mg (65 mg elemental iron) PO daily to TID
20 % elemental iron
(instead of 365 --> 325)
30
Ferrous sulfate, dried
brand/ dose/ %elemental iron
- Slow Fe
- Slow Iron
ER tablet
160 mg (50 mg elemental iron) PO daily to TID
30 % elemental iron
31
Ferrous fumarate
brand/ dose/ % elemental iron
- Ferretts (retts)
- Ferrimin 150 (min?)
- Hemocyte
324 mg (106 mg elemental Iron) PO daily to TID
33%
32
Ferrous gluconate
brand/dose/%elemental iron
Ferate
324 mg (38 mg elemental iron) PO to TID
(dose is like fumurate and it also took the rate for brand)
12 % elemental iron
33
Carbonyl iron
- FerraPlus 90
- Ferralet 90
- Iron Chews
90 mg (90 mg elemental iron) PO daily or as directed
100 % elemental iron
34
Polysaccharide iron complex
- Ferrex 150 (complex --> rex)
150 mg (150 mg elemental iron) PO daily
100 % elemental iron
35
Ferric maltol
Accrufer (malta has an ecru whitish color)
30 mg (30 mg elemental iron) PO BID (rony stayed there for 3 months)
100% elemental iron
36
BBW for iron supp:
1) ... mainly in ages...
- Accidental overdose of iron-containing products is a leading cause of fatal poisoning in children under 6;
- keep iron out of the reach of children;
- in the case of an accidental overdose, go to the emergency department or call a poison control center immediately (even if asymptomatic)
37
CI for iron supp
- Hemochromatosis (build up too much iron in the skin, heart, liver, pancreas, pituitary gland, and joints)
- Hemolytic anemia (a disorder in which red blood cells are destroyed faster than they can be made)
- Hemosiderosis (an overload of iron in your organs or tissues. About 70 percent of the iron in your body is found in your red blood cells. When your red blood cells die, they release that iron, which becomes hemosiderin.)
38
SE of iron supp
- Constipation (dose-related)
- Dark and tarry stools
- Nausea
- Stomach upset
39
Lab monitoring with iron supp
- Hgb
- Iron studies
- RBC indices
- Reticulocyte count
40
what to take to prevent iron induced constipation
A stool softener such as DOCUSATE is often recommended to prevent iron induced constipation
41
antidote for iron
Deferoxamine (Desferal)
42
Drugs that dec iron absorption by inc gastric pH.
- Antacids
- H2RAs
- PPIs
43
By how long should you space iron and antacids
Patients should take iron 2 hours before or 4 hours after taking antacids.
44
By how long should you space iron and H2RAs or PPIs?
H2RAs and PPis raise gastric pH for up to 24 hours; separating the administration of these agents from iron supplements does not improve absorption.
45
Can iron dec absorption of other drugs? How?
Yes
Iron is a polyvalent cation that can dec the absorption of other drugs by binding with them in the GI tract to form nonabsorbable complexes.
(Chelation)
46
What antibiotics interact with iron? How should you counsel?
Quinolone and tetracycline antibiotics (less of a concern with doxycycline and minocycline):
take iron two hours before or 4 - 8 hours after these agents
47
Bisphosphonate and iron; how should you counsel?
Bisphosphonates:
Take iron
- 60 minutes after oral ibandronate or
- 30 minutes after alendronate/risedronate.
48
other drugs that iron dec their absorption
- Cefdinir
- dolutegravir
- levothyroxine
- levodopa
- methyldopa
--> separate from iron by 2 - 4 hours.
49
What can you give to enhance absorption of iron?
Vitamin C inc the absorption of iron (by providing an acidic environment).
Giving iron with ascorbic acid (vitamin C 200 mg) may enhance the absorption to a minimal extent.
50
Parenteral iron benefits:
- faster
- less GI issues
- can give total required dose of iron in 1 infusion
51
Parenteral iron disadvantages:
- cost
- Severe adverse events
- restricted to few patients
52
5 Indications of parenteral iron:
1) CKD on hemodialysis (most common use of IV iron).
2) CKD receiving erythropoiesis-stimulating agents (ESAs).
3) Unable to tolerate oral iron or failure of oral therapy (e.g., IBO, celiac disease, certain gastric bypass procedures, achlorhydria and bacterial overgrowth syndromes such as H. pylori).
4) Losing iron too fast for oral replacement.
5) As an alternative when blood transfusions are not accepted by the patient (e.g., for religious reasons).
53
Iron sucrose brand/ how is it given?
Venofer
IV
(vin = wine is sweet)
54
Ferumoxytol
Feraheme
IV
(feru = fera)
55
Iron dextran complex
INFeD
IV
(Dexter aamel complex word
in (iron) Fe (iron) d (dextrose)
56
Sodium ferric gluconate
Ferrlecit
IV
(diff than ferrous gluconate)
(felicitation, ktir innovative into)
57
Ferric carboxymaltose
lnjectafer
IV
(injected)
(daya3una b carbonyl w maltol fa hayyano l brand)
58
Ferric derisomaltose
Monoferric
IV
(kamen dayya3una b maltol bs hayda deriso once so mono)
59
Ferric pyrophosphate citrate
Triferic
(pyro phos phate (3 parts))
60
BOXED WARNING (IRON DEXTRAN AND FERUMOXYTOL)
- Serious and sometimes fatal anaphylactic reactions have occurred with the use of iron dextran or ferumoxytol;
- all patients receiving iron dextran should be given a test dose prior to the first full therapeutic dose;
- fatal reactions have occurred even in patients who tolerated the test dose;
- a history of drug allergy or multiple drug allergies may inc this risk
61
SE of parenteral iron
- Muscle aches
- Flushing
- Hypotension
- Hypertension
- Tachycardia
- Chest pain
- Peripheral edema
All parenteral iron products carry a risk for hypersensitivity reactions (including anaphylaxis)
62
Monitoring with IV iron
- Hgb
- Iron studies
- Reticulocyte count
- Vital signs
- signs and symptoms of anaphylaxis
63
- Give by slow IV injection or infusion to:
- Give by slow IV injection or infusion to dec the risk of hypotension
64
- All agents are stable in:
- this IV product is stable in:
- All agents are stable in NS;
- Feraheme is stable in NS or DSW
65
- Triferic is only indicated for in:
- it should be added to:
- Ferric pyrophosphate citrate
- Triferic is only indicated for iron replacement in patients with hemodialysis-dependent CKD;
- It should be added to the bicarbonate concentrate of the hemodialysate for patients receiving hemodialysis
(3: triferic
2: bicarb
1: only given for ckd undergoing hemodialysis)
66
Macrocytic anemia is caused by:
vitamin Bl2 or folate deficiency, or both.
67
Most common cause of vit b12 def is:
Pernicious anemia, the most common cause of vitamin B12 deficiency, occurs due to a lack of intrinsic factor (IF)
(khabiss w bye2ze mn tahet la tahet)
68
IF is required for:
adequate vitamin Bl2 absorption in the small intestine; without IF, vitamin Bl2 deficiency will occur.
69
If pernicious anemia is suspected, how can patients be diagnosed?
This test replaced the old test:
For how long should you treat?
If pernicious anemia is suspected, patients can be diagnosed with a positive test for autoantibodies to IF.
Testing for autoantibodies has replaced the Schilling test, which was previously used to diagnose pernicious anemia.
Of note, this type of anemia requires lifelong parenteral vitamin B12 replacement.
70
What are some other causes of macrocytic anemia?
What drugs can dec absorption of vit b12?
Other causes of macrocytic anemia include:
- Alcoholism
- Poor nutrition
- Gastrointestinal disorders (e.g., Crohn's & celiac dx)
- Pregnancy
The long-term use (>2 years) of metformin, H2RAs or PPis can decrease the absorption of vitamin Bl2.
71
What can Vit B12 def lead to?
When do these Sx become irreversible
Vitamin B12 deficiency can result in serious neurologic dysfunction, including:
- Cognitive impairment
- Peripheral neuropathies.
If vitamin Bl2 deficiency goes undiagnosed for more than three months, neurologic symptoms can become irreversible.
72
Folic acid deficiency causes...
What neurologic sx does it cause?
- Ulcerations of the tongue and oral mucosa
- Changes to skin, hair
- Fingernail pigmentation
Folic acid deficiency does not result in neurologic symptoms
73
How can you diagnose macrocytic anemia?
- Low Hgb
- High MCV
- Low reticulocyte counts
- Low serum levels of vitamin B12 and/or folate
Since vitamin B12 is required for enzyme reactions involving methylmalonic acid and homocysteine, they accumulate when vitamin B12 is deficient.
Homocysteine levels can also be elevated in folate deficiency.
Vit b12 def: MMA & homocys
Folate def: homocys
74
For initial treatment of vitamin Bl2 deficiency, do you give IV or oral? Why? Do you switch later on?
What is the 1st line for severe def or neurologic sx?
The initial treatment of vitamin Bl2 deficiency typically involves vitamin Bl2 injections, to bypass absorption barriers, followed by oral supplements, if appropriate.
Vitamin Bl2 injections are recommended first-line for anyone with a severe deficiency or neurological symptoms.
75
Cyanocobalamin, vitamin B12 Brand / Formulations/ Dose?
- B-12 Compliance,
- Nascobal
- Physicians EZ Use B-12
- other oral generics
- Injection
- Lozenge
- Tablets (including ER and SL forms)
- SL liquid
- NASAL SOLUTION
Dose:
- IM or deep SC:
100 - 1,000 mcg daily/weekly/ monthly
(varies depending on severity of deficiency)
- Oral/sublingual:
1,000- 2,000 mcg daily
- Nascobal: 500 mcg in one nostril once weekly
76
Folic acid, folate, vitamin B9
brand/ formulation/ dose
- FA-8
- Tablet, capsule, injection
- Dose: 0.4 - 1 mg daily
77
CI to vit b12
Allergy to cobalt or vitamin B12
- An intradermal test dose is recommended for any patient suspected of vitamin B12 sensitivity prior to intranasal or injectable administration
78
Warnings of vit b12 & folate parenteral formulations in specific populations?
Parenteral products may contain:
- Aluminum (which can accumulate and cause CNS and bone toxicity if renal function is impaired)
- Benzyl alcohol (which can cause fatal toxicity and "gasping syndrome" in neonates)
79
SE with vit b12
- Pain with injection
Rare:
- Rash
- Polycythemia vera (overproduction of RBC)
- Pulmonary edema
80
Monitoring with vitamin B 12
Hgb, Hct, vitamin B12, reticulocyte count
81
SE with folate
Bronchospasm, flushing, rash, pruritus, malaise (all rare)
82
Monitoring with folate
Hgb, Hct, folate, reticulocyte count
83
Chloramphenicol & Vit B12 DDI?
Chloramphenicol can dec the efficacy of vitamin Bl2
84
Colchicine and Vit b12 DDI?
Colchicine can dec the absorption of vitamin Bl2.
85
Raltitrexed & folic acid?
The efficacy of raltitrexed (a chemotherapeutic agent) can be decreased by folic acid
Avoid combination
86
Folic acid can dec the serum concentration of:
Folic acid can dec the serum concentration of fosphenytoin, phenytoin, primidone and phenobarbital.
87
... may dec the serum concentration of folic acid.
Green tea and sulfasalazine may dec the serum concentration of folic acid.
88
1) What is erythropoietin?
2) Def of EPO causes...
3) How do you treat?
ANEMIA OF CHRONIC KIDNEY DISEASE
1) Erythropoietin (EPO) is a hormone produced by the kidneys that stimulates the bone marrow to produce RBCs.
2) A deficiency of EPO causes anemia of chronic kidney disease (CKD).
3) Iron therapy and erythropoiesis-stimulating agents (ESAs) are the treatments for anemia of CKD.
89
1) 1st line for HD pts?
2) non HD CKD pts with anemia can be treated with:
IV iron is first-line for hemodialysis (HD) patients.
Non-HD CKD patients with anemia can be treated with oral iron supplements.
90
The KDIGO (Kidney Disease Improving Global Outcomes) guidelines recommend iron therapy in both non-HD and HD patients if
- TSAT is <= 30 % &
- Ferritin levels are < = 500 ng/mL.
The KDOQI (Kidney Disease Outcomes Quality Initiative) guidelines recommend iron therapy if
- TSAT is <= 20% (non-HD and HD patients) &
- Ferritin levels are <= 100 ng/mL in non-HD patients &
- Ferritin <= 200 ng/mL in HD patients
- These criteria are important when using ESAs.
91
Why are ESAs imp?
When are they ineffective?
ESAs help maintain Hgb levels and reduce the need for blood transfusions, but they are ineffective if iron stores are low.
92
Epoetin alfa
- Epogen
- Procrit
- Retacrit-biosimilar
IV, SC
Single dose and multidose vials
93
Dose of epoetin alfa in Chronic Kidney Disease
Indication?
50-100 units/kg IV or SC 3x/week
- Initiate when Hgb < 10 g/dl
- Dec or interrupt dose when Hgb
1) approaches or exceeds 11 g/dl (CKD on HD), or
2) > 10 g/dl (CKD not on HD)
93
Dose of epoetin alfa in Chronic Kidney Disease
Indication?
50-100 units/kg IV or SC 3x/week
- Initiate when Hgb < 10 g/dl
- Dec or interrupt dose when Hgb
1) approaches or exceeds 11 g/dl (CKD on HD), or
2) > 10 g/dl (CKD not on HD)
94
Dose of epoetin alfa in pts with Cancer (taking chemotherapy)
- 150 units/kg SC 3x/week or
- 40,000 units SC weekly
Initiate when Hgb < 10 g/dl and when at least 2 additional months of chemotherapy are planned
95
How should you inc or dec dose of epoeitin or darbepoeitin? should you titrate? frequency of changes?
All Indications:
Titrate dose up or down based on Hgb levels; do not inc the dose more frequently than once every 4 weeks
96
Darbepoetin brand
- Aranesp
- IV/ SC
- Single dose vial
- Single dose prefilled syringe (needle included)
97
Darbepoetin in ckd dose
HD: 0.45 mcg/kg IV or SC weekly or 0.75 mcg/kg IV or SC every
2 weeks
Non-HD: 0.45 mcg/kg IV or SC q 4 w
98
Darbepoetin and Cancer (taking chemotherapy) dose
2.25 mcg/kg SC weekly or
500 mcg SC every 3 weeks
99
BBW or epoeitin and darbepoeitin
- Inc risk of death, Ml, stroke, VTE, thrombosis of vascular access
- Use the lowest effective dose to reduce the need for blood transfusions
- Chronic Kidney Disease: Inc risk of death, serious cardiovascular events and stroke when Hgb level> 11 g/dl
- Cancer: shortened overall survival and/or inc risk of tumor progression or recurrence in clinical studies of patients with some cancers.
Not indicated when the anticipated outcome is cure; discontinue when chemotherapy completed
- Perisurgery (epoetin alfa only): DVT prophylaxis is recommended due to t risk of DVT
100
CI of ESAa
Uncontrolled hypertension, pure red cell aplasia (PRCA)that begins after treatment Epoetin alfa: multidose vials contain benzyl alcohol (contraindicated in neonates, infants, pregnancy and lactation)
101
Warning with ESAa
Hypertension, seizures, serious allergic reactions, serious skin reactions (SJS/TEN)
Epoetin alfa: contains albumin from human blood (remote risk for transmission of viral dx
102
SE of esa
Arthralgia/bone pain, fever, headache, pruritus/rash, N/V, cough, dyspnea, edema, injection site pain, dizziness
103
monitoring with esa
Hgb,Hct,TSAT,serumferritin, BP
104
Notes with esa
- IV route is recommended for patients on hemodialysis
- Store in the refrigerator; protect from light; discard multi dose vials 21 days after initial entry
- Do not shake
- The darbepoetin t1⁄2 is 3-fold longer than epoetin alfa (it can be given weekly)
105
Aplastic anemia
- Aplastic anemia (AA) occurs when the bone marrow fails to make enough RBCs, WBCs and platelets.
- It can be caused by drugs, infectious diseases, hereditary conditions or autoimmune disorders.
- Patients with AA are at risk for life-threatening infections or bleeding.
- Treatment can include immunosuppressants, blood transfusions or a stem cell transplant.
- Eltrombopag (Promacta), a thrombopoietin non peptide agonist, increases platelet counts and is approved for the treatment of severe aplastic anemia in patients who are unresponsive to immunosuppressive therapy.
106
Hemolytic anemia
- Hemolytic anemia develops when RBCs are destroyed and removed from the bloodstream before their normal lifespan of 120 days.
- This type of anemia can be
1) acquired (e.g., drug- induced or associated with an immune disorder) or
2) inherited (e.g., sickle cell disease, G6PDdeficiency).
- There is more than one mechanism of drug-induced hemolytic anemia, but most often the medication binds to the RBC surface and triggers the development of antibodies that attack the RBC.
The direct Coombs test is used to detect antibodies that are stuck to the surface of RBCs
107
Glucose-6-phosphate dehydrogenase (G6PD) deficiency
- X-linked inherited disorder
- Most commonly affects persons of African, Asian, Mediterranean or Middle Eastern descent.
- The G6PD enzyme protects RBCs from harmful substances (e.g., reactive oxygen species).
- Without sufficient levels of G6PD, RBCs hemolyze (break apart) 24 - 72 hours after exposure to oxidative stress.
- Infections, certain foods (e.g., fava beans), severe stress and certain drugs can increase the risk of hemolysis in a patient with G6PD deficiency.
- Most individuals do not need treatment but should be instructed to avoid certain high-risk medications, foods or other known triggers.
- Not all medications that can cause drug-induced hemolysis are prohibited in patients with G6PD deficiency.
- If a high-risk drug is used, monitor closely and discontinue immediately if hemolysis develops.
108
Drugs that can cause hemolytic anemia
Cephalosporins
Dapsone*
lsoniazid
Levodopa
Methyl dopa
Methylene blue*
Nitrofurantoin*
Pegloticase*
Penicillins
Primaquine*
Quinidine
Quinine
Rasburicase*
Rifampin
Sulfonamides*
*Avoid in G6POdeficiency
109
Counseling with oral iron
Oral Iron
■ Take on an empty stomach.
If stomach upset occurs, it can be taken with food, but AVOID:
- cereals
- tea
- coffee
- eggs
- milk
- high-fiber products
as these decrease iron absorption.
Drug interactions due to:
o Binding.
o High gastric pH.
Can cause:
o Dark stools, which is expected.
o Constipation.
110
Counseling with ESA
■ Can cause:
o Blood clots
o Hypertension
■ Do not shake the vial or syringe; this will ruin the medication and it will not work.
■ ESA injection sites:
- arm
- thigh
- glutes
- belly
