Haemotology Drugs

Question 1

Causes of anaemia

Answer 1

Blood loss
Insufficient dietary intake
Malabsorption of iron eg coeliac disease

Question 2

Iron deficiency anaemia- definition by Hb level

Answer 2

Haemoglobin Level Health Status
120g/l or above Healthy
Below 120g/l Anaemic
100-120g/l Mildly Anaemic
80-100g/l Moderately Anaemic
Below 80g/dl Severely Anaemic

Question 3

Oral iron tablets for anaemia

Answer 3

Oral Tablets –
§ Mild/moderate IDA – low Hb, low MCV, low serum ferritin
§ Oral ferrous sulphate – if not tolerated, consider ferrous fumarate or ferrous gluconate

§200mg 2-3xDaily

§ Do not wait for investigations to be carried out before prescribing iron
§ Side effects – dark stools, constipation/diarrhoea, nausea, epigastric pain. GI symptoms occur in ~30% patients

Question 4

IV iron infusion for anaemia

Answer 4

Ferinject
§ IV Ferinject –
§Severe anaemia – IV iron enables higher doses of iron to be
§Used in Inflammatory Bowel Disease patients, who are frequently affected by iron deficiency, as oral iron preparations can worsen IBD symptoms
§ Can also be used in patients who cannot tolerate oral iron supplements, this can occur more frequently in the elderly
§ Side effects – headaches, dizziness, nausea and vomiting

Question 5

Blood transfusion for Iron deficiency anaemia

Answer 5

§ Blood Transfusion –

§In emergency situations, where patients have life-threatening anaemia and are haemodynamically unstable, red blood cell (RBC) transfusions should be given
§ This type of transfusion increases a patient’s haemoglobin and iron levels, while improving the amount of oxygen in the body
§ Side effects – back pain, fever, dizziness, dark urine monitor closely for transfusion reactions

Question 6

Further investigations for iron deficiency anaemia

Answer 6

§ Screen all patients with IDA for coeliac disease using coeliac serology (tissue transglutaminase antibody). If positive, refer to gastroenterology.
§Further investigations are unnecessary in otherwise healthy young individuals with a clear cause for the IDA
§ Possible further investigations e.g.in patients with GI symptoms or a family history of colorectal cancer include:

§ Urine dip for blood.
§ Refer for upper and lower gastrointestinal investigations.
§ Consider stool examination to detect parasites, test for H.Pylori
§ If there is a poor response to empirical iron treatment, or recurrence of anaemia without an obvious cause, seek specialist advice regarding further assessment and investigation.

Question 7

What type of anaemia is B12 deficient anaemia?

Answer 7

Macrocytic anaemia

Question 8

Vitamin B12 deficiency

Answer 8

Vitamin B12 Deficiency
• Vitamin B12 is protein bound and released during digestion, where it then binds to intrinsic factor in the stomach.
• This complex is then absorbed in the terminal ileum. Pernicious anaemia is the loss of parietal cells which make intrinsic factor.
• In B12 deficiency, red blood cell production is slow. Causes of deficiency are divided into dietary, malabsorption and congenital metabolic disorders

• Tests: Low Hb (30 g/l – 110g/l), High MCV, Low Serum B12 (<180 ng/l) and Low WCC & Platelets

Question 9

Precautions with B12 and folate

Answer 9

Check B12 + folate at the same time
Replace B12 before folate

Question 10

Oral B12 vs IM hydroxocobalamin

Answer 10

• Treat the cause if possible!
• If the low B12 is due to poor dietary
intake, oral B12 can be given
• Oral cyanocobalamin, 50–150 mcg daily between meals, or have a twice-yearly hydroxocobalamin
1 mg injection (often preferred in the elderly)
• If the low B12 is due to malabsorption, intramuscular injections are required
• Hydroxocobalamin (B12) 1mg IM alternate days for 2 weeks – then maintenance dose of 1mg IM every 3 months

Question 11

Side effects of cyanocobalamin (oral B12)

Answer 11

• Headaches
• Dizziness
• Weakness
• Numbness/Tingling
• Nausea

Question 12

Side effects of IM hydroxocobalamin

Answer 12

• Side effects of IM Hydroxocobalamin
• Nausea
• Headache
• Acne
• Red tinge to urine (tell patient)

Question 13

Management of folate deficiency anaemia

Answer 13

Oral Tablets – Folic Acid
§ Oral folic acid 5mg/day for 4 months
§ Never give without B12, unless B12 level is known to be normal – neurological impact
§ Maternal folate deficiency causes neural tube defects
§ In pregnancy, prophylactic doses of folate (400ug/day) are given from conception until at least 12 weeks gestation

Question 14

Further investigations for folate deficiency

Answer 14

• What further investigations could be done?
• Food diary – the most common cause of folate deficiency is a poor diet - dietician
• Always refer urgently to haematology if the patient has neurological symptoms or if they are pregnant
• Do antibody testing to check for coeliac disease (anti-transglutaminase antibodies) – refer to gastroenterology if positive

Question 15

Indications for a blood transfusion

Answer 15

• Hb <70 g/l
• CCF and Hb <90 g/l
• Acute bleed
• Severely symptomatic of anaemia e.g. very short of breath

Question 16

Complications of blood transfusion

Answer 16

• It is very important to monitor the patient for signs of a transfusion reaction. These signs include:
• back pain
• dark urine
• chills
• fainting or dizziness
• fever
• flank pain
• skin flushing
• shortness of breath

• In rare cases, patients can go into pulmonary oedema, kidney failure or shock following a blood transfusion
• In these cases, the blood transfusion should be stopped immediately, bloods should be taken and each issue should be treated