Chapter 9- Blood And Nutrition Flashcards
How long does it take for a rise in haemoglobin concentration when taking oral iron
And how long is it carried in for
3-4 weeks
Carried on for 3 months to replenish body stores
First line route for iron replacement
Oral
MHRA alert for parenteral iron
Severe hypersensitivity reaction and Incidence of anaphylaxis
Side effects of oral iron
GI irritation: nausea, epigastric pain and diarrhoea or constipation
Can discolour the stool
How should oral iron be taken
Best taken before food but if GI effects are bad can take after food
What are some foods naturally rich in iron?
Pork
Beans
Red meat
What’s the choice of iron salt treatment dependent on
Side effects
Cost
What can be given in sickle cell disease to reduce the frequency of crisis
Hydroxycarbamide
Who is G6PD Deficiency more common in
People from Africa, Asia, Oceania and Southern Europe
Also more common in men
What are individuals with G6PD deficiency at risk of developing
Haemolytic anaemia
Drugs that may be harmful to patients with D6PD deficiency
Definite: nitrofurantoin, ciprofloxacin, co-trimoxazole
Potential: aspirin, quinine, gliclazide
When is prophylaxis with iron prep indicated
Malabsorption Menorrhagia Pregnancy Post gastrectomy Haemodialysis Low birth weight infants
What can be given to aid iron absorption
Ascorbic acid (Vit C)
What is megaloblastic anaemia usually due to
Lack of either vitamin B12 or folate
When should vitamin b12 be given prophylactically?
After total gastrectomy or ileal resection
What’s the drug treatment of choice for vitamin B12 deficiency and why’s it preferred
Hydroxycobalamin
It is preferred over cyanacobalamin as it is retained in the body longer and thus requires fewer dosing intervals (upto 3 months)
What can cause vitamin b12 deficiency?
Being Vegeterian
People who’ve had total or partial gastrectomy
What can cause folate deficiency
Poor diet
Pregnancy
Anti epileptic drugs
What’s a good dietary source of folic acid
Broccoli
What is iron overload usually as a result of
Repeated blood transfusion
How can you treat iron overload
Iron cheating compound (desferrioxamine)
Enhanced by administration of ascorbic acid
What can be used in neutropenia follow bone marrow transplant or chemo
What should be monitored
Lenograstim or Filgrastim
FBC and WBC and platelets should be monitored
What’s more likely to occur with agranulocytosis and neutropenia
Acquiring an infection
Warning signs for agaranulocytosis and neutropenia
Fever Headache Sore throat Mouth ulcer Fatigue Flu like symptoms
Drugs that may cause bone marrow suppression
Carbimazole Clozapine Co-trimoxazole Mesalazine Sulfalazine Methotrexate Mirtazapine
What’s the normal plasma level for sodium, potassium, bicarbonate, chloride and calcium. (mmol/L)
Sodium= 133-146 Potassium= 3.5- 5.3 Bicarbonate= 26 Chloride= 103 Calcium= 2.1-2.58 Magnesium = 0.7-1.05 Phosphate= 0.85-1.45
How is acute sever hyperkalaemia treated
Calcium Gluconate to protect the heart
Insulin to reduce serum potassium levels
Salbutamol used to reduce potassium levels
Sodium bicarbonate given in acidotic state, useful for increasing the pH of the urine and in dyspepsia - not in the same line as can cause thrombosis
What is considered hyperkalaemia and what is acute severe hyperkalaemia
Serum potassium >5 mmol/L
Acute severe >6.5mmol/L
Symptoms of hyperkalaemia
Fatigue Numbness Tingling Nausea and vomiting Trouble breathing Chest pain Irregular heart beat
Drugs that can cause hyperkalaemia (HADBEANS)
Heparin ACEi/arbs Digoxin BB Eplerenone Amoloride NSAIDs Spironolactone
Treatment for hypokalaemia
Ready mixed infusion containing potassium (potassium chloride)
Given via slow infusion at a rate not exceeding 20mmol potassium per hour
Symptoms of hypokalaemia
Constipation Irregular heartbeat Fatigue Muscle damage Muscle spasm Tingling Dumbness
What can rapid infusion of potassium chloride cause
Arrhythmia as it can be cardiotoxic
Drugs that can cause hypokalaemia
Diuretics Beta 2 agonist Insulin Corticosteroids Laxative Theophylline
Symptoms of hypernatremia
Dehydration Thirst Osmotic damage to cells Confusion Muscle twitching or spasms Seizures
Drugs that can cause hypernatremia
Corticosteroids
IV abx with sodium
Oral contraceptive
Sodium bicarbonate
Treatment for hypernatremia
Dextrose or saline infusion
Symptoms of hyponatremia
Nausea and vomiting Headache Confusion Fatigue Loss of appetite Irritable Osmotic damage to cells
Drugs that can cause hyponatremia
Anti-depressants Desmopressin Carbamazepine Diuretics Lithium Gliclazide Amphotericin Quetiapine
Treatment of hyponatremia
Hypovolemia= IV saline
Hypervolemia= address underlying HF or liver failure
Euvolemic= fluid restriction and remove stimuli for ADH
When is replacement of potassium loss especially necessary
Patients taking digoxin or anti arrhythmic drugs when K depletion can induce arrhythmias
Patients where secondary aldosteronism occurs
Patients with excessive K loss in faeces
Elderly
Symptoms of hypercalaemia
Bone pain
Kidney Stones
Psychiatric issues
Constipation
Drug Treatment for hypercalaemia
Cincalcet
Symptoms of hypocalcaemia
Convulsion
Arrhythmia
Numbness
Diarrhoea
Treatment for hypocalcaemia and hypercalcaemia
Hypo:
Calcium salts
Hyper: bisphosphonates/ steroids Calcitonin Cinalcet Paracalcotil
Why is magnesium retained in renal failure
Is excreted by the kidneys
Symptoms of hypomagnesaemia
Arrhythmia
Hypokalaemia
Hypocalcaemia
(Common in alcoholism)
Drug treatment for hypomagnesium imbalance
Magnesium salts
Iv mangesium sulphate
Symptoms of hyperphosphataemia
Ectopic calcification
Hyperparathyroidism
Drug treatment for hyperphosphate imbalance
Aluminium hydroxide
Phosex
Sevlamer
Or calcium containing preps
Symptoms of hypophosphate
Weak muscles
Mental issues
Blood disorder
Treatment for hypophosphate
Phosphate salts
Where is magnesium not absorbed
GI tract
What should oral rehydration therapy do
Enhance the absorption of water and electrolytes
Replace the electrolyte deficit adequately and safely
Be slightly hyper-osmolar to prevent induction of osmotic diarrhoea
Be simple to use in hospital and homes
Be palatable and acceptable
Be readily available
How is intestinal absorption of sodium and water enhanced
By glucose and other carbohydrates (eg: rice starch)
If calcium is high would phosphate be low or high?
Low
They work in opposites
What’s supplemental parenteral nutrition
Nutrition given by IV infusion in addition to ordinary oral or tube feeding
What’s total parenteral nutrition
Nutrients given by IV infusion as the sole source of nutrition
What does parenteral nutrition contain
What route is it given via
Amino acids Glucose Fat Electrolytes Trace elements Vitamins
Via central or peripheral vein
What is vitamin A and what is deficiency associated with
Retinol
Associated with ocular defects, dry eyes and in increased susceptibility to infections
What are the vitamin B’s
B1- thiamine B2- riboflavin B3- Nicotinamide/ nicotininic acid B6- pyridoxine B7- Biotin B12- cyan/ hydroxycobalamin
What’s vitamin C and what’s it essential in
Ascorbic acid
Essential in scurvy, gingivial bleeding and helps wound healing, common colds and aids iron absorption
What’s vitamin D and what’s it essential in
Colecalicerol/ alfacalcidol
Preventing or curing rickets
Needed for dietary absorption of calcium
What’s vitamin E and what’s the benefits
Tocopherol
Inhibits platelet aggregation and a powerful antitoxidant which protects free radical
What’s vitamin K and what’s the benefits
Phytomenadione
Necessary for the production of blood clotting factors and proteins necessary for the normal calcification of bones
Sources for vitamin A, C, D, E, K
A- fish liver oil, raw eggs C- orange, pepper, tomato, blackcurrent D- natural sunlight E- plant oils K- green leafy vegetable
Which are fat soluble vitamins and which are water soluble?
Fat soluble- ADEK
Water soluble- BC
Benefits of vitamin A
Night vision
Immune system
Healthy skin
Benefits of vitamin c
Protects cells
Wound healing
Collagen formation
Benefits of vitamin D
Maintains calcium and phosphate levels
Healthy bones and teeth
Benefits of vitamin E
Powerful antioxidant which protects free radicals
Healthy skin
Eyes
What is straight forward vitamin D deficiency treated with
D2- ergocalciferol
D3- cholecalciferol
What is complicated vitamin D deficiency caused by malabsorption or chronic renal disease treated with?
The hydroxylated version (active form)= alfacalcidol or calcitriol
What’s the benefit and source of vitamin B1
Benefit: releases energy from food, healthy CNS
source: whole grain, cereal
What’s the benefit and source of vitamin B2
Benefits: healthy skin, nerves and eyes
Source: milk, eggs, cereal, rice
What’s the benefit and source of vitamin B3
Benefits: healthy skin and eyes
Sources: meat, fish. Wheat flour, eggs, milk
What’s the benefit and source of vitamin B6
Benefits: helps make several neurotransmitters, haemoglobin
Sources: chicken, vegetable, cereal
What’s the benefit and source of vitamin B7
Benefits: essential for fat metabolism
Sources: range of foods, whole cereal, vegetables
What’s the benefit and source of vitamin B12
Benefits: healthy NS, makes red blood cells, processing folic acid
Sources: meat, salmon, fortified cereal
When is thiamine used
Wernickes encelophalopathy
Alcohol abuse
Main told is the metabolism of carbohydrates
What is pyridoxine used for
Prevents peripheral neuropathy
Given with isoniazid (as this can cause deficiency)
What’s biotin used for?
To strengthen hair and nails
What’s B12 used for
Treat megaloblastic anaemia
What can scurvy symptoms nowadays indicate
Leukaemia
Why may folic acid be taken in pregnancy
To reduce risk of neural defects
Who’s at high risk of neural defects pregnancy
People on anti elliptic meds
People with diabetes
Previous neural defects pregnancy
Sickle cell disease
What’s the dose of folic acid to reduce the risk of neural defects
Normal risk: 400mcg before conception daily till 12 weeks
High risk: 5mg daily before conception till 12 weeks
Sickle cell: taken for whole pregnancy
What can a high dose of vitamin B6 be associated with
Neuropathy
What’s the CHM alert for IV thiamine
Anaphylaxis can occur but don’t withhold the use of treatment required especially if patient is at risk of wernicke korsakoff syndrome
IV should be given over 30 minutes
Facilities for treating anaphylaxis should be readily available
What is acute porphyrias
Group of disorders affecting the synthesis of Haem
Many drugs can induce acute crisis so canning be given or should be avoided
What drug is taken 2 hours apart from iron and why
Levothyroxine
Oral iron salts reduce absorption of levothyroxine
Drugs that cause hypercalcaemia
Thiazides
Vitamin A and D supplements
Lithium
What can cause hypocacaemia
Vitamin D deficiency
Bisphosphonates
Phenytoin
What can cause hypomagnesaemia
Alcoholism
Diuretics
Digoxin
PPI
What can cause hypermagnesaemia
Antacids and laxatives
When is parenteral iron preparations indicated
Chronic renal failure with haemodialysis
Malabsorption syndrome
Chemotherapy induced anaemia
How is ORT administered in diarrhoea and hypernatraemia dehydration (eg: diabetes insipidus)
Over 3/4 hours in diarrhoea
Over 12 hours in hypernatraemia dehydration
What do you give for high chloride
Sodium bicarbonate
If caused by low potassium give potassium bicarbonate
Treatment for acute porphyric crisis
Haem Arginate
What other electrolyte imbalance does hypomagnesaemia also lead to
Low calcium potassium and sodium
What are epoetins used for?
Symptomatic anaemia in CKD or chemo patients
What are the main side effects of epoetins?
- Severe skin reactions and stop treatment and seek medical attention if they develop a rash (which often follow flu-like symptoms) - Hypertensive crisis with encepathalopathy and tonic clonic seizures- Pure red cell aplasia
In what situations would you opt for IV iron over oral iron?
Oral therapy is unsuccessful; Intolerable of oral iron Continuing blood loss Malabsorption CKD patients on dialysis
IV iron does not work more quickly than oral iron except in what group of patients?
Patients with severe renal failure receiving haemodialysis
What is the MHRA advice surrounding injectable iron?
Serious hypersensitivity reactions including anaphylaxis Pts should be monitored for such signs for 30 minutes after administration Not recommended 1st trim. of preg. and only in 2nd and 3rd if vital
What is pernicious anaemia?
An autoimmune gastritis causing malabsorption of vitamin B12
Why should folic acid never be given alone in pernicious anaemia?
Can cause compression of spinal cord
Haemochromatosis is associated with an overload of what?
Iron Built up over several years
How do you manage haemochromatosis (result of iron overload)?
Venesection (removal of blood)If contraindicated- long-term administration of the iron chelating compound Desferrioxamine mesilate - Vit C aids iron chelation started 1 month after desferrioxamine, taken daily, not with food.
What drug inhibits platelet formation and is used for thrombocythaemia (when too many platelets are produced in the bone marrow)?
Anagrelide
Chronic hyponatraemia from inappropriate secretion of ADH should ideally be managed by what?
Fluid restriction
Why should calcium gluconate IV be given slowly?
If given too rapidly, risk of arrhythmias
Calcium carbonate is used for what two indications?
Calcium deficiency Phosphate binding in renal failure
What is sevelamer used for?
Phosphate binder for CKD patients including those on dialysis
What is Wilson’s disease?
Genetic disorder causing build up of copper in body tissues e.g. brain
Hypocalcaemia effects
convulsions, arrhythmias, numbness<= Ca salts
In renal patients, why is alfacalcidol and calcitrol more appropriate for Vitamin D deficiency treatment over other Vitamin D replacement?
Vitamin D requires hydroxylation by the kidney to its active form, therefore the hydroxylated derivatives alfacalcidol or calcitriol should be prescribed if patients with severe renal impairment require vitamin D
If Vitamin D replacement is needed in severe renal impairment, what are the most appropriate to prescribe?
Alfacalcidol Calcitriol
What vitamin should pregnant women avoid
Vitamin a
What’s given to new borns to prevent haemorrhagic disease
Vitamin k
