Folate Deficiency Anaemia

Question 1

What is the definition of folate anaemia?

Answer 1

Macrocytic RBCs, folate deficiency

Question 2

what is the epidemiology of folate anaemia?

Answer 2

Rare, no more than 5% prevalence

Question 3

what is the aetiology of folate anaemia?

Answer 3

Main cause is poor intake e.g. poverty, alcoholics and elderly
Increased demand e.g. pregnancy or increased cell turnover i.e.=haemolysis, malignancy, inflammatory disease and renal dialysis
Malabsorption e.g. coeliac disease or Crohn’s disease
Antifolate drugs e.g. methotrexate and trimethoprim

Question 4

what are the risk factors for folate anaemia?

Answer 4

• Poor nutrition, malabsorption
• Elderly
• Poverty
• Alcoholic
• Pregnant
• Crohn’s or coeliac disease

Question 5

what is the pathophysiology of folate anaemia?

Answer 5

in folate deficiency there is an impairment of DNA synthesis resulting in delayed nuclear maturation resulting in large RBCs as well as decreased RBC production in the bone marrow

• This DNA impairment will affect all cells, but bone marrow is most affected since it’s the most active in terms of cell division
• Folate is also essential for fetal development - deficiency can result in neural tube defects

Question 6

what are the key presentations of folate anaemia?

Answer 6

Patients may be asymptomatic

• May present with symptoms of anaemia e.g. pallor, fatigue, dyspnoea, anorexia and headache
• Glossitis (red sore tongue) can occur
• NO NEUROPATHY unlike B12 deficiency - how you can differentiate

Question 7

what are the signs of folate anaemia?

Answer 7

Anorexia, pallor

Question 8

what are the symptoms of folate anaemia?

Answer 8

Fatigue, dyspnoea, headache, red sore tongue

Question 9

what are the first line investigations for folate anaemia?

Answer 9

Blood count & film:
• Typical of megaloblastic anaemia
• RBC’s are MACROCYTIC
• Peripheral film shows oval macrocytes (large RBC’s) with hypersegmented neutrophil polymorphs with six or more lobes in the nucleus

Question 10

what are the gold standard investigations for folate anaemia?

Answer 10

Serum and red cell folate is LOW

• GI investigation e.g. small bowel biopsy to exclude occult GI disease
• Serum bilirubin may be raised as a result of ineffective erythropoiesis resulting in increased RBC breakdown

Question 11

how is folate anaemia managed?

Answer 11

Replace orally. Do not replace folate without checking B12

• Treat underlying cause
• Give FOLIC ACID TABLETS daily for 4 months - NEVER WITHOUT B12 as well (unless the patient is known to have NORMAL B12) since in low B12 states it may precipitate/worsen subacute combined degeneration of the spinal cord

Question 12

how is folate anaemia monitored?

Answer 12

regular blood tests

Question 13

what are the complications of folate anaemia?

Answer 13

Infertility, CVD, cancer, problems in childbirth, neural tube defects, low WBC counts

Question 14

what is the prognosis of folate anaemia?

Answer 14

Easily treated, Severe side effects rare, risk of CVD and cancer raised, fertility affected