Chapter 9: Blood and nutrition Flashcards
1
Q
Before starting treatment for anaemia what is imperative?
A
To find out what type of anaemia it is due to risks associated with iron overload.
2
Q
What is sickle cell disease?
A
Impaired haemoglobin structure (moon-like) of red blood cells. Can lead to blockage/infracts = lack of bloody supply to vital organs and leads to severe pain. Can cause severe hospitalisation.
3
Q
Increased folate levels helps to __________
A
make new red blood cells
4
Q
What type of anaemia is associated with sickle cell disease?
A
Haemolytic anaemia
5
Q
What drug is used to reduce the frequency of crises and blood transfusions in sickle cell?
A
hydroxycarbamide
6
Q
What does sickle cell disease increase the risk of (in terms of vasculature)?
A
Stroke
7
Q
What is G6PD deficiency?
A
Inborn error with the metabolism of carbohydrates. Common in those from africa, asia, oceania
8
Q
Risks of G6PD deficiency?
A
- haemolytic anemia (spontaneous destruction of RBC)
9
Q
What is haemolysis?
A
Spontaneous destruction of RBC
10
Q
Which drugs have a definite risk of haemolysis in those that are G6PD-deficient?
A
Nitrofurantoin
Sulfonamides: co-trimoxazole
Quinolones
Rasburicase
Possible risk - gliclazide (sulfonylureas) = haemolytic anaemia
11
Q
MHRA warnings associated with epoetins?
A
1) Risk of SCARs
2) Tumour progression in those with cancer related anaemia
12
Q
Key side-effect of epoetins?
A
Hypertensive crisis
13
Q
What is the role of iron?
A
Helps to make healthy RBC that carry oxygen around the body
14
Q
Symptoms of iron deficiency?
A
Fatigue Pale skin SOB Palpitations Hair loss
15
Q
what conditions would require iron prophylaxis and why? hint: you can give it parenterally for these reasons
A
Chrons - nutrients and vits poorly absorbed from the gut
Gastrectomy - stomach removal so insufficient absorption
Menorrhagia - blood loss and haemodialysis
Renal failure - dialysis
Pregnancy - extra iron required for baby
Pre-term neonates with low birth weight - nutritional deficiencies
Due to malabsorption
16
Q
Which iron preparation has the highest amount of ferrous iron?
A
Ferrous fumarate 210mg (65mg) + ferrous sulphate 200mg (65mg)
17
Q
Patient counselling with oral iron preparations?
A
Take with or after food (reduce GI SE e.g. constipation)
- though best absorbed on empty stomach
Can take with vitamin c e.g. orange juice - better absorbed
Black, tarry stools as a side-effect
18
Q
name an iron-containing compound preparation and which category of patients would this be suitable in?
A
iron + folic acid: for pregnant women - only if deficient in both
19
Q
A patient asks you how long they need to continue their iron therapy for. What do you say?
A
Continue till 3 months after levels return to normal
20
Q
What is the normal iron level range? (NICE)
A
In men aged over 15 years — Hb below 130 g/L.
In non-pregnant women aged over 15 years — Hb below 120 g/L.
In children aged 12–14 years — Hb below 120 g/L.
In pregnant women — Hb below 110 g/L throughout pregnancy. An Hb level of 110 g/L or more appears adequate in the first trimester, and a level of 105 g/L appears adequate in the second and third trimesters.
Postpartum — below 100 g/L.
21
Q
Iron has a ceiling effect with dose. Above what dose does iron demonstrate no further evidence of absorption?
A
200mg
22
Q
If iron is used in iBD what can it exacerbate?
A
diarrhoea
23
Q
Why is parenteral iron not routinely recommended?
A
No evidence of benefit compared to oral.
24
Q
Give an example of iron infusion used in practice.
A
Monofer max 20mg/kg in one sitting and then repeat after a week if needs more (not licensed for >20mg/kg in one seating)
25
In what disease/condition states would you require parenteral iron?
Chemo-induced anaemia
Chronic renal failure with haemodialysis
Malabsorption syndrome
26
What is an MHRA warning with IV iron?
serious hypersensitivity reactions therefore, monitor for signs during and 30mins after
- can happen even if tolerated previously
- ensure resus equipement and facilities available and the dose is given by trained staff
27
What category of patients are at higher risk of hypersensitivity rx with parenteral iron?
- asthma
- allergies
- eczema
28
Recommendations on parenteral iron in pregnancy.
Avoid 1st trimester but can give in 2nd or 3rd if there is no other choice
29
Two causes of megaloblastic anaemia?
vit b12 deficiency or folic acid deficiency
30
Symptoms of megaloblastic anaemia?
Muscle weakness
Tingling of hands and feet
Numbness
Depression
31
Drug treatment for dietary vitamin b12 deficiency?
Oral cyanacobalamin (B12)
32
Drug treaåtment for malabsorption vitamin b12 deficiency e.g. chrons?
IM Hydroxocobalamin every 3 months
33
Emergency treatment for vitamin b12 deficiency?
folic acid + b12 but not folic acid alone due to risk of neuropathy
34
Which vitamin b12 therapy is the therapy of choice? cyanocobalamin or hydroxocobalamin?
Hydroxocobalamin as retained in the body for longer hence 3 monthly injections
35
Causes of folate deficiency?
pregnancy
malabsorption e.g. chrons
anti-epileptics
methotrexate (not licensed as adjunct therapy)
36
Treatment for folate deficiency?
Folic acid daily for 3 months
37
Why would you NEVER give folic acid alone for megaloblastic anemia and with unknown folate levels?
Risk of neuropathy of spinal cord (if emergency - give with b12)
38
Max OTC dose for folic acid?
500micrograms
39
What is the dose of folic acid used to prevent neural tube defects in pregnant women?
folic acid 5mg daily to take before conception and upto week 12 of pregnancy
40
risk of iron overdose?
Can damage organs e.g. liver, heart, pancreas and can be fatal especially in children
41
Antidote for iron overdose?
Desferrioxamine
42
Role of neutrophils?
Form of WBC and help to fight infection.
43
What drug can be used to increase neutrophil count and how does it work?
Filgrastim: has a recombinant growth stimulating factor which boosts formation of neutrophils
44
What indication is filgrastim commonly used in?
chemotherapy induced neutopaenia (as chemo kills healthy, rapidly dividing cells too)
45
Filgrastim main side-effect?
osteoporosis: monitor bone mass density
46
Consequence of potassium depletion?
Arrhythmias, ventricular fibrillation, cardiac arrest
47
Drugs that cause hypokalaemia?
Corticosteroids
Laxative abuse
Loop diuretics: furosemide/bumetanide
Thiazide like diuretics: Bendroflumethiazide/indapamide
48
How do potassium sparing diuretics affect potassium?
Cause hyperkalaemia e.g. spironolactone, eplerenone, amiloride
49
Potassium range (normal)?
3.5-5.3mmol/L
50
Treatment options for hyperkalaemia?
Insulin (soluble) with 50ml glucose 50%
Salbutamol
Calcium gluconate 10% - slow iv inj
calcium resonium
51
Why shouldnt you give sodium bicarbonate and calcium salts in the same line?
Risk of precipitation + Thrombosis
52
What potassium level is classified as acute, severe hyperkalaemia?
>6.5mmol/L
53
Drug treatment of acute, severe hyperkalaemia +/- eCG changes to protect against myocardium excitability?
Calcium gluconate - slow iv injection
then give soluble insulin IV if needed or as continuous infusion (5-15mins)
salbutamol if needed
54
Drug treatment of mild-mod hyperkalaemia + no ECG changes?
Calcium resonium
55
Hyperkalaemia causing drugs?
HAD-c-BEANS
Heparin - UFH
ACEi/ARB
Digoxin (overdose = hyperkal but hypokal induces toxicity)
Ciclosporin
```
B-blockers
Eplerenone (pot sparing)
Antibiotic - trimethoprim
NSAIDS
Spironolactone/amiloride
```
56
Which antibiotic used for UTI causes hyperkalaemia?
Trimethoprim
57
Symptoms of hypokalaemia?
Muscle hypotonia (stiff and tense), arrhythmias
58
Drugs causing hypokalaemia?
Diuretics: Loops, thiazides
Insulin
B2 agonist e.g. salbutamol
Corticosteroids
Theophylline
Rarely - PPIs
59
Treatment for mild hypokalaemia?
Oral potassium supplements based on levels e.g. Sando K
if due to diuretic --> switch to potassium sparing diuretic
60
Treatment for severe hypokalaemia?
IV potassium chloride (dont add glucose as that reduces potassium levels)
KCL in overdose = fatal so use pre-mixed solutions
61
Which drug exhibits a risk of toxicity with hypokalaemia?
digoxin
62
Why give smaller doses of potassium in renal impairment?
Reduce risk of hyperkalaemia
63
indication for Nacl IV
Sodium depletion
64
Chronic sodium depletion conditions e.g. renal disease/salt-losing bowel can be treated with
Oral sodium bicarbonate/sodium chloride
65
What temporary condition required the usage of oral rehydration therapy - ORT?
Diarrhoea: to replenish fluid and electrolytes
66
What is metabolic acidosis?
ph <7.1 (high level of chloride in blood) - counteract with bicarbonate, if hyponatraemia present give sodium bicarb, if hypokal present give potassium bicarb
67
Normal sodium range?
136-145mmol/L
68
Signs and symptoms of hypernatraemia?
```
Dehydration
Thirst
Oliguria (sml amounts of urine)
Hypovolaemia (reduced blood volume)
Tachycardia
Postural hypotension
```
69
Drug causes of hypernatraemia?
```
Contraceptive
Corticosteroids
Sodium bicarbonate
Sodium in IV antibiotics
Lithium
```
70
What happens in diabetes insipidus?
Reduced excretion of water so hypernatraemia due to vol depletion: give IV glucose
71
Treatment for hypernatraemia due to volume depletion?
IV Glucose
72
Symptoms of hyponatraemia?
```
Drowsy
Confused
Cramps
N/V
Headache
Convulsions
```
73
Drugs causing hyponatraemia?
```
Loop/thiazide diuretics
SSRIs
PPI
Carbamazepine
Desmopressin
NSAIDs
Trimethoprim
```
74
How to treat mild/mod hyponatraemia?
Fluids: NaCl/Na bicarbonate.
If PH is acidic - give sodium bicarbonate to help neutralise
75
How to treat severe hyponatraemia?
IV saline
76
Drug options for persistent hyponatraemia despite fluid restriction and oral na? e.g. due to SIADH
Tolvaptan - risk of demyelination so monitor for neural side effects
Demeclocycline
77
What electrolytes are in ORT
Sodium, Potassium, Chloride
78
How would you adivse ORT to be given for diarrhoea
Over 3-4 hours
79
How would you adivse ORT to be given for hypernatraemic dehydration?
>12hrs
80
How to treat severe dehydration?
IV glucose (but rarely given alone): only alone in states where only fluid is lost and no electrolytes are lost e.g. diabetes inspidus and hypercalcaemia
81
When would a patient require calcium supplements?
```
If dietary intake is too low and therefore there is an increased risk of osteoporosis/bone loss.
e.g.
- pregnancy
- elderly
- childhood
(due to malabsorption)
```
82
Treatment for severe acute hypocalcaemia?
Calcium gluconate 10%: Slow IV (due to risk of arrhythmias), calcium chloride inj is more irritant and there is an increased risk of extravasation
(mild-mod: vitd and ca supplements)
83
How would you correct hypomagnesaemia?
magnesium sulfate
84
Risks of hypercalcaemia?
```
Impaired bone health - fractures/osteoporosis
Arrhythmias
Kidney impairment
N/V
Heart issues
```
85
How would you treat hypercalcemia?
Limit dietary Ca intake
Bisphosphonates: pamidronate is most effective
Corticosteroids - only if cause is due to sarcoidosis/vitamin D as takes several days to work
86
What medication/vitamins can cause hypercalcaemia?
Vitamin D, thiazides (bendroflumethiazide, indapamide)
87
What drug used for gastro purposes can cause hypomagnesemia?
PPIs
88
How would you manage hypercalciuria?
Bendroflumethiazide
| Increase fluid intake
89
Risk of hypercalciuria?
Increased calcium in the urine so can lead to impaired renal function and CKD
90
Range of adjusted calcium?
2.15-2.5mmol/l
91
Normal range for hypomagnaesemia?
0.7-1.05mmol/l
92
What kind of patients commonly suffer from hypomagnesemia and why?
Those with diarrhoea/alcoholics due to most mg in GI fluid. (hypomag can lead to hypocalc,hypokal and hyponat)
93
Some indications for IV mg sulphate are:
pre-eclampsia in pregnancy (to treat and prev seizures - if longer than 5/7 days can cause skeletal imp in neonate MHRA)
TDP (torsade de pointes)
94
What causes hyperparathyroidism?
Disorder of parathyroid glands where non cancerous tumour is in one of the glands. The excess parathyroid causes hypercalcaemia, hypophosphataemia and hypercalciuria.
95
Main symptoms of hypercalcaemia:
thirst
fatigue
memory impairment
long term: CVD, kidney stones, osteoporosis and fractures
96
Treatment for hyperparathyroidism?
1) Surgery
2) Cinacelet - can prolong QT
(paracalcitol in renal failure)
3) Vit d supplements
4) bisphosphonates
97
MHRA warning with calcium gluconate?
Repeated/prolonged administration in 10ml glass bottles is contraindicated in <18yrs and those with renal impairment due to risk of aluminium accumulation.
Use packaged plastic containers for these patients.
98
What to use in magnesium toxicity?
Calcium gluconate
99
How to treat hyperphosphataemia?
Calcium-containing preparations (phosphate binding agents)
100
How to treat hypophosphataemia?
Give PO phosphate (give IV if mod-sev)
101
What would you use for wilson's disease?
Zinc acetate
102
What is the role of selenium?
Helps metabolism/thyroid function, boosts immune system, slows mental decline, CVS benefits
103
Give some foods that contain selenium?
Brazilian nuts, eggs, fish, poultry, soya
104
For patients who are unable to eat, what is available?
TPN - Total parenteral nutrition
eg.
1) major surgery
2) cancer e.g. mouth/oral
3) prolonged disorders
105
What should glucose be infused through to prevent thrombosis?
central venous catheter
| + give enough phosphate to allow glucose phosphorylation
106
Give examples of sugars in medicine.
Glucose
Fructose
Sucrose
107
Give examples of sweeteners
Sorbitol
108
What is contained in TPN?
Amino acids, glucose, electrolytes, trace elements, vitamins via central/peripheral vein
109
what is SPN?
Supplementary parenteral nutrition given in addition to oral/enteral feeds
110
Can you give liquid feeds prepared for adults to children?
No - different dietary requirements - seek guidance from paeds dietician
111
What should be avoided in coeliac disease
Gluten
Bodys immune system attacks body when gluten in bod. This damages small intestine in gut and results in malabsorption of nutrients
112
Which vitamins are fat-soluble?
ADEK
113
Which vitamins are water soluble?
B and C
114
Vitamin A deficiency causes what?
it is rare.
| Can cause ocular defects and increased susceptibility to infections.
115
Another name for Vitamin A
Retinol
116
What vitamin needs to be avoided in pregnancy and why?
Vitamin A - teratogenic
117
Benefits of vitamin A?
healthy skin
good vision especially night
immune system
118
Sources of vitamin A?
Fish oil, Liver, Raw eggs
119
overdose of vitamin a can cause?
Rough skin
liver enlargement
dry lips
dry hair
120
What vitamin B deficiency is the most common in UK?
B12
121
Name the different vitamin B's and their medical drug names.
B1 - Thiamine
B2 - Riboflavin
B6 - Pyridoxine (give with isoniazide to prevent ocular toxicity)
B12 - hydroxocobalamin: meat, salmon, cereal
122
Indications for using Vitamin B?
1) Chronic alcoholism - to prevent wernicke's encephalopathy and korsakoffs: give iV pabrinex and then maintenance with thiamine
2) megaloblastic anaemia: vit b12 +/- folic acid
123
Risk of IV pabrinex?
Hypersensitivity reactions
124
Role of vitamin B?
Responsible to make new RBC, convert food into energy, maintain healthy skin and brain cells and body tissues
125
What is the medical drug name for vitamin C?
Abscorbic acid
126
Deficiency of vitamin C can cause?
scurvy
gingival bleeding/swelling
petechiae - small, red, flat spots on skin - rare and sign of leukaemia
127
Vitamin c goes hand in hand with what other mineral?
Iron, vitamin c increases its absorption
128
Benefits of vitamin C?
protects cell
wound healing
collagen formation
129
Source of vitamin C?
Oranges
Peppers
Tomatoes
Blackcurrants
130
Vitamin D is responsible for?
Healthy bones and teeth and required for calcium absorption
131
Medical drug names for vitamin D
Vitamin D - calciferol
D2 - ergocalciferol
D3 - cholecalciferol (inactive and needs to be metabolised)
Hydroxylated (Active): alfacalcidol/calcitriol
132
What vitamin D should be given in those with renal impairment?
Alfacalcidol/calcitriol - active forms of vitamin D
133
Thiamine (vitamin b1) MHRA?
Serious allergic adverse reactions
134
Vitamin E medical drug name?
Tocopherol
135
Vitamin E role?
Inhibits platelet aggregation and increased risk of bleeding especially with warfarin
136
Benefits of vitamin E?
Powerful antioxidant that protects from free radicals so: healthy skin and eyes
137
Sources of vitamin E?
Plant oils - olive oils, nuts/seeds, wheat germ
138
What is the medical drug name for vitamin K?
Phytomenadione - lipid soluble
139
Role of vitamin K?
Production of clotting factors and proteins necessary for blood clotting
140
What can be given to prevent vitamin K deficiency in malabsorption?
Menadiol - water soluble used in liver impairment
141
Indication of vitamin K?
new born babies: to prevent neonatal haemmorhage
142
Should not give vitamin K with what....
Warfarin - antagonising effect
143
Source of vitamin K
Green, leafy vegetables
144
Pyridoxine (vit b6) is given alongside which TB drug to reduce the risk of peripheral neuropathy?
Isoniazide
145
Prolonged use with pyridoxine is safe but long-term use is associated with what?
Neuropathy (safety info)
146
What are the risk factors for neural tube defects in pregnancy?
Previous hx of them
antiepileptic drugs
folate/b12 deficiency
smoking
diabetes
obesity
147
How to prevent neural tube defects in pregnancy?
1) antiepilepstics: levetiracetam and lamotrigine are the safest
2) folic acid 5mg before conception and up to week 12.
(smaller doses in those without risk factors e.g. pregnacare)
148
ow to prevent neural tube defects in pregnancy in someone with sickle cell disease?
Give folic acid 5mg throughout the WHOLE pregnancy
