Treatment of Anemia Flashcards
First line therapy for IDA (Iron deficiency anemia)?
Drawbacks of this?
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
SE of po iron?
Non-compliance rate?
- constipation
- diarrhea
- metallic taste
- thick green/black stool
- may exacerbate inflammatory bowel disease
70% non-compliance rate
Where is iron best absorbed?
Recommendations for administration?
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
What could you try if lowering the dose of the pills doesn’t work before going to IV therapy?
Ferrous sulfate elixir 44mg/5nL
- may be tolerated better than tablets
- can stain teeth
What is the adult dosing of iron?
What is the least expensive form?
adults: 150-200mg/day of elemental iron
Ferrous sulfate 325mg (contains 65mg of elemental iron)
How long do you continue iron therapy after hgb has normalized?
- some stop treatment at that point (post op patient)
- others treat for 6 months after to replete iron stores (ferritin) (for chronic anemia)
How does the body respond to iron therapy and in what time frame?
- 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
Indications for IV (parenteral) iron
- 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
Is IM iron approved?
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
SE of IV iron
- 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
Dose calculation of iron deficit?
Sike! go online.
How do you treat folic acid deficiency?
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.
How do you treat B12 (Cyanobalamin) defiency?
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
How does the body respond to B12 therapy and in what time frame?
- 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
What are some drugs to stimulate RBC production?
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
Erythropoiesis-Stimulating Agents (ESA)
MOA
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
Erythropoiesis-Stimulating Agents (ESA)
Indications
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.
What is important to remember when treating a chronic kidney disease patient with Erythropoiesis-Stimulating Agents (ESA)?
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)
What is important to remember when treating a chemo patient with Erythropoiesis-Stimulating Agents (ESA)?
You have to follow them!
You change the treatment a bunch. If no response in hgb in 8 weeks, its not going to work.
What is important to remember when treating a HIV patient with Erythropoiesis-Stimulating Agents (ESA)?
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
Labs/ monitoring in ESA patients
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
Due to the risks of ESAs in cancer patients, what do you have to do?
enroll in ESA APPRISE to prescribe and enroll pt in it too.
ESAs have a black box warning for what patient populations?
Cancer patients- can make cancer worse and decrese overall survival
CKD patients- increased risk of death
CV events- increased risk of CV events
ESA
SE
- 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)
ESA
CI
- uncontrolled hypertension
- history of pure red cell aplasia (due to ESAs)
- allergy to the drug or any component of the formulation
ESA take home points
- 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
First line therapy in Anemia of chronic disease?
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
