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Heme > Treatment of Anemia > Flashcards

Treatment of Anemia Flashcards

1
Q

First line therapy for IDA (Iron deficiency anemia)?

Drawbacks of this?

A

Oral iron
-adjust dose down if patient complains of side effects

drawbacks

  • 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
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2
Q

SE of po iron?

Non-compliance rate?

A
  • constipation
  • diarrhea
  • metallic taste
  • thick green/black stool
  • may exacerbate inflammatory bowel disease

70% non-compliance rate

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3
Q

Where is iron best absorbed?

Recommendations for administration?

A

The duodenum and proximal jejunum, not stomach

Take on a empty stomach with acidic juice, not food or calcium. Give two hours before or 4 hours after antacids

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4
Q

What could you try if lowering the dose of the pills doesn’t work before going to IV therapy?

A

Ferrous sulfate elixir 44mg/5nL

  • may be tolerated better than tablets
  • can stain teeth
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5
Q

What is the adult dosing of iron?

What is the least expensive form?

A

adults: 150-200mg/day of elemental iron

Ferrous sulfate 325mg (contains 65mg of elemental iron)

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6
Q

How long do you continue iron therapy after hgb has normalized?

A
  • some stop treatment at that point (post op patient)

- others treat for 6 months after to replete iron stores (ferritin) (for chronic anemia)

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7
Q

How does the body respond to iron therapy and in what time frame?

A
  • Pica for ice and restless leg syndrome disappear right away
  • Feel better in a few days
  • reticulocytosis will be noted in 7-10 days
  • hgb increases slowly after 1-2 weeks of treatment and should rise 2 g/dL at 5 weeks, normalize in 6-8 weeks
  • Tongue (if smooth) returns to normal in weeks to months
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8
Q

Indications for IV (parenteral) iron

A
  • excessive ongoing blood loss
  • inflammatory bowel disease
  • chronic kidney disease
  • cancer patients (with severe anemia)
  • inability to tolerate oral iron

**Don’t use IV iron if blood is going to do a better job

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9
Q

Is IM iron approved?

A

Yes, Iron dextran (INFeD).

Would not recommend this due to: painful, can stain skin at injection site, mobilization of irom from IM sites is slow, associated with gluteal sarcomas

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10
Q

SE of IV iron

A
  • life threatening adverse drug effects
  • fever, arthralgias, myalgias, rheumatoid arthritis flares
  • *H/o asthma, rheumatoid arthritis, or more than one drug allergy, premedicate with methylprednisolone to prevent
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11
Q

Dose calculation of iron deficit?

A

Sike! go online.

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12
Q

How do you treat folic acid deficiency?

A

Treat with 1-5 mg/day of folic acide for 1-4 months.

***Rule out B12 before treating with folic acid! B12 def can cause permanent neuro sx.

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13
Q

How do you treat B12 (Cyanobalamin) defiency?

A

Generally give IM B12

  • 1000mcg IM daily for 1 week
  • followed by 1000mcg IM for 4 weeks
  • followed by 1000mcg IM once monthly or until corrected

Can give IV
-when treating a pt that has a permanantly decreased ability to absorb dietary vitamin B12 (pernicious anemia, gastrectomy, surgical removal of the terminal ileum)

Can give oral replacement

  • 1000-2000 mcg/day
  • need to monitor them closely
  • might try this after restoring deficiency with parenteral B12
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14
Q

How does the body respond to B12 therapy and in what time frame?

A
  • feel better in a few days
  • reticulocytosis noted in 3-4 day
  • hgb rises within 10 days and normalizes within 8 weeks
  • neurologic abnormalities improve over 3 months and max noted at 6-12 months
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15
Q

What are some drugs to stimulate RBC production?

A 
Epoetin alfa (Epogen, Procrit)
Darbepoetin alfa (Aranesp)

These are in the drug class Erythropoiesis-Stimulating Agents (ESA), growth factor, recombinant human erythropoietin, colony stimulating factor

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16
Q

Erythropoiesis-Stimulating Agents (ESA)

MOA

A

MOa

  • induces erythropoiesis by stimulating the division and differentiation of committed erythroid progenitor cells
  • induces the release of reticulocytes from the bone marrow
  • basically just replacing EPO
17
Q

Erythropoiesis-Stimulating Agents (ESA)

Indications

A

Used for the PREVENTION od blood transfusion in the following causes of anemia:

  • chronic kidney disease(hgb 12)
  • pre-op surgery planning (but not cardiovascular or vascular surgery) (hgb >10 and =13)
  • myelodysplastic syndrome (off label)(no parameterrs given)

These indications are the same for Epoetin alfa and Darbepoetin alfa)

**Its not instead of transfusion. If they need blood, give them blood.

18
Q

What is important to remember when treating a chronic kidney disease patient with Erythropoiesis-Stimulating Agents (ESA)?

A

You have to follow them!

You change the treatment a bunch. If no response in hgb in 12 weeks, its not going to work.

(they don’t produce EPO and they don’t absorb well)

19
Q

What is important to remember when treating a chemo patient with Erythropoiesis-Stimulating Agents (ESA)?

A

You have to follow them!

You change the treatment a bunch. If no response in hgb in 8 weeks, its not going to work.

20
Q

What is important to remember when treating a HIV patient with Erythropoiesis-Stimulating Agents (ESA)?

A

If no response in hgb in 8 weeks, increase dose by 50-1000U/kg at 4-8 week intervals. If no response by 8 weeks, then stop.

Stop once hgb is >12

21
Q

Labs/ monitoring in ESA patients

A

Prior to therapy:

  • make sure they dont have: B12, folate, or bleeding
  • treat other causes of anemia
  • hgb once weekly until matintenace is reached then once monthly
  • likely continue oral iron therapy
  • monitor iron studies
  • monitor for blood clots and HTN
22
Q

Due to the risks of ESAs in cancer patients, what do you have to do?

A

enroll in ESA APPRISE to prescribe and enroll pt in it too.

23
Q

ESAs have a black box warning for what patient populations?

A

Cancer patients- can make cancer worse and decrese overall survival

CKD patients- increased risk of death

CV events- increased risk of CV events

24
Q

ESA

SE

A
  • cancer patients: tumore may grow faster and they may die sooner
  • htn, edema, abd pain, dyspnea
  • rare: chest pain, CHF, MI, shit like that.
  • Pure red cell aplasia (when the bone marrow ceases to produce red cells- autoimmune)
25
Q

ESA

CI

A
  • uncontrolled hypertension
  • history of pure red cell aplasia (due to ESAs)
  • allergy to the drug or any component of the formulation
26
Q

ESA take home points

A
  • use only in symptomatic anemia to avoid having to transfuse RBCs
  • use the lowest dose necessary
  • educate the pts
  • treat the patient not the lab result
  • watch for clots
  • patients reliable for follow up only
27
Q

First line therapy in Anemia of chronic disease?

A

1st- treat underlying cause

  • ESAs are indicated after other treatments have been tried and failed
  • target hgb 12 g/dL for blood transfusion and endpoint for using ESAs
  • off-lable but common use

Heme (13 decks)

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