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Pharmacotherapy I > Exam 3 Anemia and Drug-Induced Hematologic disorders > Flashcards

Exam 3 Anemia and Drug-Induced Hematologic disorders Flashcards

1
Q

What stimulates the release of erythropoietin from the kidney?

A

Hypoxia

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2
Q

What does TTP stand for?

A

Thrombotic thrombocytopenic purpura (thousands of tiny clots all over the body)

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3
Q

What should you take into account when considering a pregnant patient?

A

Even though lab values might show low Hbg, Hct, and RBC count, they are likely actually polycythemic (high # RBC) because their plasma volume is so expanded

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4
Q

True or false: An acute bleed immediately drops Hbg and Hct so these values can help us diagnose bleeds.

A

False – drops in Hgb and Hct may not show until 36-48 hours later even though pt may be hypotensive.

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5
Q

What populations are especially at risk for anemia?

A

Females, the elderly, smokers (although HCT might look higher, masking it), teens, married people, poor people, alcoholics

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6
Q

What are common causes of normocytic anemia?

A

Acute blood loss, mixed anemias (microcytic + microcytic), chronic illness (CKD, etc)

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7
Q

What are common causes of microcytic anemia?

A

Iron deficiency, copper deficiency, zinc deficiency, toxins (alcohol poisoning, etc), thalassemias, iron metabolism defect. COMMONLY IRON deficiency

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8
Q

Name four symptoms of iron deficiency anemia

A

Pica (desire to eat metal), angular stomatitis (inflammation at corners of mouth), glossitis (tongue inflammation), koilonychia (spoon-like nails)

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9
Q

In treating iron deficiency anemia (IDA), what is the goal elemental iron daily dose in adults?

A

200mg/day PO or IV, especially for symptomatic IDA

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10
Q

How is elemental iron dosed for children 9-12 months?

A

3mg/kg once or twice daily for 2-3 months after anemia corrected

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11
Q

How is elemental iron dosed for other older children?

A

6mg/kg per day divided into 2-3 daily doses

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12
Q

Which PO iron products have the highest percentage elemental iron?

A

Polysaccharide-iron complex (Niferex) and Carbonyl iron (Feosol), both 100% elemental iron

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13
Q

What three ferrous salts are also used orally for IDA?

A

Ferrous sulfate, ferrous gluconate, and ferrous fumarate, given as 325, 300, and 300mg tablets. Ferrous gluconate has the lowest % elemental iron. Ferrous sulfate is dosed TID whereas the others are BID

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14
Q

What side effects are common to PO iron?

A

Stomach upset, cramping, nausea, constipaiton, discolored feces

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15
Q

What can be taken with iron to increase absorption?

A

Vitamin C – maybe orange juice

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16
Q

What should you never take with PO iron?

A

Anything that will decrease the acidity of the stomach (H2 blockers, PPIs, calcium coffee/tea/wine)

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17
Q

How should you take PO iron?

A

Take with orange juice on an empty stomach or small snack. Separate from milk/antacids by 2 hours before or after. Keep away from children. Drink lots of fluids or use a stool softener to prevent constipation.

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18
Q

Name the four IV iron products

A

Iron dextran (Infed, Dexferrum), iron sucrose (Venofer), ferric gluconate (Ferrlecit), and ferraheme (Ferumoxytol)

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19
Q

The equation following is used to dose which IV iron for IDA? Why?
Dose (mL!) = 0.0442 (Desired Hb - Observed Hb) x IBW x IBW x 0.26

A

It is used for iron dextran because it is the cheapest option, even though it is a pain in the butt
NOTE: dose is given in mL. Iron dextran is 50mg/mL.

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20
Q

How often should TSAT and ferritin be monitored when a patient is being treated for IDA?

A

Every 3 months.

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21
Q

What patients is the following equation used for?

Dose of iron (mg) = blood loss (mL) x Hct (decimal)

A

Acute blood loss patients or long-term dialysis patients.

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22
Q

When do we administer a blood transfusion for IDA?

A

If symptomatic anemia or Hgb < 8 g/dL

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23
Q

Name 3 acute and 4 chronic symptoms of anemia

A

Acute: tachycardia, tachypnea, orthostatic hypotension, light-headedness, angina
Chronic: fatigue, weakness, headache, dyspnea, dizziness, sensitivity to cold, pallor, exacerbation of cardiac disease (angina, CHF)

24
Q

About how many milliliters is one unit of packed red blood cells? How much would one unit raise Hgb? Hct?

A

~300mL per unit, Hgb increase ~1g/dL, Hct increase ~3%

25
Q

Name complications of transfusions

A

Acquired infections, transfusion reactions, alloimmunization (immune reaction to transplanted blood), volume overload, iron overload, hyperviscocity

26
Q

What are common causes of macrocytic anemia?

A

B12 or folic acid deficiency, alcoholism, liver disease, hypothyroidism, drugs, hemolysis/reticulocytosis

27
Q

What is “pernicious” anemia?

A

Anemia due to a B12 (cobalmin) deficiency due to years of inadequate intake (body stores are large). RDA = 2mcg/day

28
Q

What nutrient essentially must combine with intrinsic factor for absorption? What drugs interfere with this?

A

Vitamin B12. H2 blockers, PPIs, and metformin interfere with this process.

29
Q

What symptoms should you specifically look for in vitamin B12 deficiency?

A

Psychiatric symptoms – irritability, mood changes, memory impairment, depression, psychosis, etc. Paresthesias and peripheral neuropathy as well as muscle weakness and anorexia can also happen.

30
Q

How do you treat B12 deficiency?

A

Oral B12 (cyanocobalmin) – 1000 - 2000 mcg daily for 1-2 weeks then 1000 mcg daily for life
OR Parenteral B12 – 1000 mcg IM or deep SC injection daily for a week, then weekly for a month, then monthly for life
PLUS diet
Note–maintenance PO dose is 500x RDA

31
Q

What can cause folic acid deficiency anemia?

A

Decreased intake, absorption, or utilization, or hyper utilization (think pregnancy). Also drugs altering metabolism.

32
Q

How do you treat folic acid deficiency anemia?

A

PO folic acid – 1mg daily normally but up to 5mg daily for malabsorption patients and 0.5mg for patients on anticonvulsant
PLUS dietary intake

33
Q

What chronic diseases often cause anemia?

A

CKD, infection (trying to hide iron from bacteria!), malignancy, autoimmune disorders

34
Q

What is commonly used to treat anemia in chronic disease patients?

A

Erythropoietin stimulating agents– Epoetin Alpha (Epogen) 50-100 units/kg 3x per week or Darbepoetin Alpha (Aranesp) 0.45mcg/kg once a week

35
Q

What is the name of the symptom that patients with sickle cell anemia get that causes a lot of pain?

A

Microvasculature infarcts – due to capillary obstructions all over the body from the rigid cells getting stuck

36
Q

What would a sickle cell anemia patient present with? What would your lab values show you?

A

Chronic anemia, pallor, weakness, anorexia, enlarged liver/spleen/heart, hematuria, possibly jaundice.
Lab values: decreased Hgb but increased bilirubin, reticulocytes, platelets, WBC count, and sickle cells.

37
Q

What are the three acute complications that a patient with SCA can present with?

A

Acute chest syndrome (leading cause of death for SCA pts), sickle cell crisis, and priapism (in males)

38
Q

What is acute chest syndrome? How do we treat it?

A

Acute chest syndrome is caused by blood and other materials infiltrating the lungs, causing respiratory symptoms that don’t respond clearly to antibiotics and may or may not present with fever.
Treat with pain management, broad spectrum antibiotics, supportive care, steroids

39
Q

What are the sickle cell crises? How do we treat them?

A

Vasoocclusive pain crisis – localized intense pain from occluded capillary. Treat with hydration, analgesia.

Acute splenic sequestration crisis – sudden enlargement of the spleen and liver, spleen fills with large amount of blood. Leads to exacerbation of anemia, hypotension, and shock. Associated with infections. Treat with blood transfusion, broad spectrum antibiotics, possibly splenectomy.

40
Q

What is priapism? How is it treated?

A

Prolonged, painful erection due to sickling in sinusoids. Treat with analgesia, irrigation/aspiration, vasoconstriction and vasodilation

41
Q

What chronic problems are patients with SCA especially prone to?

A

Pulmonary HTN, bone and joint problems, ocular problems, cholelithiasis, cardiovascular problems, depression

42
Q

What drug should SCA patients <5 years old be on continuously?

A

Penicillin

43
Q

What antineoplastic agent decreases the number of all SCA acute complications and the risk of death?

A

Hydroxyurea – 10-15 mg/kg/day (MAX 35 mg/kg/day)

SE: bone marrow suppression, skin ulcers, nausea, diarrhea, constipation

44
Q

What maintenance treatment is important for both SCA and COPD patients?

A

Immunizations – especially influenza and pneumococcal

45
Q

What drugs will almost every SCA patient be on?

A

Folic acid, hydroxyurea, opioids for pain management, periodic transfusions to increase the amount of normal Hgb

46
Q

What is aplastic anemia?

A

A condition where your body does not produce enough RBCs (anemia), WBCs (neutropenia), or platelets (thrombocytopenia)– together called pancytopenia. Very serious/high mortality rate – more susceptible to infection, bleeds, and hypoxia. Need two of four possible criteria to diagnose.

47
Q

In evaluating an anemia patient, what can you check for hemolysis or a GI bleed?

A

GI bleed – check for dark tarry stools or red stool or abdominal pain or coffee ground vomiting
Hemolysis – check for jaundice, elevated bilirubin

48
Q

Name a few possible drugs that could cause aplastic anemia

A

Carbamazepine, phenytoin, thiazides, sulfonamides, methimazole, propylthiouracil

49
Q

What is drug-induced agranulocytosis?

A

Low or absent neutrophils present in the blood within 60 days of drug exposure. Presents with signs of infection. Psychotropic medications especially to blame – clozapine esp.

50
Q

What is hemolytic anemia?

A

Anemia do to intrinsic factors like sickle cell anemia or G6PD deficiency or extrinsic factors like TTP (thrombotic thrombocytopenia purpura), HUS (hemolytic uremic syndrome), malaria, autoimmune causes too (IgG–warm, IgM–cold). Very vague presentation (fatigue, malaise, pallor, SOB)
Also caused by phenytoin, phenobarbital, quinidine

51
Q

G6PD deficiency is the most common enzyme defect in which cells?

A

RBCs – causes hemolytic anemia. Pts with this deficiency avoid precipitating factors and get supportive care.

52
Q

What is megaloblastic anemia?

A

Macrocytic anemia caused by abnormal development of RBC precursors. Possible suspects include methotrexate, cotrimoxazole, phenytoin, phenobarbital.

53
Q

What is thrombocytopenia?

A

Decreased platelets in the blood caused often by heparin but also non-heparin causes (chemo, quinidine, rifampin, procainamide).

54
Q

What is methemoglobinemia?

A

A defect in hemoglobin (Fe 3+ instead of 2+) so it cannot bind oxygen – functional anemia. Can be congenital or acquired/drug-induced (dapsone, benzocaine, lidocaine, prilocaine). Pt presents with cyanosis, hypoxia, shock, seizures. Deadly >70%
If >20% methemoglobin, methylene blue 1-2mg/kg IV over 5 minutes – alternate metabolic pathway for reduction

55
Q

In calculating a parenteral iron dose (not iron dextran), what should you assume the blood volume to be?

A

65 mL/kg

56
Q

In calculating a parenteral iron dose (not iron dextran), what should you assume the goal Hgb to be?

A

14 g/dL

57
Q

In calculating a parenteral iron dose (not iron dextran), what should you assume the amount of iron per gram of Hgb to be?

A

1 gm Hgb = 3.3 mg iron

Pharmacotherapy I (15 decks)

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