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NRS 271A: optho, pulm, GU, Renal, Heme/onc > Heme Meds > Flashcards

Heme Meds Flashcards

1
Q

Normal HGB levels

A

Male: 14-17.5

Female:12.3-15.3

women < men due to menstrual cycle

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2
Q

S/sxs of Anemia

A
  • fatigue, lethargy dizziness
  • SOB, HA, tachycardia
  • edema, dry skin, chapped lips
  • nail brittleness
  • hunger for ice (pagophagia) , starch, or clay (pica)
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3
Q

Distribution of Fe in the body

A
  • absorbed intake: 1-2mg/day
  • myoglobin (muscle): 300mg
  • Bone Marrow: 300mg
  • Reticuloendothelial macrophages: 600mg
  • Liver: 1000mg
  • circulating erythrocytes (hemoglobin): 1800mg
  • avg. iron loss/day: 1-2 mg
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4
Q

Types of Macrocytic Anemia

A

MCV >100

  • Megaloblastic (immature RBCs)
    • folate deficiency
    • Cobalamin (Vitamin B12) deficiency
    • Drug-Induced
  • Non-Megaloblastic
    • alcohol use disorder
    • liver disease
      *
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5
Q

Types of Microcytic Anemias

A

MCV <80fL

  • Iron deficiency
  • anemia of chronic disease
  • thalassemias
  • lead poisoning
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6
Q

Types of Normocytic Anemia

A

MCV: 80-100fL

  • Hemolytic:
    • Intrinsic:
      • hereditary spherocytosis
      • paroxsymal nocturnal hemoglobinuria
      • G6PD deficiency
      • Sick cell anemia
    • Extrinsic:
      • micro/macroangiopathic hemolytic anemia
      • autoimmune hemolytic anemia
  • Non-Hemolytic
    • iron deficiency
    • anemia of chronic disease
    • CKD
    • aplastic anemia
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7
Q

When to transfuse pts without significant CV disease?

A
  • hgb = 7gm/dL
  • pt with acute sxs (i.e. dyspnea, CP) + hgb 7-9
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8
Q

Tx of Iron Deficiency Anemia

A
  • Provide 150-200mg/day of elemental iron
  • should increased hgb by 1g/dL/week
  • if proper tx will see reticulocytes in 7-10 days
  • if HGB increases <2 g/dL/3weeks → should reassess
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9
Q

Overview of Tx of B12/Folic Acid Anemia

A

B12/Folic Acid Supplement

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10
Q

Overview of Tx of Anemia of Chronic Disease

A
  • tx the chronic disease
  • ESA (erythropoietin stimulating agent)
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11
Q

Fe Treatment

A
  • 50-65 elemental Fe PO BID-TID on empty stomach to maximize absorption
    • 20% elemental iron in 325 ferrous sulfate = 65mg
      • ferrous fumarate (33%)
      • ferrous gluconate = 12 %
  • SEs: abdominal pain, nausea, heartburn, constipation, dark stools
  • DDI: vitamin C, orange juice can decrease stomach pH = more absorption
    • fluoroquinolones, TCN, & macrolides, mycophenolate mofetil can chelate with iron and decrease absorption
      • ****give iron 2 hours before or 4 hours after***
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12
Q

Parenteral FE

A
  • iron dextrose: hypersensitivity black box warning
  • sodium ferric gluconate complex
  • iron sucrose
  • Indications:
    • Pts cannot tolerate PO formulations
    • non-compliant
    • malabsorption syndromes
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13
Q

B12 (Cyanocobalamin)

A

needed for RBC production and maturation

  • PO & parenteral = equally effective
    • PO poorly absorbed
    • Dose: B12 1000mcg Qday IM x 1 week, then 1000mcg Qweek x 1 month or until hgb normalizes
    • Lifelong tx:
      • 1000mcg Qmonth for pernicious anemia/surgical resection of ileum
  • SEs: injection site rxn, pruritus, rash
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14
Q

Folic Acid

A
  • Dose: 1mg POQday
    • if malabsorption: may need up to 5mg Qday
    • hgb should rise after 2 weeks
      • should have resolution of sxs and reticulocytosis within a few days
  • SEs: allergic rxn, flushing, malaise, rash
  • DDI: no significant interactions
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15
Q

Tx for Anemia of Chronic Disease

A
  • Goals: reduced requirement for transfusion
  • ESA:
    • binds to EPO receptors on RBC precursor cells in Bone Marrow → increased RBC production
    • do not use if hgb >10g/dL
    • Epoetin
    • Darbepoetin
      • synthetic analog of Epoetin
      • longer t½ → longer dosing interval
  • Drugs that are biosimilar (not generics, but similar) for anemia:
    • Retacrit (epoetin alfa-apbx)
      • first approved biosimilar to epoetin alpha
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16
Q

ESA monitoring in CKD

A
  • Dialysis:
    • start 50-100units/kg SC/IV 3x/week
    • hgb <10
    • use lowest dose
    • may increase dose q 4 weeks
      • if no/inadequate response by 3 months (12 wks) do not increase dose more
    • if hgb response >1 g/dL/2week → decrease dose by 25%
    • decrease dose or interrupt tx if hgb near or exceeds 11g/dL
  • Non-dialysis:
    • decrease dose or interrupt tx if hgb nears or exceeds 10g/dL
17
Q

Non-pharmacologic tx of Sickle Cell Anemia

A
  • splenectomy
  • screen for:
    • ischemic retinopathy, nephropathy, pulmonary HTN, vascular disease, stroke
  • blood transfusion for pts with splenic sequestration & O2 sats <90% even with O2 supplementation
  • vaccines: flu, menveo, PCV-13, PPSV23
18
Q

Pharmacologic Tx of Sickle Cell Anemia

A
  • PCN prophylaxis: 1st line for prevention of pneumococcal sepsis in kids
    • can also use amox, erythromycin, azithromycin, cephalosporin or fluoroquinolones (contraindicated in kids <16 due to cartilage damage)
  • for mild-mod pain: NSAIDS
    • for severe pain: opioids
  • Hydroxyurea:
    • inhibits DNA synthesis; increases fetal hgb, increases water content in RBC; alters RBC adhesion to endothelium → makes RBCs “less sticky”
    • if CrCl <60mL/min → reduce dose by 50%
    • SEs: myelosuppression; stomatitis (mouth ulcers); n/v/d/c; HA; drowsiness; nail & skin hyperpigmentation/atrophy
    • risk of teratogenic effects → need to do a baseline pregnancy test
    • DDI: myelosuppressive effects
19
Q

SEs & DDI of ESA

A
  • SEs:
    • tumor progression
    • thromboembolism
    • MI, stroke, CHF, HTN
    • tachycardia, dyspnea
    • seizures, HA, dizziness, N/B
    • Hypersensitivity rxn, arthralgia, rash, fever, edema, diarrhea
  • DDI with ESA:
    • combined. oral contraceptives → thromboembolism
    • droxidopa (Northera) = prodrug of NE → increased supine HTN
    • tamoxifen (selective estrogen receptor modulator) ; thalidomide; tranexamic acid → thromboembolism
20
Q

Thrombocytopenia General Info

A
  • platelets lower than normal (Normal 150-450)
    • mild bleeding <50K
    • serious bleed <20K
    • platelet life span: 8-12 days for humans
  • causes:
    • bone marrow: under production, damage to stem cells; excessive destruction; splenic sequestration
    • Drug induced: diuretics (thiazides); chloramphenicol (50s inhibitor), ASA, ibu, heparin, PCN, phenytoin, vancomycin, rifampin
    • EtOH: reduces production of platelets
    • Viruses: chickenpox, mumps, rubella, EBV →decreased platelet count
    • Risk factors: CA, autoimmune diseases, genetic conditions, infections, medications
21
Q

S/sxs and Tx of Thrombocytopenia

A
  • Mild-serious bleeding:
    • purpura & petechia
    • abnormal vaginal bleeding, internal bleeding
    • blood in urine, dark tarry stools, HA
  • Dx tests: CBC, blood smear, bone marrow tests - aspiration or biopsy, PT, aPTT, spleen U/S
  • Treatments:
    • steroids PO or IV (slow platelet destruction)
    • IVIG → for immune thrombocytopenia
    • rituximab - blocks immune system → reduces B-cell activity
    • “-trombags” → eltrombopag, avatrombopag
    • romiplostim
    • blood or platelet transfusions
    • splenectomy
22
Q

“-trombopag”

A

MOA: activates thrombopoietin receptors → increased platelet production

“EAL”

  • eltrombopag (promacta):
    • SEs: hepatotoxicity, thrombosis, cataracts, URI, UTI, n/v/d, skin discoloration
    • Precautions: asian ancestry → start at lower dose (25mg)
    • thromboembolism risk
    • CI: LFTs > 5x ULN, Albumin <3.5
  • Avatrombopag (Doptelet):
    • SEs: hyponatremia, HA, peripheral edema
    • Precautions: thromboembolism risk
    • Contraindication:
      • breastfeeding, and wait at least 2 weeks after d/c
  • Lusutrombopag (Mulpleta):
    • SEs: HA, thromboembolism
    • Precautions: thromboembolism risk
    • Contraindications: breastfeeding, during and wait at least 28 days (4 weeks) after d/c
23
Q

Romiplostim (Nplate)

A

for thrombocytopenia : MOA: activates thrombopoietin receptors → increased platelet production

for chronic immune thrombocytopenia (ITP)

  • max dose: 10mcg/kg/wk
    • Hold dose if platelets > 400K; d/c if no increase in platelets after 4 weeks
  • SEs: bone marrow collagen fibrosis
    • thromboembolism, angioedema, HA, arthralgia, myalgia
    • insomnia, dizziness, n/v/d, cough
  • Contraindications:
    • breastfeeding; myelodysplastic syndrome; chronic hepatic disease; hematologic malignancy
24
Q

Populations with High Prevalence of Anemia

A

elderly (85+ yo)

black, non hispanic

mexican america

females (85+)

25
Q

Retacrit

A

used to tx anemia of chronic disease

  • biosimilar to EPO (but not identical so not called “generic”
    *
26
Q

Darbepoetin (Aranesp)

A

synthetic analog of Epoetin

longer ½ life = longer dosing interval

used to tx anemia of chronic disease if hgb <10

27
Q

Hydroxyurea

A
  • inhibits DNA synthesis; increases fetal hgb, increases water content in RBC; alters RBC adhesion to endothelium → makes RBCs “less sticky”
  • if CrCl <60mL/min → reduce dose by 50%
  • SEs: myelosuppression; stomatitis (mouth ulcers); n/v/d/c; HA; drowsiness; nail & skin hyperpigmentation/atrophy
  • risk of ****TERATOGENIC**** effects → need to do a baseline pregnancy test
  • DDI: myelosuppressive effects
28
Q

Platelet count in mild bleeding vs serious bleeding

A

Mild bleeding < 50K

Serious Bleeding <20 K

29
Q

Average lifespan of platelet

A

8-12 days in humans

30
Q

Eltrombopag (Promacta)

A

Activates thrombopoietin receptions and increase platelet production

  • SEs: hepatotoxicity, hemorrhage, thrombosis, cataracts, URI, UTI, n/v/d, skin discoloration
  • Precautions: asian ancestry → start at lower dose (25mg)
  • thromboembolism risk
  • CI: LFTs > 5x ULN, Albumin <3.5
31
Q

Avatrombopag (Doptelet)

A

Activates thrombopoietin receptions and increase platelet production

  • SEs: hyponatremia, HA, peripheral edema
  • Precautions: thromboembolism risk
  • Contraindication:
    • breastfeeding, and wait at least 2 weeks after d/c
32
Q

Lusutrombopag (Mulpleta)

A

Activates thrombopoietin receptions and increase platelet production

  • SEs: HA, thromboembolism
  • Precautions: thromboembolism risk
  • Contraindications: breastfeeding, during and wait at least 28 days (4 weeks) after d/c

NRS 271A: optho, pulm, GU, Renal, Heme/onc (10 decks)

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