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Heme/Genetics > Pharm > Flashcards

Pharm Flashcards

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1
Q

form of iron most easily absorbed

A

Ferrous iron Fe2+

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2
Q

Goals of therapy for iron deficient anemia

A
  • Replenish iron stores
  • Improve sx
  • Treat underlying cause of IDA (must ID cause!!). In men and non-menstruating women new onset IDA need to rule out blood loss from occult GI malignancy or other bleeding lesion
  • Prevent organ damage, ischemia, progression of anemia
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3
Q

Iron deficient anemia Indications for Oral therapy for

A
  • IDA
  • IDA w/o anemia
  • Nutritional support to prevent deficiency
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4
Q

Iron deficient anemia

indications for parenteral therapy

A
  • GI intolerance of oral iron therapy
  • Preference to replenish iron stores in 1-2 visits vs. several months
  • Mal-absorption syndromes
  • Long-term non-adherence
  • Ongoing blood loss that exceeds the capacity of oral iron to meet needs
  • Refusal to accept blood transfusions for a significant blood loss
  • Anemia due to chronic kidney disease, esp undergoing hemodialysis
  • CA pts receiving chemo on EPO-stimulating agents
  • Co-existing inflammatory state that interferes with iron homeostasis
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5
Q

How is dietary supplementation used in treatment of iron deficient anemia

A

Never used alone, only in addition to iron supplementation

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6
Q

Recommendations for children dietary intake to avoid iron deficient anemia

A
  • <12 months fed breast milk or iron-fortified formula
  • cow’s milk ok if no evidence of cow’s milk protein-induced colitis
  • Infants should not be given low-iron formula or unmodified cows milk
  • 6+ months, esp breastfed, ensure adequate iron consumption in food (fortified cereals, meats)
  • 12+ months: cow’s milk limited to no more than 20 oz a day (higher intake of milk related to increased risk for iron deficiency)
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7
Q

Oral Iron

A
  • OTC
  • Avoid slow release or sustained-release products
  • Soluble Fe2+ iron salts are best
  • % of elemental iron will differ by salt
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8
Q

Oral Iron Dosing

A
  • Depends on age, estimated iron deficit, speed needs to be corrected, and tolerance - Traditional: 150-200 mg elemental iron daily in 2-3 divided doses
  • Fall 2017 Update: lower dose (40-80 mg/daily) every other day
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9
Q

Older patient oral iron dosing

A

lower doses may be needed to avoid toxicity and ADE

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10
Q

Children patient oral iron dosing dose forms

A

tabs

liquid (drops, elixer, syrup)

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11
Q

duration of oral iron therapy

A
  • Differs among experts and in different settings
  • Some stop when hgb normalizes bc allows earlier detection of recurrent anemia
  • Others treat 6 montsh past hgb normalization to completely replenish iron stores and to prevent relapse

** Might take 6-8 weeks to fully ameliorate anemia and as long as 6 months to replete iron stores

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12
Q

monitoring parameters oral iron therapy - adults

list two labs and one other thing to check

A
  1. Hgb
  2. Reticulocytes
  3. Ability to tolerate iron
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13
Q

Monitoring parameters for oral iron therapy

- Hgb

A
  • will rise slowly after 1-2 weeks of treatment
  • should rise by 2 g/dL over three weeks
  • 50% correction after a month
  • normal after 6-8 weeks
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14
Q

Monitoring parameters for oral iron therapy

- reticulocyte count

A

should peak 7-10 after treatment initiated, is a good sign of response to therapy (mod to severe)

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15
Q

Monitoring parameters children with mild anemia

A

(Hgb ≥ 9 g/dL)

Hgb or CBC 4 weeks after therapy, should see hgb rise of >1g/dL

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16
Q

Monitoring parameters children with moderate to severe anemia

A

(Hub < 9 g/dL)

  • Rise in retic in 72 hours
  • Check Hgb or CBC 1-2 weeks after treatment starts, Hgb should rise at least 1 g/dL within 2 weeks
  • Check CBC, Hgb, MCV, RDW, serum ferritin 3 months after starting treatment
  • Continue iron supplements additional month after all parameters normalize to ensure replacement of body stores
  • F/u essential to confirm anemia was due to iron deficiency and that it was adequately treated (neuro deficits d/t iron deficiency!!)
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17
Q

Potential oral iron drug interactions

A
  • Aluminum, magnesium, calcium containing antacids (give Fe 2 hrs before or 4 hrs after ingestion of antacids)
  • Tetracycline and doxycycline
  • OTC acid blockers (ranitidine, famotidine)
  • PPI (omeprazole)
  • Cholestyramine (bile acid binder)
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18
Q

How to calculate amount of elemental iron in a dose of oral iron salt

A

% elemental Fe X dose

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19
Q

Ferrous sulfate example of how to calculate elemental iron

A

Dose - 325 mg
% elemental Fe - 20-30%
Fe per tablet

(325)(20%) = 64 mg

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20
Q

what factors affect bioavailability and absorption of iron

A
  • Some foods inhibit absorption
  • vitamin C enhances absorption
  • best absorbed as Fe2+ in mildly acidic stomach (empty stomach)
  • divide daily dose into multiple doses: percent of iron decreases as the dose increases
21
Q

Foods to avoid with oral iron

A
  • calcium containing foods like milk, yogurt, cheese
  • calcium supplements including antacids
  • dietary fiber
  • tea and coffee
  • eggs
22
Q

List 5 reasons for oral iron treatment failure

A
  • Non-adherence!!
  • Misdiagnosis
  • Mal-absorption due to previous gastrectomy, celiac disease, inflammatory bowel disease,
  • Blood loss equal to rate of production
  • Impaired response when coexisting cause for anemia exists
23
Q

List of 3 common reasons for oral iron treatment in kids

A
  • Cow’s milk protein-induced colitis
  • Celiac disease
  • Inflammatory bowel disease
24
Q
  1. ID the foods that should be recommended to improve iron deficient anemia
A

Animal products (heme) are more easily absorbed

  • Meat
  • Fish
  • Poultry

Plant products (non-heme)

  • Eggs (not a plant but non-heme)
  • Vegetables
  • Fruits
  • Legumes
  • Enriched breads and cereals
  • Other: molasses, peanuts, pine nuts, etc.
25
Q

oral iron therapy ADE

A
  • GI side effects most common (dark feces, constipation/diarrhea, nausea, vomiting
  • Metallic taste
  • Epigastric distress
  • Flatulence
  • Black/green tarry stools that stain clothing ☹
  • Children: liquid preps can stain teeth and hands if suck
26
Q

Strategies to improve tolerability of oral iron

A
  • Take iron with meals or reduce daily dose
  • Gradually increase dose of iron to minimize GI effects (easier to titrate on liquid than tablet)
  • Stool softeners are largely ineffective
  • Make dietary modification: take with food or milk (might reduce absorption)
  • Switch to formulation with lower amt of elemental iron
  • Consider IV iron which does not have GI side effects (if switch, discontinue oral iron)
27
Q

Goal of Vitamin B12 therapy

A
  • Reverse hematologic manifestations
  • Replace vitamin B12 body stores
  • Prevent or resolve neurologic manifestations
28
Q

Foods that should be recommended to improve vitamin B12 deficiency

A
  • Meat, organs, clams
  • Fortified breakfast cereals
  • Fish: rainbow trout, sockeye salmon, canned tuna
  • Milk and yogurt
29
Q

Vitamin B12 forms

A
  • Liquid
  • Tablet
  • Lozenge
  • Injection
  • Nasal spray
  • Sublingual tablet
30
Q

Pernicious Anemia B12 treatment dose

A
  • 1000 mcg every day for a week
  • then 1 mg every week for four weeks
  • 1 mg for month if needed
31
Q

Bariatric surgery B12 treatment dose

A
  • Oral 350 – 500 mcg daily
  • 1000 mcg IM of SQ monthly
  • 1 per week nasal spray
32
Q

Oral B12

  • good for what diet
  • what is required
  • avoid what
A
  • Good for vegetarians
  • Requires much greater adherence
  • Avoid timed release
33
Q

Response to B12 tx

A
  • Markers of hemolysis: serum iron, indirect bilirubin and LDH will fall rapidly after parental B12
  • Retic count changes from megaloblastic to normoblastic within 3-4 days
  • Anemia improves 1-2 week and normalizes 4-8 weeks. Will feel better before any blood work changes
  • Hypokalemia during first week due to increase in K+ use during production of new hematopoietic cells
  • Neuro abnormalities, if present, improve over 3 months, max improvement 6-12 months
34
Q

Goals of folic acid deficiency anemia treatment

A
  • Induce hematologic remission
  • Replace folic acid body stores
  • Resolve signs & symptoms of folic acid deficiency
35
Q

drugs that may either interfere with the absorption of or antagonize the actions of folic acid

A

a. Phenytoin and other anticonvulsants
b. Oral contraceptives
c. Methotrexate
d. Trimethoprim
e. alcohol

36
Q

Three factors that place pt at risk for folic acid deficiency

A
  • Impaired absorption
  • Increased requirement
  • Impaired utilization
37
Q

Impaired absorption for folic acid

A
  • Intestinal short circuits
  • Celiac disease
  • Inflammatory bowel disease, infiltrative bowel disease
38
Q

Increased requirement for folic acid

A
  • Pregnancy
  • Infancy
  • Growth spurts in adolescent
  • Hemolytic anemia
  • Neoplastic disease (leukemia, lymphoma)
  • Chronic inflammatory diseases
39
Q

Impaired utilization of folic acid

A
  • Folic acid antagonists
  • Increased loss
  • hemodialysis
40
Q

foods that should be recommended to improve folic acid deficiency

A
  • Dark leafy greens, broccoli, asparagus, carrots, celery, avocado, beets
  • Fruit: papaya, orange, grapefruit, strawberries
  • Legumes
41
Q

common signs and symptoms of folic acid deficiency

A
  • Fatigue, pallor, tachycardia, pale mucous membranes, SOB, cardiac decompensations, dizziness, lightheadedness, weakness
  • Dysphagia, anorexia, weight loss, beefy red tongue, personality changes, ecchymosis, purpura
  • Loss of skin elasticity, early graying hair
42
Q

What is major sx diff between vitamin B12 deficient anemia and folic acid deficient anemia

A

neuro sx in B12 but not folic acid

43
Q

Folic acid deficient anemia lab findings

A
  • Increased MCV, MCH (macrolytic anemia)

- Decreased serum folic acid level, retic count, Hgb, Hct, RBC

44
Q

Folic acid dosing

  • Deficient anemia
  • Megaloblastic anemia from anticoag therapy
  • Pregnant/lactating women
  • Women of childbearing age
  • High risk females
A
  • 1 mg daily for megaloblastic and macrolytic anemia due to folic acid deficiency
  • 0.5 mg daily for megaloblastic anemia from anticonvulsive therapy
  • Pregnant/lactating women: 800 mcg/day
  • Females of childbearing potential: 400 to 800 mcg/day to prevent neural tube defects
  • High risk females (previous preg with neural tube defects, hx of neural tube defects) 4 mg/day
45
Q

Duration of folic acid treatment

A
  • 1-4 months to restore folic acid stores

- chronic therapy when not possible to correct underlying problem

46
Q

Monitoring parameters for folic acid treatment

A
  • Should feel better in 2-3 days
  • Peak retic response in 7-10 days
  • Hct and Hgb should increase within two weeks
    (Recheck in 2-4 weeks after starting therapy)
47
Q

Mechanism of ESA (anemia of chronic disease)

A
  • Same biological effect as EPO produced by the kidney

- Stimulates division/differentiation of erythroid progenitors in bone marrow

48
Q

Monitoring parameter for anemia of chronic disesae

A
  • Hgb must be monitored
49
Q

What are Hgb goals for anemia of chronic disease treatment

A
  • Not to exceed 12 g/dL with treatment

- Hgb should not increase more than 1 g/dL every two week

Heme/Genetics (15 decks)

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