Linger Anemia CIS

Question 1

Iron drugs

Answer 1

Oral preparations:
Ferrous sulfate
Ferrous gluconate
Ferrous fumarate

Parenteral preparations:
Iron dextran
Iron-sucrose complex
Sodium ferric gluconate complex

Question 2

Iron Chelators

Answer 2

Deferoxamine

Deferasirox

Question 3

Vitamin B12 Preparations

Answer 3

Cyanocobalamin

Hydroxocobalamin

Question 4

Erythrocyte-stimulating agents (ESAs)

Answer 4

Epoetin alfa (Epogen, Procrit)
Darbepoetin alfa

Question 5

Myeloid growth factors

Answer 5

Granulocyte colony-stimulating factor (G-CSF):
Filgrastim (Neupogen)
Pegfilgrastim

Granulocyte-macrophage colony-stimulating factor: (GM-CSF)
Sargramostim

Question 6

Megakaryocyte growth factors

Answer 6

Oprelvekin, Interleukin-11

Romiplostim

Question 7

what is Oprelvekin used for?

Answer 7

to treat patients with prior thrombocytopenia following chemotherapy

Question 8

what do granulocyte factors stimulate?

Answer 8

production and function of neutrophils
GM-CSF also stimulates other myeloid & megakaryocyte precursors
G-CSF and, to a lesser degree, GM-CSF mobilize PBMCs for autologous stem cell transplantation

Question 9

Which of the listed agents may be appropriately given for low iron PO?

Ferric gluconate
Ferrous sulfate
Iron dextran
Iron-sucrose complex
Sodium ferric gluconate complex

Answer 9

Ferrous sulfate

ferrous, Fe2+, better absorbed. Ferric can only be given IM or IV

Question 10

What should you tell the patient about the prescribed ferrous sulfate?

Answer 10

Patient information:
Childproof container
Take on empty stomach
Gastric side effects (e.g., nausea, constipation, abdominal cramps, dark stools)
Separate iron supplement and tetracycline/proton pump inhibitor

Iron and tetracycline absorption are decreased when administered concomitantly

Increased stomach pH decreases ferrous salt solubility

Question 11

When would parenteral iron therapy be indicated for this patient?

Continuing blood loss less than the rate of RBC production
Dark stools
Malabsorption
Patient’s refusal to give up dairy products

Answer 11

Malabsorption

dark stools- expected side effect

Other indications for parenteral therapy:
Intolerance to oral therapy
Advanced chronic renal disease
Small bowel resection
Inflammatory bowel disease
Gastrectomy

Question 12

what agent can we give for iron overdose?

Acetylcysteine
Activated charcoal
Deferoxamine
Flumazenil
Pralidoxime

Answer 12

Deferoxamine- iron chelator

acetylcysteine is for tylenol overdose

activated charcoal- for several things but not iron

flumazenil- for benzodiazepines

pralidoxime- Ach regenerator

Question 13

Iron Poisoning:

Answer 13

1- GI, .5-6 hrs
Abdominal pain, vomiting, diarrhea, hematemesis, melena, lethargy, shock, metabolic acidosis

2- Latent 6-24 hours
Improvement in GI symptoms; may have poor perfusion, tachypnea, tachycardia

3- Shock and Metabolic acidosis 4 hrs- 4 days
Hypovolemic, distributive, or cardiogenic shock with profound metabolic acidosis, coagulopathy, renal insufficiency/failure, pulmonary dysfunction/failure, CNS dysfunction

4- Hepatotoxicity- within 2 days
Coma, coagulopathy, jaundice. Severity is dose dependent

5. Bowel obstruction- 2-4 weeks
   Vomiting, dehydration, abdominal pain, usually gastric outlet obstruction

Question 14

Anemia of chronic disease

Answer 14

mild to moderate anemia associated with a number of disorders including:

Rheumatoid arthritis
Systemic lupus erythematosus
Chronic infections
Chronic renal failure
AIDS
Neoplastic disease/myelosuppressive chemotherapy

Question 15

Malignancy-Related Anemia

Answer 15

50-60% of patients with non-Hodgkin lymphoma, multiple myeloma, or treatment for ovarian and lung cancer develop anemia that requires blood transfusions

Anemia associated with chemotherapy predominantly occurs following treatment with agents that inhibit DNA synthesis

• Antimetabolites – folic acid analogs, hydroxyurea, purine antagonists, pyrimidine antagonists
• Alkylating agents – nitrogen mustards, nitrosoureas, platinum compounds
• Many others

Question 16

Which agent will stimulate an increase in the production of reticulocytes?

Cyanocobalamin
Epoetin alpha
Filgrastim 
Oprelvekin 
Pegfilgrastim

Answer 16

Epoetin alpha

Question 17

Common anemia management options in anemia of chronic disease brought on by chemotherapy

Answer 17

Delay the course of chemotherapy
Red blood cell transfusion allowing increased chemotherapy tolerance
Treatment with erythropoiesis stimulating agents (ESAs)

Question 18

Erythropoiesis Stimulating Agents (ESAs)

Answer 18

Epoetin alpha and darbepoetin alpha are the most common
Reticulocytes peak after 10 days; Hct and Hgb rise within 2-6 weeks
Decreases the need for blood transfusions
Most common cause of nonresponse is iron deficiency

Question 19

Black Box warnings for ESAs

Answer 19

Reduced overall survival and/or increased risk of progression or recurrence in anemic patients with breast, cervical, head and neck, lymphoid, and non-small cell lung cancer
Not recommended for anemic cancer patients receiving myelosuppressive chemotherapy when the expected outcome is curative (controversial)
Studies show an increased risk of death and serious CV events (e.g., MI, stroke) when ESAs were used to achieve higher target Hgb compared with lower Hgb levels

Other risks include hypertension and thrombosis

Question 20

Several causes of macrocytic anemias:

Answer 20

Anemia associated with B12 deficiency
Anemia associated with folic acid deficiency
Anemia caused by metabolic or inherited defects associated with decreased ability to utilize vitamin B12 or folic acid

Question 21

treatment of various causes of macrocytic anemias

Answer 21

Low vitamin B12 – vitamin B12 supplementation
Cyanocobalamin and hydroxocobalamin
Low folic acid – folic acid supplementation
No effect on the neurological symptoms associated with megaloblastic anemias

Determine whether malabsorption is an issue (PO vs. IM/IV)