Nutritonal Anemias

Question 1

Macrocytic Anemia’s—MCV > 100 fL

Answer 1

Vitamin B12 (cobalamin, Cbl) deficiency
Folate deficiency

Question 2

Vitamin B12 deficiency

Answer 2

Meat & dairy products ONLY dietary sources of B12 for humans

Adequate absorption

Question 3

Etiologies of B12 defiency

Answer 3

Pernicious anemia:

Chronic Atrophic Gastritis:

Question 4

Clinical presentation

Answer 4

Macrocytic anemia
Hyperhomcysteinemia:
Neurologic changes (only seen in B12 deficiency):
Increased risk of osteoporosis:

Question 5

Folate deficiency–Etiologies

Answer 5

Poor nutrition*—folate is found in meats, green leafy vegetables, nuts and fruit
Alcoholism
Infant’s who are primarily fed goat’s milk
When there are increased requirements:
Pregnancy (Folate prevents ? neural tube defects)
Patients w/ chronic hemolytic anemia
Drugs that interfere w/ folate metabolism— Trimethoprim, methotrexate, phenytoin

Question 6

Folate Deficiency–Presentation

Answer 6

Macrocytic anemia and hyperhomocysteinemia

NO neurologic findings

Question 7

Time frame for B12 and Folate Deficiency

Answer 7

Folate deficiency can occur within 4-5 months intake is diminished
B12 deficiency occurs after YEARS of inadequate intake because B12 stores in the body are so high

Question 8

Diagnosing B12/Folate deficiency Suspect:

Answer 8

Presence of hypersegmented neutrophils/patient who has neurologic symptoms even if NOT anemic
Oval macrocytic RBCs on peripheral smear
Pancytopenia of uncertain cause
Unexplained neurologic signs: dementia, sensory ataxia, and parestheisias

Question 9

Diagnosing B12/Folate deficiency Special Populations

Answer 9

Older adults
Alcoholics
Patients w/ malnutrition
Strict vegans
Patients who have undergone bariatric surgery and are not being compliant w/ their vitamins

Question 10

Laboratory evaluation B12/Folate

Answer 10

Measure serum B12 level:
Measure serum folate level:
Metabolite testing

Question 11

Laboratory evaluation B12/Folate Metabolic testing

Answer 11

Measure the metabolic intermediates: methymalonic acid and homocysteine
If these are ELEVATED then true B12 deficiency exists
If MMA is normal and homocysteine is increased folate deficiency is present

Question 12

Diagnosing pernicious anemia

Answer 12

Measure antibodies to IF—specificity of 100%
Elevated gastrin/low pepsinogen—highly sensitive if antibodies negative
Schilling test NO LONGER used

Question 13

Treatment of folate deficiency

Answer 13

Folic acid 1-5 mg po daily for 1-4 months or until complete hematologic recovery
Usually 1 mg a day is sufficient
Taking folic acid can partially reverse some of the hematologic effects of B12 deficiency

Question 14

Treatment for B12 deficiency

Answer 14

Usually treated w/ IM or deep SQ injections of Cbl
Oral Cbl available—1-2 mg a day (200 x higher then the minimum daily requirement!
Also sublingual** and nasal spray preparations

Question 15

Iron deficiency anemia—MCV < 80 fL

Answer 15

More than one quarter of the world’s population is anemic
½ of that burden is iron deficiency anemia
Most prevalent among preschool children and women

Question 16

Absolute iron deficiency:

Answer 16

Iron stores in the bone marrow & in the liver/spleen are ABSENT
Serum ferritin is LOW

Question 17

Absolute iron deficiency:

Etiologies

Answer 17

Poor dietary intake (foods, meds, celiac dz, atrophic gastritis)
Reduced iron absorption (gastric bypass)
Increased blood loss—Western world safest to assume cause is blood loss and search for that cause
Intravascular hemolysis
Congenital iron deficiency

Question 18

Functional iron deficiency:

Answer 18

Insufficient availability of iron in the face of normal or increased iron stores

Question 19

Functional iron deficiency:

Anemia of inflammation (anemia of chronic disease)

Answer 19

Hepcidin-induced block in the release of iron from the macrophage back into circulation
This makes iron less available for red cell production
Seen in patients w/ infection, inflammation, or malignancy

Question 20

Functional iron deficiency treatment

Answer 20

erythropoiesis- stimulating agents
Available body iron stores may be unable to release iron rapidly enough to satisfy the increase brought about by the stimulating agent

Question 21

Clinical manifestations for Iron deficiency

Answer 21

Asymptomatic**
Weakness
Fatigue
Headache
Irritability
Exercise intolerance
Glossal pain & reduced salivary flow (lead to dry mouth)
May lead to exacerbation of co-morbidity (heart failure,angina(chest pain))
Pica
Restless leg syndrome

Question 22

Iron studies—normal values

Answer 22

Serum Iron (Fe) mcg/dL – 60 – 170
Ferritin ng/mL – 12 – 150 (females)/12 – 300 (males)
Transferrin/Total iron binding capacity (TIBC) microgm/dL –240 – 360*
Transferrin saturation (Fe/TIBC) % –15– 50
Rarely is it necessary to due a bone marrow biopsy for testing for stainable iron*

Question 23

Differential diagnosis Iron deficiency

Answer 23

Thalassemia:
Anemia of chronic inflammation:
Sideroblastic Anemias:

Question 24

Thalassemia:

Answer 24

May be + family hx
Serum Fe are normal to high
Hgb A2 level increased
RBC count is high

Question 25

Anemia of chronic inflammation:

Answer 25

Serum Fe and TIBC are low
Normal or increased Ferritin
Critical to look at the clinical setting and do thorough evaluation for chronic inflammation**

Question 26

Sideroblastic Anemias:

Answer 26

Diagnosis made by demonstrating ringed sideroblasts on Prussian Blue stain of the bone marrow
Most commonly drug induced or may be due to a myelodysplastic disorder

Question 27

Treatment Iron deficiency anemia

Answer 27

Oral iron therapy is generally considered front line therapy

There are conditions where oral iron therapy is either poorly tolerated or ineffective:

Question 28

Iron salts should not be given with:

Answer 28

Food because many substance in food bind iron and impair its absorption
Antacids, H2 blockers, PPIs
Calcium containing foods, cereals, dietary fiber, coffee, tea and milk
Certain anitbiotics (e.g. quinalones, tetracyclines)

Question 29

how should iron be taken

Answer 29

Iron should be given 2 hours before or 4 hours after antacids
Iron is best absorbed in a mildly acidic medium so adding vitamin C or OJ is beneficial

Question 30

iron treatment side effects

Answer 30

Recommended treatment is 150 – 200 mg of ELEMENTAL Fe daily

50%) nausea, constipation, diarrhea, epigastric pain, vomiting (black stools

Question 31

iron treatment side effects options

Answer 31

Switch to a preparation w/ lower dose of elemental iron
Slowly increase from 1 pill a day to 3
Iron may be taken with meals, but it will decrease absorption some
Use a liquid preparation (especially helpful in older adults)
Try IV iron