Treatement of Anemia Flashcards
First line therapy of IDA?
oral iron
Drawbacks of oral therapy
2
- Absorption is limited in malabsorptive states and in chronic kidney disease
- May not be able to keep up with the bleeding in cases of ongoing blood loss
70% non-compliance rate due to GI side effects. What are they?
7
Constipation Nausea/vomiting Diarrhea Metallic taste Thick green/black stool May exacerbate inflammatory bowel disease
Where are iron supplements absorbed?
Is not absorbed in the stomach but best in the duodenum and proximal jejunum
How do you decrease the degree of side effects?
decrease the dose
What are the kinds of formulas for oral iron administration?
Avoid enteric coated or sustained release
When should we eat with iron supplementation?
What are the worst offenders?
- Give on an empty stomach as most foods impair the absorption 2. (worst offenders are calcium containing foods, cereals, fiber, tea, coffee, eggs, milk)
What meds should we avoid or take at a later time when taking oral supplementation?
2
- Give 2 hours before or 4 hours post antacids
- Calcium significantly impairs absorption
- To increase absorption give with Ascorbic acid or orange juice
What could you try if lowering the dose of the pills doesn’t work before going to IV therapy?
Ferrous sulfate elixir 44mg/5mL may be better tolerated than the tablets if patients have significant GI upset on the tablets
-rinse mouth out
How much of elemental iron is recommened a day for adults?
150-200mg/day of elemental iron
Whats the best option and how much elemental iron does it have?
Least expensive is ferrous sulfate 325mg tabs contain 65mg of elemental iron (varies from 300-325 iron salts and 60-65 elemental iron)
HOw much elemental iron is in Ferrous fumerate?
67-106 mg
How much elemental iron is in ferrous sulfate (325mg) ?
60-65 mg
How much elemental iron is in ferrous gluconate 325mg?
How much elemental iron is in Elixir (ferrous sulfate)?
28-37 mg
44 mg/5mL
Duration of therapy?
2
Some stop treatment when the Hgb normalizes
Others treat for 6 months after the Hgb has normalized
Whats the advantages and disadvantagses of stopping when it normalizes?
could still have a low iron even though the HgB has normalized
If youre giving the iron for pica or RLS how long will it take to go away?
often disappears right away
May feel better in a few days
When will reticulocytosis go away with iron treatment?
7-10 days
How long will it take for HgB to start getting better and nromalize?
Hgb increases slowly after 1-2 weeks of treatment and should rise 2 g/dL at 5 weeks, hgb should normalize in 6-8 weeks
How long will it take for smooth tongue to go away with iron?
returns to normal in weeks to months
Whats an alternative to pills and how should we take this?
3
- 10 mL of iron sulfate elixir once daily (88 mg elemental iron)
- mixed in a small glass of orange juice and taken
- 30 min prior to breakfast (reduce the dose to 5 mL if irritation occurs, if unable to drink juice can give with 50-100 mg vitamin C (ascorbic acid)
Indications for IV iron?
5
Excessive ongoing blood loss Inflammatory bowel disease Chronic kidney disease Cancer patients Inability to tolerate oral iron
Why is iron IM not recommended?
4
- PAINFUL,
- can stain the skin at injection site,
- mobilization of iron from IM sites is slow,
- has been associated with gluteal sarcomas
What are the kinds of IV iron?
4
Iron Dextran (INFeD) Ferris gluconate (ferriecit) Iron sucrose aka saccharate (Venofer) Ferumoxytol (Faraheme)
If they have any asthma or drug allergy in their history or RA what do you have to medicate with?
prednisone
What drug could alter MRI results?
Ferumoxytol
Side effects of IV iron?
5
1. Life threatening adverse drug effects have been seen in all preparations SE – 2. fever, 3. arthralgias, 4. myalgias, 5. Rheumatoid arthritis flares
How much folic acid should we take daily for a deficiency and for how long?
1-5 mg/day
Continue for 1-4 months
Why do we need to rule out B12 deficiency before treating folate?
Can partially reverse some the hematologic abnormalities of B12 deficiency BUT the neurologic manifestations will progress!
How should we treat permanenetly decreased ability to absorb detary B12?
3
- IV
- 1000mcg IM daily for 1 week
1000mcg IM weekly for 4 weeks
1000mcg IM once monthly - Or until corrected
When is the most appropraite time to try oral replacement of B12?
What kind of preparations that we should avoid?
after restoring deficiency with parenteral B12 (1000-2000mcg/day)
Avoid sustained or time released preparations
MUST MONITOR CLOSELY
Effects fo therapy:
When will they feel better?
When will reticulocytes go up?
When will HgB rise?
When will neuro symptoms improve?
- Patient may feel better within a few days
- Reticulocytosis noted in 3-4 days
- Hgb rises within 10 days and normalizes within 8 weeks
- Neurologic abnormalities improve over 3 months and maximum improvement noted at 6-12 months
Drugs used to stimulate RBC production?
2
Epoetin alfa (Epogen, Procrit)
Darbepoetin alfa (Aranesp)
MOA for Erythropoiesis-Stimulating Agents?
- Induces erythropoiesis by stimulating the division and differentiation of committed erythroid progenitor cells
- Induces the release of reticulocytes from the bone marrow
Patients disease state really matters when dosing RBC production drugs
LOOK them up
Indications for Erythropoiesis-Stimulating Agents?
Used for the prevention of blood transfusion in the following causes of anemia
Examples of when they would need Erythropoiesis-Stimulating Agents?
5
- Chronic kidney disease hgb
HgB level for EPS in Chronic kidney disease on dialysis?
below 10 and treat up to 11
HgB level for EPS in Chronic kidney disease not on dialysis?
below ten and treat up tpt ten
HgB level for EPS with cancer?
start with hgb
HgB levl for EPS with HIV?
hgb levels should not >12 g/dL
HgB level for EPS in presurgical patients?
> 10 mg/dL ≤13 g/dL
Dose adjustments in CKD: If Hgb increases by greater than 1 in 2 weeks what do we do?
Decrease dose by ≥25%
Dose adjustments in CKD: If Hgb does not increase by greater than 4 weeks what do we do?
Increase dose by 25%
If no response in HgB by how many weeks its not going to work?
12 weeks