exam 3 lecture 8 Flashcards
what is anemia
low RBC count or decrease of hemoglobin
How do you know if patient has anemia
Hemoglobin in blood
signs and symptoms of anemia
exertional dyspnea (SOB)
Angina
Tachycardia
Fatigue
Pallor (being pale)
may be asymptomatic
Normal hemoglobin for men and women
13.5-18 for men
12-16 for women
Normal MCV for rbc
mean corpuscular volume (size of RBC)
80-100 mm3
What is a normal RDW
RBC distribution width (11.5-14.5%)
What is a normal HCT value
38-50% male
36-46% female
true or false, iron is first line tx for anemia
False, depends on the cause of anemia
What are the reasons a patient might have anemia
- decreased RBC production
- Increased RBC destruction
- Increased RBC loss
What could be reasons for decreased RBC production
-Chronic disease (CKD, cancer)
-Nutritional deficiencies (iron, folic acid, B12)
What could cause increased RBC destruction
- drugs
- Sickle cell anemia/Thalassemia
What causes increased RBC loss
- Acute blood loss
-chronic NSAIDS/ASA
Classify RBC based on size
- Microlytic
- MCV<80
Iron deficiency, sickle cell, Thalassemia - Normocytic
- MCV- 80-100
- Anemia of chronic disease, blood loss, hemolysis - macrocytic
MCV>100
Folic Acid and or B12 deficiency
consequences of anemia
Impaired cognitive function
Falls
Heart failure
A fib
CV events
Mortality
What would blood work look like for iron deficiency anemia
Ferritin and TSAT is low
What is ferritin? Normal range?
Ferritin is a measure of iron stores.
15-200 ng/ml
( IRON DEFICIENCY IS STILL LIKELY FOR FERRITIN BELOW 45)
What is TSAT? normal range?
TSAT is the amount of iron ready for erythropoiesis
range- 20-50%
Drug causes for iron deficiency?
Drug causes unlikely for iron deficiency anemia
What are causes of iron deficiency
- Blood loss (menstruation, blood odnation)
- decreased absorption ( maximal absorption in duodenum (celiac disease and gastric bypass are at risk)
- Vegetarian diet
- Increased consumption (pregnancy)
additional signs and symptoms of anemia only for iron deficiency
Spoon-shaped nails
Inflamed tongue (glossitis)
Pica (craving substance that do not have nutritious value)
How to treat iron deficiency anemia
- Iron supplements
- oral or IV iron
(oral preferred)
When do we use IV instead of oral iron for low iron levels
Can not tolerate (side effects)
Cannot absorb
ESRD
HF
How much oral iron do we give patients
65 mg of elemental iron every other day
or
120-200 mg of elemental iron per day (divided into BID or TID)
takes 3-6 months to repletes stores
Why is every other day dosing for iron better?
Hepcidin
- Is an iron regulating hormone produced in the liver
- decreases dietary iron absorption and iron transfer to the plasma
- hepcidin is increased after a dose of oral iron for 24 hrs and normalizes within 48 hrs
Hepcidin is also elevated during inflammation
What are the different oral iron products along with their doses and elemental iron concentrations
Ferrous fumarate, strength- 300 mg, elemental iron- 100 mg (33%)
Ferrous sulfate, strength- 325 mg, elemental iron- 65 mg (20%)
Ferrous gluconate, strength- 300 mg, elemental iron- 30 mg (10%)
Polysaccharide complex, strength- strength varies, 100% elemental iron
Counseling points for iron supplements
-Take it on an empty stomach for absorption
- It is better tolerated with food if it causes upset stomach
- absorption increased by ascorbic acid
- Take 2 hours after PPI
- Red tarry stools
-Constipation
Side effects of IV iron
Hypotension during infusion (common)
Skin tattooing (rare)
Indications of IV iron
ESRD, HF, failed oral iron, malabsorption
What are labs the point to B12 deficiency anemia
large MCV
large RDW
serum b12 levels low
Causes of B12 deficicncy
Diet (vegeterians/vegans), alcoholism
Lack of intrinsic factor
Medications (PPI, metr=formin)
Can our bodies make B12? Consquences of B12 deficineccy
our bodies can not make B12. Must absorb from diet.
Consequences
- neurologic
Weakness, Numbness, cognitive dysfunction
How to treat B12 deficiency anemia
Vitamine B12 replacement (Oral or IM or SC)
What do blood works look like for folic acid decicient anemia
- MCV elevated
B12 normal
FOlic acid levels low
Treatment of folic acid deficiency
Folic acid supplementation (oral)
(1-5 mg daily until it normalizes)
What diseases cause anemia of chronic disease
One of the most common causes of anemia
- patients with chronic disease lasting months to years.
- CKD
- CHF
- Cancer
-HIV/AIDS
Describe how anemia of CKD occurs
Erythropoietin is produced in the kidneys and stimulates production of RBCs
Anemia occurs bc
1. decreased erythropoietin production
2. Chronic inflammatory state which causes anemia of chronic disease
3. Nutritional deficiencies (iron, folate, vitamin B12)
How to treat anemia of chronic kidney disease
- avoid blood transfusions
- especially patients eligible for kidney transplantation - Correct nutritional deficiencies
- folate/b12 supplement if low
- iron
-use oral iron in stage 3-5 CKD if possible
- Use IV iron in hemodialysis patients
- target transferrin saturation (TSAT) above 30%
What is unique in the way we treat anemia of chronic kidney disease
Erythropoiesis stimulating agents (ESA)
- epoietin, darbapoietin,
What is very important to know about using ESAs in anemia of CKS?
DO NOT target normal hemoglobin levels.
Use minimum dose to maintain Hgb >10
Increased risk of CV events, stroke and death
How do we treat anemia associated with HF
IV iron (no oral iron)
Why do we not give iron supplements every day, only BID or every other day
It does not have high enough iron and it also does not wait until hepcidin levels are low
Does IV iron improve survivability with HF
IV iron does not improve survivability in HF patients. it only decreases hospitalization
How to treat blood loss anemia
Stop bleeding
Transfuse packed red blood cells (PRBC) when Hgb<7
- each unit of PRBC contains 250 mg iron
When do we transfuse for blood loss
when hgb <7
what is hemolytic anemia? How do you get it?
RBC being destroyed too quickly (before their normal 120 days)
Inherited: sickle cell anemia, G6PD deficiency
acquired: drug induced
Define sickle cell anemia
RBC are irregular shape (sickles)
RBC collect in spleen and are destroyed faster than they can be produced
it is inherited
How to treat sickle cell anemia
FOlic acid supplementation
Blood transfusion
Hydroxyurea
Make sure they are up to date with immunizations
Pain control (sickle cell can be painful)
- opioids in pain crisis
What drugs could cause drug induced anemia
-Metformin, PPIs, (cause vitamin B12 deficiency)
- Methotrexate, phenytoin, sulfasalazine or Bactrim (cause folic acid deficiency)
What are labs that point towards Folic acid deficiency anemia? Name the numbers
High MCV (macrocytic) (over 100)
low B12 (low B12 level is less than 200)
What would we use to treat folic acid deficiency? Include dose
Oral folic acid, 1000 micro grams QD
(if neurologic symtoms start IV)
How long to see changes in hemoglobin after giving folic acid supplemet
3 months
Normal hemoglobin level
Male- <13.5
female<12
Normal MCV
80-100 normal
<80 micor
>100 Macro
What is normal ferritin
<45 we consider anemia
Normal TSAT?
< 20 anemia
B12 value for anemia
<200 is anemia
What value is folate for folic acid deficiency
<10 is anemia (folic deficiency)
