Chapter 35: Anemia Flashcards
Anemia is a decrease in ___ & ___ concentrations below the normal range
Hgb & Hct
Another name for immature RBCs
reticulocytes
Anemia can result from:
nutritional deficiencies (e.g., iron, folate, vitamin B12) or it can occur as a complication of another medical disorder, such as CKD or malignancy
Classic symptoms of anemia
fatigue, weakness, SOB, exercise intolerance, HA, dizziness, anorexia and/or pallor
Which signs/symptoms can occur with iron deficiency anemia
Glossitis (an inflamed, sore tongue), koilonychias (thin, concave, spoon-shaped nails) or pica (craving and eating non-foods)
Vitamin B12 deficiency can present with
peripheral neuropathies
A low MCV means that RBCs are ____ than normal, which is called ___ anemia
smaller
microcytic
A high MCV means that RBCs are ____ than normal, which is called ___ anemia
larger
macrocytic
Likely cause of MCV < 80 fL anemia
iron deficiency
MCV 80-100 fL (normocytic) anemia likely cause
acute blood loss, malignancy, CKD, bone marrow failure (aplastic anemia), hemolysis
Likely cause of MCV > 100 fL anemia
B12 or folate deficiency
A reticulocyte count measures
production of RBCs
Reticulocyte count is low in
untreated anemia due to iron, folate or B12 deficiency and with bone marrow suppression
The most common nutritional deficiency in the US
iron deficiency
Causes of iron deficiency
- Iron-poor diets (e.g., vegetarian)
- Blood loss
- decreased iron absorption (High gastric pH, GI diseases)
- Pregnancy, lactation
Lab findings in iron deficiency anemia
- ↓ Hgb, MCV < 80 fL, ↓ RBC production (low reticulocyte count)
- ↓ serum iron, ferritin and TSAT
- ↑ TIBC
Recommended dose range of oral iron for treating iron deficiency anemia
100-200 mg elemental iron per day
How should oral iron be taken
on an empty stomach
Oral iron should be avoided with
H2RAs and PPIs, separate from antacids
Goal of oral iron therapy
↑ 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
% elemental iron in oral products:
- Ferrous gluconate = x%
- Ferrous sulfate = x%
- Ferrous sulfate, dried = x%
- Ferrous fumarate = x%
- Carbonyl iron, polysaccharide iron complex, ferric maltol = x%
- Ferrous gluconate = 12%
- Ferrous sulfate = 20%
- Ferrous sulfate, dried = 30%
- Ferrous fumarate = 33%
- Carbonyl iron, polysaccharide iron complex, ferric maltol = 100%
Parenteral iron is primarily used in
dialysis
Ferrous sulfate dosing
325 mg (65 mg elemental iron) PO daily to TID
Ferrous sulfate, dried 160 mg has how much elemental iron
50 mg
Oral iron BW
Accidental overdose of iron-containing products is a leading cause of fatal poisoning in children under 6; in the case of accidental OD, go to the ED or call a poison control center immediately (even if asymptomatic)
Oral iron SE
Constipation (dose-related), dark and tarry stools
Antidote for iron overdose
deferoxamine (Desferal)
Which drugs decrease iron absorption
Antacids, H2RAs, and PPIs
Iron should be separated from the following meds since it can decrease their absorption:
Quinolone & tetracycline antibiotics
Bisphosphonates
Levothyroxine
Which supplement can increase the absorption of iron
Vitamin C (Giving iron with ascorbic acid may enhance the absorption to a minimal extent)
IV iron is restricted to which patients:
- CKD on hemodialysis (most common use of IV iron)
- CKD receiving erythropoiesis-stimulating agents (ESAs)
- Unable to tolerate oral iron or failure of oral therapy
- Religious reasons
Iron sucrose brand name
Venofer
Ferumoxytol brand name
Feraheme
IV iron BW
Serious and sometimes fatal anaphylactic reactions with iron dextran or ferumoxytol; all patients receiving iron dextran should be given a test dose prior to the first full therapeutic dose
Triferic is only indicated for iron replacement in patients with hemodialysis-dependent CKD; it should be added to the ____ concentrate of the hemodialysate for pts receiving hemodialysis
bicarbonate
____ anemia is the most common cause of vitamin B12 deficiency & occurs due to a lack of _____
Pernicious anemia
intrinsic factor
IF is required for B12 absorption in the small intestine
Pernicious anemia can be diagnosed using the ____ test and requires lifelong parenteral _______
positive autoantibody test to Intrinsic factor (IF)
(replaced Schilling test)
vitamin B12 replacement
Other causes of macrocytic anemia besides B12 and folate deficiency
alcoholism, poor nutrition, GI disorders (e.g., Crohn’s disease, celiac disease)
Long-term use (≥ 2 years) of ___, ____ or ___ can decrease the absorption of vitamin B12
Metformin, H2RAs, PPIs
b12 deficiency can cause
serious neurologic dysfunction - cognitive, peripheral neuropathies.
if undiagnosed for > 3 months –> irreversible damage
Folic acid deficiency causes
ulcerations of the tongue and oral mucosa
Diagnosis of macrocytic anemia
Low Hgb and high MCV
First-line treatment for macrocytic anemia
B12 injections (caynocobalamin) - IM or deep SC
with severe deficiency or neurologic symptoms
How is Cyanocobalamin nasal solution (Nascobal) used
once nostril once weekly
EPO is a hormone produced by the kidneys that stimulates the ____ to produce ____
bone marrow
RBCs
Deficiency of EPO causes anemia of
CKD
Treatment for anemia of CKD
Iron therapy and ESAs
What is first-line for hemodialysis patients
IV iron
KDIGO guidelines recommend iron if TSAT ≤ ____ and ferritin is ≤ ____
KDOQI guidelines recommend iron if TSAT ≤ ____ and ferritin is ≤ ____ (non-HD) and ____ (HD)
KDIGO: 30% and 500 ng/mL (both HD and non-HD)
KDOQI: 20% and 100 ng/mL (non-HD) and 200 ng/mL (HD)
ESAs help maintain ___ levels & reduce the need for _____, but they are ineffective if iron stores are low
Hgb
Blood transfusions
Epoetin alfa brand name
Epogen, Procrit
Darbepoetin brand name
Aranesp
How many times per week is Epoetin alfa given in CKD
3x/week
Epoetin alfa is initiated when Hgb < __ g/dL in CKD and cancer patients
10
Epoetin alfa dose should be decreased or interrupted when Hgb approaches or exceeds __ g/dL (CKD or HD)
11
Darbepoetin for CKD is given IV or SC how many times per week (for HD)
once weekly (or q2weeks)
non-HD is every 4 weeks
ESA boxed warnings
Increases risk of death, MI, stroke, VTE, thrombosis
CKD: increased risk of death when Hgb level > 11 g/dL
Cancer: not indicated when the anticipated outcome is cure
ESAs can cause what side effects
Hypertension, arthralgia
ESA monitoring
Hgb, Hct, TSAT, serum ferritin, BP
ESA’s recommended route for HD patients
IV
How should ESAs be stored
in the refrigerator; do not shake
The darbepoietin half-life is __-fold longer than epoetin alfa
3-fold (can be given once weekly for this reason)
Causes of hemolytic anemia
Drug-induced or G6PD deficiency
Which test is used to detect antibodies that are stuck to the surface of RBCs in hemolytic anemia
Direct Coombs test
what is the basic role of G6PD
protect RBCs from harmful substances - that’s why deficiency is dangerous with certain drugs
Most people with G6PD deficiency should be instructed to avoid which high-risk medications
- Cephalosporins
- Dapsone+
- Isoniazid
- Levodopa
- Methyldopa
- Methylene blue+
- Nitrofurantoin+
- Pegloticase+
- Penicillins
- Primaquine+
- Quinidine
- Quinine
- Rasburicase+
- Rifampin
- Sulfonamides+
+ avoid in G6PD deficiency
