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Anemia Flashcards

1
Q

class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:

What is the % of elemental iron in oral products having:

A

class:

Indications:

MOA:

Dosage forms:

Dosing:

Max dose:

Contraindications:

Warnings:

Side Effects:

Monitoring:

Pearls/Notes:

Drug-Drug/Food interactions:

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2
Q

What is anemia?

Anemia is defined as: a decrease in ___________

A

hemoglobin (Hgb) and hematocrit (Hct) concentrations below the normal range for age and gender

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3
Q

what is the normal range for (Hgb or Hb) in:

For Females
For Males

A

For Females: (12-16 g/dL)

For Males: (13.5-18 g/dL)

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4
Q

what is the normal range for Hct in:

For Females
For Males

A

For Females: (36-46%)

For Males: ( 38-50%)

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5
Q

Hemoglobin (Hgb):

A
  • is an iron rich protein found in red blood cells.
  • its main purpose is to carry oxygen from the lungs to the tissues
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6
Q

RBCs are formed in the ________, where they take up ______________ before being released into the circulation as immature RBCs, known as ____________.

After 1-2 days these RBCs then mature into __________ which have a lifespan of about ___________.

The mature red blood cells are removed from circulation by ___________

A

bone marrow

Hgb & iron

reticulocytes

erythrocytes

120 days

macrophages, mainly in the spleen

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7
Q

Anemia can occur a number of different ways which includes:

-
-

A
  • impaired red blood cell production
  • increased red blood cell destruction (hemolysis)
  • blood loss
  • nutritional deficiencies (vitamin B12, folate, iron)
  • can occur as a complication of another medical disorder like chronic kidney disease or a malignancy
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8
Q

A decrease in Hgb or RBC volume results in ___

A

decreased oxygen carrying capacity of the blood.

A decreased oxygen supply can cause ischemic damage to many organs. In chronic anemia, the heart tries to compensate for the low oxygen by pumping faster (tachycardia). This can increase the mass of the ventricular wall (hypertrophy) and lead to heart failure.

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9
Q

When anemia becomes prolonged, the lack of oxygen in the blood can lead to classic symptoms:

A
  • fatigue
  • weakness
  • shortness of breath
  • exercise intolerance
  • headache
  • dizziness
  • anorexia
  • pallor “an unhealthy pale appearance”
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10
Q

If anemia becomes severe (like with acute blood loss), symptoms can be:

A

chest pain, palpitations, /tachycardia, fainting

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11
Q

With Iron deficiency anemia, some symptoms which can develop include:

A
  • Glossitis (an inflamed sore tongue)
  • koilonychias (thin, concave, spoon-shaped nails)
  • pica (cravings and eating non-foods such as chalk or clay or ice)
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12
Q

With vitamin B12 deficiency anemia, patients can present with ___

A

neurologic symptoms, including peripheral neuropathies, visual disturbances and/or psychiatric symptoms.

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13
Q

Vitamin B12 is also known as ______

A

Cobalamin

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14
Q

The type and cause of anemia CANNOT be determined based on ____.

The __________, which reflects the size or average blood volume of RBCs, can help determine the type of anemia and the possible underlying cause.

A

signs and symptoms alone.

(MCV) Mean Corpuscular Volume

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15
Q

What is the normal range for (MCV) Mean Corpuscular Volume?

A

80-100 fL

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16
Q

What does it mean when the MCV is < 80 fL?

A

microcytic anemia, red blood cells are smaller than normal. This is due to iron deficiency.

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17
Q

What does it mean when the MCV is > 100 fL?

A

macrocytic anemia, red blood cells are bigger than normal. This is due to vitamin B12 deficiency OR folate (vitamin B9) deficiency.

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18
Q

Red Blood Cell production is dependent on ________ and ______

A

erythropoietin, which is a hormone produced in the kidneys.

iron

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19
Q

reticulocytes are __________

A

immature red blood cells

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20
Q

Vitamin B12 is required for enzyme reactions involving _______

A

methylmalonic acid & homocysteine

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21
Q

A reticulocyte count measures ___________

What is the normal range for Reticulocyte Count?

A

the production of immature RBCs being made by the bone marrow.

(0.5%-2.5%)

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22
Q

When is the reticulocyte count higher than normal?

A

the reticulocyte count is elevated in acute blood loss (which can occur due to some trauma) or hemolysis.

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23
Q

When is the reticulocyte count lower than normal?

A

the reticulocyte count is decreased in untreated anemia due to iron, folate, or B12 deficiency and with bone marrow suppression.

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24
Q

What is the normal range for Vitamin B12?

A

> 200pg/mL

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25
Q

What is the normal range for folate (folic acid/vitamin B9)?

A

5-25 mcg/L

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26
Q

What medications can decrease the Vitamin B12 level?

A

PPIs
metformin

colchicine
chloramphenicol

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27
Q

what medications can decrease the folate level?

A

-phenytoin/fosphentoin
- phenobarbital
- primidone
- methotrexate
-Bactrim

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28
Q

For anemia, diagnosis of the underlying problem is important because___________

A

patients will present with similar symptoms, but the cause may be very different.

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29
Q

Dietary Iron is available in 2 forms:

A

Heme iron (found in meat and seafood)

non-heme iron (found in nuts, beans, vegetables, and fortified grains, such as cereals)

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30
Q

Which Dietary Iron is more readily absorbed?

A

Heme iron

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31
Q

How can one increase the absorption of non-heme iron?

A

consuming vitamin C (ascorbic acid)

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32
Q

Causes of Iron deficiency anemia, include:

A
  • iron poor diets (vegetables, vegan diets), malnutrition, disease related (dementia)
  • blood loss (acute hemorrhage, Chronic (heavy menses, peptic ulcer disease, inflammatory bowel disease), drug induced (NSAIDs, steroids, antiplatelets/anticoagulants)
  • decreased iron absorption (High gastric pH) from PPis, GI diseases (celiac disease, gastric bypass)
  • increased iron requirements (pregnancy, lactation)
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33
Q

With Iron deficiency anemia, the iron studies (iron panel) has 4 components:

-
-

A
  • serum iron (which is usually low), serum iron is transported via transferrin, so is bound to it.
  • serum ferritin (which is low), these are iron stores
  • transferrin saturation (TSAT) (is low), this is the amount of transferrin binding sites occupied by iron. “Meaning the % of binding sites that iron is binding to is low”
  • total iron binding capacity (TIBC) (is increased), this is the amount of transferrin binding sites available to bind iron or unbound sites. “Meaning this is the % of binding sites, the potential of binding sites, that iron is NOT bound too, which is high”
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34
Q

The Treatment for Iron Deficiency Anemia:

A

oral iron: 1st line
- 100-200mg elemental iron daily “dosing is based on ELEMENTAL iron”

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35
Q

What is the % of elemental iron in oral products having:

Ferrous gluconate

Ferrous Sulfate

Ferrous Sulfate, dried

Ferrous fumarate

Carbonyl iron, polysaccharide iron complex, ferric maltol

A

Ferrous gluconate = 12%

Ferrous Sulfate = 20%

Ferrous Sulfate, dried = 30%

Ferrous fumarate = 33%

Carbonyl iron, polysaccharide iron complex, ferric maltol = 100%

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36
Q

What is the % of elemental iron in oral products having:

Ferrous gluconate

A

12% elemental iron

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37
Q

What is the % of elemental iron in oral products having:

Ferrous Sulfate

A

20% elemental iron

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38
Q

What is the % of elemental iron in oral products having:

Ferrous Sulfate, dried

A

30% elemental iron

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39
Q

What is the % of elemental iron in oral products having:

Ferrous fumarate

A

33% elemental iron

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40
Q

Iron is a polyvalent ____

A

cation

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41
Q
A

class:

Indications:

Dosage forms:

Dosing:

Boxed Warnings:
- *Accidental overdose of iron-containing products is a leading cause of fatal poisoning in children under 6 years old; keep iron out of reach of children; in case of an accidental overdose, go to the emergency department or call a poison control center immediately (even if asymptomatic)

Contraindications:
hemochromatosis, hemolytic anemia, hemosiderosis

Warnings:

Side Effects:
- *constipation (dose-related), *dark and tarry stools, nausea, stomach upset

Monitoring:
- Hgb, iron studies, RBC indices, reticulocyte count

Pearls/Notes:
- to relieve GI upset patient can take with food. Food does decrease its absorption. Preferably want patient to take on an empty stomach, this is best for absorption. A stool softener (docusate) is often recommended to prevent iron induced constipation.

  • An acidic environment increases irons absorption
  • Sustained-release forms or EC forms of iron are NOT recommended. These agents release later on in the GI tract in a more alkaline environment, they move past the most acidic environment “the stomach” and release further downstream.
  • Antidote for iron overdose is deferoxamine (Desferal)

Drug-Drug/Food interactions:
-PPI & H2 receptor antagonists will increase pH, so iron absorption will decrease.

  • Antacids, H2 receptor antagonists and PPIs decrease iron absorption. Take iron 2 hours before or 4 hours after Antacids

Iron decreases absorption of:

  • tetracyclines & quinolones
    (take iron 2-4 hours before or 4-8 hours after)
  • levodopa, methyldopa, *levothyroxine, cefdinir
    (separate from iron by 2-4 hours)
  • oral bisphosphonates:
    (take iron 30 minutes after alendronate/risedronate or 1 hour after ibandronate)
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42
Q

What is the treatment goal for iron deficiency anemia?

A

1g/dL increase in Hgb every 2-3 weeks

**” we want to increase serum Hgb by 1g/dL every 2-3 weeks; continue treatment for 3-6 months after anemia has resolved until iron stores return to normal”

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43
Q

What is the treatment dose for oral iron therapy in iron deficiency anemia?

A

*recommended dose: 100-200mg of Elemental Iron per day

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44
Q

FeroSul

class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:

What is the % of elemental iron in oral products having:

Dosing: *325mg (65mg elemental iron) PO daily to TID

Pearls/Notes:
- most commonly prescribed and least effective
- 20% of drug is elemental iron in oral products

A

ferrous sulfate

Indications:

Dosage forms:

Dosing:

Boxed Warnings:
- *Accidental overdose of iron-containing products is a leading cause of fatal poisoning in children under 6 years old; keep iron out of reach of children; in case of an accidental overdose, go to the emergency department or call a poison control center immediately (even if asymptomatic)

Contraindications:
hemochromatosis, hemolytic anemia, hemosiderosis

Warnings:

Side Effects:
- *constipation (dose-related), *dark and tarry stools, nausea, stomach upset

Monitoring:
- Hgb, iron studies, RBC indices, reticulocyte count

Pearls/Notes:
- to relieve GI upset patient can take with food. Food does decrease its absorption. Preferably want patient to take on an empty stomach, this is best for absorption. A stool softener (docusate) is often recommended to prevent iron induced constipation.

  • An acidic environment increases irons absorption
  • Sustained-release forms or EC forms of iron are NOT recommended. These agents release later on in the GI tract in a more alkaline environment, they move past the most acidic environment “the stomach” and release further downstream.
  • Antidote for iron overdose is deferoxamine (Desferal)

Drug-Drug/Food interactions:
-PPI & H2 receptor antagonists will increase pH, so iron absorption will decrease.

  • Antacids, H2 receptor antagonists and PPIs decrease iron absorption. Take iron 2 hours before or 4 hours after Antacids

Iron decreases absorption of:

  • tetracyclines & quinolones
    (take iron 2-4 hours before or 4-8 hours after)
  • levodopa, methyldopa, *levothyroxine, cefdinir
    (separate from iron by 2-4 hours)
  • oral bisphosphonates:
    (take iron 30 minutes after alendronate/risedronate or 1 hour after ibandronate)
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45
Q

Fer-In-Sol

class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:

What is the % of elemental iron in oral products having:

A

Indications:

Dosage forms:

Dosing:

Boxed Warnings:
- *Accidental overdose of iron-containing products is a leading cause of fatal poisoning in children under 6 years old; keep iron out of reach of children; in case of an accidental overdose, go to the emergency department or call a poison control center immediately (even if asymptomatic)

Contraindications:
hemochromatosis, hemolytic anemia, hemosiderosis

Warnings:

Side Effects:
- *constipation (dose-related), *dark and tarry stools, nausea, stomach upset

Monitoring:
- Hgb, iron studies, RBC indices, reticulocyte count

Pearls/Notes:
- to relieve GI upset patient can take with food. Food does decrease its absorption. Preferably want patient to take on an empty stomach, this is best for absorption. A stool softener (docusate) is often recommended to prevent iron induced constipation.

  • An acidic environment increases irons absorption
  • Sustained-release forms or EC forms of iron are NOT recommended. These agents release later on in the GI tract in a more alkaline environment, they move past the most acidic environment “the stomach” and release further downstream.
  • Antidote for iron overdose is deferoxamine (Desferal)

Drug-Drug/Food interactions:
-PPI & H2 receptor antagonists will increase pH, so iron absorption will decrease.

  • Antacids, H2 receptor antagonists and PPIs decrease iron absorption. Take iron 2 hours before or 4 hours after Antacids

Iron decreases absorption of:

  • tetracyclines & quinolones
    (take iron 2-4 hours before or 4-8 hours after)
  • levodopa, methyldopa, *levothyroxine, cefdinir
    (separate from iron by 2-4 hours)
  • oral bisphosphonates:
    (take iron 30 minutes after alendronate/risedronate or 1 hour after ibandronate)
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46
Q

Slow Fe

class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:

What is the % of elemental iron in oral products having:

*160mg (50mg elemental iron) PO daily to TID
- 30% of drug dose is elemental iron

A

ferrous sulfate dried

Indications:

Dosage forms:

Dosing:

Boxed Warnings:
- *Accidental overdose of iron-containing products is a leading cause of fatal poisoning in children under 6 years old; keep iron out of reach of children; in case of an accidental overdose, go to the emergency department or call a poison control center immediately (even if asymptomatic)

Contraindications:
hemochromatosis, hemolytic anemia, hemosiderosis

Warnings:

Side Effects:
- *constipation (dose-related), *dark and tarry stools, nausea, stomach upset

Monitoring:
- Hgb, iron studies, RBC indices, reticulocyte count

Pearls/Notes:
- to relieve GI upset patient can take with food. Food does decrease its absorption. Preferably want patient to take on an empty stomach, this is best for absorption. A stool softener (docusate) is often recommended to prevent iron induced constipation.

  • An acidic environment increases irons absorption
  • Sustained-release forms or EC forms of iron are NOT recommended. These agents release later on in the GI tract in a more alkaline environment, they move past the most acidic environment “the stomach” and release further downstream.
  • Antidote for iron overdose is deferoxamine (Desferal)

Drug-Drug/Food interactions:
-PPI & H2 receptor antagonists will increase pH, so iron absorption will decrease.

  • Antacids, H2 receptor antagonists and PPIs decrease iron absorption. Take iron 2 hours before or 4 hours after Antacids

Iron decreases absorption of:

  • tetracyclines & quinolones
    (take iron 2-4 hours before or 4-8 hours after)
  • levodopa, methyldopa, *levothyroxine, cefdinir
    (separate from iron by 2-4 hours)
  • oral bisphosphonates:
    (take iron 30 minutes after alendronate/risedronate or 1 hour after ibandronate)
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47
Q

Slow Iron

class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:

What is the % of elemental iron in oral products having:

A

ferrous sulfate dried

Indications:

Dosage forms:

Dosing:

Boxed Warnings:
- *Accidental overdose of iron-containing products is a leading cause of fatal poisoning in children under 6 years old; keep iron out of reach of children; in case of an accidental overdose, go to the emergency department or call a poison control center immediately (even if asymptomatic)

Contraindications:
hemochromatosis, hemolytic anemia, hemosiderosis

Warnings:

Side Effects:
- *constipation (dose-related), *dark and tarry stools, nausea, stomach upset

Monitoring:
- Hgb, iron studies, RBC indices, reticulocyte count

Pearls/Notes:
- to relieve GI upset patient can take with food. Food does decrease its absorption. Preferably want patient to take on an empty stomach, this is best for absorption. A stool softener (docusate) is often recommended to prevent iron induced constipation.

  • An acidic environment increases irons absorption
  • Sustained-release forms or EC forms of iron are NOT recommended. These agents release later on in the GI tract in a more alkaline environment, they move past the most acidic environment “the stomach” and release further downstream.
  • Antidote for iron overdose is deferoxamine (Desferal)

Drug-Drug/Food interactions:
-PPI & H2 receptor antagonists will increase pH, so iron absorption will decrease.

  • Antacids, H2 receptor antagonists and PPIs decrease iron absorption. Take iron 2 hours before or 4 hours after Antacids

Iron decreases absorption of:

  • tetracyclines & quinolones
    (take iron 2-4 hours before or 4-8 hours after)
  • levodopa, methyldopa, *levothyroxine, cefdinir
    (separate from iron by 2-4 hours)
  • oral bisphosphonates:
    (take iron 30 minutes after alendronate/risedronate or 1 hour after ibandronate)
48
Q

Ferretts

class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:

What is the % of elemental iron in oral products having:

Dosing: *324mg (106mg elemental iron) PO daily to TID

A

ferrous fumarate

class:

Indications:

Dosage forms:

Dosing:

Boxed Warnings:
- *Accidental overdose of iron-containing products is a leading cause of fatal poisoning in children under 6 years old; keep iron out of reach of children; in case of an accidental overdose, go to the emergency department or call a poison control center immediately (even if asymptomatic)

Contraindications:
hemochromatosis, hemolytic anemia, hemosiderosis

Warnings:

Side Effects:
- *constipation (dose-related), *dark and tarry stools, nausea, stomach upset

Monitoring:
- Hgb, iron studies, RBC indices, reticulocyte count

Pearls/Notes:
- to relieve GI upset patient can take with food. Food does decrease its absorption. Preferably want patient to take on an empty stomach, this is best for absorption. A stool softener (docusate) is often recommended to prevent iron induced constipation.

  • An acidic environment increases irons absorption
  • Sustained-release forms or EC forms of iron are NOT recommended. These agents release later on in the GI tract in a more alkaline environment, they move past the most acidic environment “the stomach” and release further downstream.
  • Antidote for iron overdose is deferoxamine (Desferal)

Drug-Drug/Food interactions:
-PPI & H2 receptor antagonists will increase pH, so iron absorption will decrease.

  • Antacids, H2 receptor antagonists and PPIs decrease iron absorption. Take iron 2 hours before or 4 hours after Antacids

Iron decreases absorption of:

  • tetracyclines & quinolones
    (take iron 2-4 hours before or 4-8 hours after)
  • levodopa, methyldopa, *levothyroxine, cefdinir
    (separate from iron by 2-4 hours)
  • oral bisphosphonates:
    (take iron 30 minutes after alendronate/risedronate or 1 hour after ibandronate)
49
Q

Ferrimin 150

class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:

What is the % of elemental iron in oral products having:

  • 33% of drug dose is elemental iron

*324mg (106mg elemental iron) PO daily to TID

A

ferrous fumarate

class:

Indications:

Dosage forms:

Dosing:

Boxed Warnings:
- *Accidental overdose of iron-containing products is a leading cause of fatal poisoning in children under 6 years old; keep iron out of reach of children; in case of an accidental overdose, go to the emergency department or call a poison control center immediately (even if asymptomatic)

Contraindications:
hemochromatosis, hemolytic anemia, hemosiderosis

Warnings:

Side Effects:
- *constipation (dose-related), *dark and tarry stools, nausea, stomach upset

Monitoring:
- Hgb, iron studies, RBC indices, reticulocyte count

Pearls/Notes:
- to relieve GI upset patient can take with food. Food does decrease its absorption. Preferably want patient to take on an empty stomach, this is best for absorption. A stool softener (docusate) is often recommended to prevent iron induced constipation.

  • An acidic environment increases irons absorption
  • Sustained-release forms or EC forms of iron are NOT recommended. These agents release later on in the GI tract in a more alkaline environment, they move past the most acidic environment “the stomach” and release further downstream.
  • Antidote for iron overdose is deferoxamine (Desferal)

Drug-Drug/Food interactions:
-PPI & H2 receptor antagonists will increase pH, so iron absorption will decrease.

  • Antacids, H2 receptor antagonists and PPIs decrease iron absorption. Take iron 2 hours before or 4 hours after Antacids

Iron decreases absorption of:

  • tetracyclines & quinolones
    (take iron 2-4 hours before or 4-8 hours after)
  • levodopa, methyldopa, *levothyroxine, cefdinir
    (separate from iron by 2-4 hours)
  • oral bisphosphonates:
    (take iron 30 minutes after alendronate/risedronate or 1 hour after ibandronate)
50
Q

Ferate

class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:

What is the % of elemental iron in oral products having:

Dosing: 324mg (38mg elemental iron) PO daily to TID

A

ferrous gluconate

class:

Indications:

Dosage forms:

Dosing:

Boxed Warnings:
- *Accidental overdose of iron-containing products is a leading cause of fatal poisoning in children under 6 years old; keep iron out of reach of children; in case of an accidental overdose, go to the emergency department or call a poison control center immediately (even if asymptomatic)

Contraindications:
hemochromatosis, hemolytic anemia, hemosiderosis

Warnings:

Side Effects:
- *constipation (dose-related), *dark and tarry stools, nausea, stomach upset

Monitoring:
- Hgb, iron studies, RBC indices, reticulocyte count

Pearls/Notes:
- to relieve GI upset patient can take with food. Food does decrease its absorption. Preferably want patient to take on an empty stomach, this is best for absorption. A stool softener (docusate) is often recommended to prevent iron induced constipation.

  • An acidic environment increases irons absorption
  • Sustained-release forms or EC forms of iron are NOT recommended. These agents release later on in the GI tract in a more alkaline environment, they move past the most acidic environment “the stomach” and release further downstream.
  • Antidote for iron overdose is deferoxamine (Desferal)

Drug-Drug/Food interactions:
-PPI & H2 receptor antagonists will increase pH, so iron absorption will decrease.

  • Antacids, H2 receptor antagonists and PPIs decrease iron absorption. Take iron 2 hours before or 4 hours after Antacids

Iron decreases absorption of:

  • tetracyclines & quinolones
    (take iron 2-4 hours before or 4-8 hours after)
  • levodopa, methyldopa, *levothyroxine, cefdinir
    (separate from iron by 2-4 hours)
  • oral bisphosphonates:
    (take iron 30 minutes after alendronate/risedronate or 1 hour after ibandronate)
51
Q

Ferrex 150

class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:

What is the % of elemental iron in oral products having:

  • 100% of drug dose is elemental iron
A

polysaccharide iron complex

class:

Indications:

Dosage forms:

Dosing:

Boxed Warnings:
- *Accidental overdose of iron-containing products is a leading cause of fatal poisoning in children under 6 years old; keep iron out of reach of children; in case of an accidental overdose, go to the emergency department or call a poison control center immediately (even if asymptomatic)

Contraindications:
hemochromatosis, hemolytic anemia, hemosiderosis

Warnings:

Side Effects:
- *constipation (dose-related), *dark and tarry stools, nausea, stomach upset

Monitoring:
- Hgb, iron studies, RBC indices, reticulocyte count

Pearls/Notes:
- to relieve GI upset patient can take with food. Food does decrease its absorption. Preferably want patient to take on an empty stomach, this is best for absorption. A stool softener (docusate) is often recommended to prevent iron induced constipation.

  • An acidic environment increases irons absorption
  • Sustained-release forms or EC forms of iron are NOT recommended. These agents release later on in the GI tract in a more alkaline environment, they move past the most acidic environment “the stomach” and release further downstream.
  • Antidote for iron overdose is deferoxamine (Desferal)

Drug-Drug/Food interactions:
-PPI & H2 receptor antagonists will increase pH, so iron absorption will decrease.

  • Antacids, H2 receptor antagonists and PPIs decrease iron absorption. Take iron 2 hours before or 4 hours after Antacids

Iron decreases absorption of:

  • tetracyclines & quinolones
    (take iron 2-4 hours before or 4-8 hours after)
  • levodopa, methyldopa, *levothyroxine, cefdinir
    (separate from iron by 2-4 hours)
  • oral bisphosphonates:
    (take iron 30 minutes after alendronate/risedronate or 1 hour after ibandronate)
52
Q

Iron chews

class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:

What is the % of elemental iron in oral products having:

  • 100% of drug dose is elemental iron
A

carbonyl iron

class:

Indications:

Dosage forms:

Dosing:

Boxed Warnings:
- *Accidental overdose of iron-containing products is a leading cause of fatal poisoning in children under 6 years old; keep iron out of reach of children; in case of an accidental overdose, go to the emergency department or call a poison control center immediately (even if asymptomatic)

Contraindications:
hemochromatosis, hemolytic anemia, hemosiderosis

Warnings:

Side Effects:
- *constipation (dose-related), *dark and tarry stools, nausea, stomach upset

Monitoring:
- Hgb, iron studies, RBC indices, reticulocyte count

Pearls/Notes:
- to relieve GI upset patient can take with food. Food does decrease its absorption. Preferably want patient to take on an empty stomach, this is best for absorption. A stool softener (docusate) is often recommended to prevent iron induced constipation.

  • An acidic environment increases irons absorption
  • Sustained-release forms or EC forms of iron are NOT recommended. These agents release later on in the GI tract in a more alkaline environment, they move past the most acidic environment “the stomach” and release further downstream.
  • Antidote for iron overdose is deferoxamine (Desferal)

Drug-Drug/Food interactions:
-PPI & H2 receptor antagonists will increase pH, so iron absorption will decrease.

  • Antacids, H2 receptor antagonists and PPIs decrease iron absorption. Take iron 2 hours before or 4 hours after Antacids

Iron decreases absorption of:

  • tetracyclines & quinolones
    (take iron 2-4 hours before or 4-8 hours after)
  • levodopa, methyldopa, *levothyroxine, cefdinir
    (separate from iron by 2-4 hours)
  • oral bisphosphonates:
    (take iron 30 minutes after alendronate/risedronate or 1 hour after ibandronate)
53
Q

Accrufer

class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:

What is the % of elemental iron in oral products having:

  • 100% of drug dose is elemental iron
A

ferric maltol

class:

Indications:

Dosage forms:

Dosing:

Boxed Warnings:
- *Accidental overdose of iron-containing products is a leading cause of fatal poisoning in children under 6 years old; keep iron out of reach of children; in case of an accidental overdose, go to the emergency department or call a poison control center immediately (even if asymptomatic)

Contraindications:
hemochromatosis, hemolytic anemia, hemosiderosis

Warnings:

Side Effects:
- *constipation (dose-related), *dark and tarry stools, nausea, stomach upset

Monitoring:
- Hgb, iron studies, RBC indices, reticulocyte count

Pearls/Notes:
- to relieve GI upset patient can take with food. Food does decrease its absorption. Preferably want patient to take on an empty stomach, this is best for absorption. A stool softener (docusate) is often recommended to prevent iron induced constipation.

  • An acidic environment increases irons absorption
  • Sustained-release forms or EC forms of iron are NOT recommended. These agents release later on in the GI tract in a more alkaline environment, they move past the most acidic environment “the stomach” and release further downstream.
  • Antidote for iron overdose is deferoxamine (Desferal)

Drug-Drug/Food interactions:
-PPI & H2 receptor antagonists will increase pH, so iron absorption will decrease.

  • Antacids, H2 receptor antagonists and PPIs decrease iron absorption. Take iron 2 hours before or 4 hours after Antacids

Iron decreases absorption of:

  • tetracyclines & quinolones
    (take iron 2-4 hours before or 4-8 hours after)
  • levodopa, methyldopa, *levothyroxine, cefdinir
    (separate from iron by 2-4 hours)
  • oral bisphosphonates:
    (take iron 30 minutes after alendronate/risedronate or 1 hour after ibandronate)
54
Q

what is the antidote for iron overdose?

A

(Desferal) deferoxamine

55
Q

Fe 2+ iron, polyvalent cation

A
56
Q

Most Iron Deficiency Anemia is adequately treated with ___________. ____________ iron is used in __________

A

oral iron

parenteral

dialysis

57
Q

Fe, Fer, Ferr, indicate these are products which contain iron

A
58
Q

The CDC recommends low-dose iron supplementation (____________) for all _____________

A

30mg/day

pregnant women beginning at the first prenatal visit

“larger doses of iron would be required if iron deficiency anemia is diagnosed in pregnancy”

59
Q

H2 receptor antagonists and PPI raise gastric pH for up to 24 hours; separating the administration of these agents from iron supplementation, _________

A

DOES NOT improve absorption.

60
Q

giving iron with ____________ may enhance the absorption to a minimal extent.

A

ascorbic acid (Vitamin C 200mg)

61
Q

With iron therapy we want to avoid __________

A

H2RAs and PPis all together

“remember PPis we are not supposed to use long term unless absolutely necessary, because of long term risks like osteoporosis”

62
Q

Counseling points for iron:

A

-Try to take on an empty stomach
- Take with food if experiencing stomach upset
- Don’t be alarmed by dark tarry stools
- keep out of reach of children
- prevent constipation with a stool softener
- discontinue and H2RAs or PPIs and use antacids if needed for heartburn

63
Q

____________ increases Hgb faster than oral iron and reduces gastrointestinal issues seen with oral administration. The total dose needed to replenish iron stores (_____) can be provided in a ________

A

parenteral iron
class:

Indications:

Dosage forms:

Dosing:

Boxed Warnings:
- *Accidental overdose of iron-containing products is a leading cause of fatal poisoning in children under 6 years old; keep iron out of reach of children; in case of an accidental overdose, go to the emergency department or call a poison control center immediately (even if asymptomatic)

Contraindications:
hemochromatosis, hemolytic anemia, hemosiderosis

Warnings:

Side Effects:
- *constipation (dose-related), *dark and tarry stools, nausea, stomach upset

Monitoring:
- Hgb, iron studies, RBC indices, reticulocyte count

Pearls/Notes:
- to relieve GI upset patient can take with food. Food does decrease its absorption. Preferably want patient to take on an empty stomach, this is best for absorption. A stool softener (docusate) is often recommended to prevent iron induced constipation.

  • An acidic environment increases irons absorption
  • Sustained-release forms or EC forms of iron are NOT recommended. These agents release later on in the GI tract in a more alkaline environment, they move past the most acidic environment “the stomach” and release further downstream.
  • Antidote for iron overdose is deferoxamine (Desferal)

Drug-Drug/Food interactions:
-PPI & H2 receptor antagonists will increase pH, so iron absorption will decrease.

  • Antacids, H2 receptor antagonists and PPIs decrease iron absorption. Take iron 2 hours before or 4 hours after Antacids

Iron decreases absorption of:

  • tetracyclines & quinolones
    (take iron 2-4 hours before or 4-8 hours after)
  • levodopa, methyldopa, *levothyroxine, cefdinir
    (separate from iron by 2-4 hours)
  • oral bisphosphonates:
    (take iron 30 minutes after alendronate/risedronate or 1 hour after ibandronate)
    1000mg

single infusion if desired

64
Q

Due to the risks of more adverse reactions, as well as the cost of therapy, IV iron administration is typically restricted to the following patients:

A
  • CKD on hemodialysis (most common use of IV iron)
  • CKD patients receiving erythropoiesis-stimulating agents (ESAs)
  • ## Unable to tolerate oral iron OR failure or oral therapy (So patients with inflammatory bowel diseases, celiac disease, certain gastric bypass procedure, achlorhydria,)-
65
Q

Before giving parenteral iron dextran ______________ is required.

All parenteral iron products have a warning/risk for _____

All parenteral iron products have a characteristic ____________ color

A

a Test dose

hypersensitivity reactions/ anaphylaxis

brown

66
Q

Which 2 parenteral iron products have a boxed warning for Hypersensitivity reactions?

A

iron dextran (INFeD)

ferumoxytol (feraheme)

67
Q

Venofer

class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:

A

iron sucrose

Indications:
Iron Deficiency Anemia restricted to–

  • CKD on hemodialysis (most common use of IV iron)
  • CKD patients receiving erythropoiesis-stimulating agents (ESAs)
  • Unable to tolerate oral iron OR failure or oral therapy (So patients with inflammatory bowel diseases, celiac disease, certain gastric bypass procedure, achlorhydria,)

MOA:

Dosage forms: parenteral iron

Dosing:

Boxed Warning: Serious and sometimes fatal anaphylactic reactions have occurred with the use of iron dextran or ferumoxytol; all patients receiving iron dextran should be given a test dose prior to the first full therapeutic dose; fatal reactions have occurred even in patients who tolerated the test dose; a Hx of drug allergy or multiple drug allergies may increase this risk.

Contraindications:

Warnings:
All parenteral iron products carry a risk for hypersensitivity reactions (including anaphylaxis)

Side Effects:
hypotension, chest tightness, peripheral edema, muscle aches, flushing, tachycardia,

Monitoring:
Hgb, iron studies, reticulocyte count, vital signs, signs and symptoms of anaphylaxis

Pearls/Notes:
*Feraheme is stable in NS or D5W
*All parenteral iron products are stable in NS
- give by slow IV injection or infusion to decrease the risk of hypotension

Drug-Drug/Food interactions:

68
Q

Feraheme

class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:

A

ferumoxytol

Indications:
Iron Deficiency Anemia restricted to–

  • CKD on hemodialysis (most common use of IV iron)
  • CKD patients receiving erythropoiesis-stimulating agents (ESAs)
  • Unable to tolerate oral iron OR failure or oral therapy (So patients with inflammatory bowel diseases, celiac disease, certain gastric bypass procedure, achlorhydria,)

MOA:

Dosage forms: parenteral iron

Dosing:

Boxed Warning: Serious and sometimes fatal anaphylactic reactions have occurred with the use of iron dextran or ferumoxytol; all patients receiving iron dextran should be given a test dose prior to the first full therapeutic dose; fatal reactions have occurred even in patients who tolerated the test dose; a Hx of drug allergy or multiple drug allergies may increase this risk.

Contraindications:

Warnings:
All parenteral iron products carry a risk for hypersensitivity reactions (including anaphylaxis)

Side Effects:
hypotension, chest tightness, peripheral edema, muscle aches, flushing, tachycardia,

Monitoring:
Hgb, iron studies, reticulocyte count, vital signs, signs and symptoms of anaphylaxis

Pearls/Notes:
*Feraheme is stable in NS or D5W
*All parenteral iron products are stable in NS
- give by slow IV injection or infusion to decrease the risk of hypotension

Drug-Drug/Food interactions:

69
Q

INFeD

class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:

A

iron dextran

Indications:
Iron Deficiency Anemia restricted to–

  • CKD on hemodialysis (most common use of IV iron)
  • CKD patients receiving erythropoiesis-stimulating agents (ESAs)
  • Unable to tolerate oral iron OR failure or oral therapy (So patients with inflammatory bowel diseases, celiac disease, certain gastric bypass procedure, achlorhydria,)

MOA:

Dosage forms: parenteral iron

Dosing:

Boxed Warning: Serious and sometimes fatal anaphylactic reactions have occurred with the use of iron dextran or ferumoxytol; all patients receiving iron dextran should be given a test dose prior to the first full therapeutic dose; fatal reactions have occurred even in patients who tolerated the test dose; a Hx of drug allergy or multiple drug allergies may increase this risk.

Contraindications:

Warnings:
All parenteral iron products carry a risk for hypersensitivity reactions (including anaphylaxis)

Side Effects:
hypotension, chest tightness, peripheral edema, muscle aches, flushing, tachycardia,

Monitoring:
Hgb, iron studies, reticulocyte count, vital signs, signs and symptoms of anaphylaxis

Pearls/Notes:
*Feraheme is stable in NS or D5W
*All parenteral iron products are stable in NS
- give by slow IV injection or infusion to decrease the risk of hypotension

Drug-Drug/Food interactions:

70
Q

Ferrlecit

class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:

A

sodium ferric gluconate

Indications:
Iron Deficiency Anemia restricted to–

  • CKD on hemodialysis (most common use of IV iron)
  • CKD patients receiving erythropoiesis-stimulating agents (ESAs)
  • Unable to tolerate oral iron OR failure or oral therapy (So patients with inflammatory bowel diseases, celiac disease, certain gastric bypass procedure, achlorhydria,)

MOA:

Dosage forms: parenteral iron

Dosing:

Boxed Warning: Serious and sometimes fatal anaphylactic reactions have occurred with the use of iron dextran or ferumoxytol; all patients receiving iron dextran should be given a test dose prior to the first full therapeutic dose; fatal reactions have occurred even in patients who tolerated the test dose; a Hx of drug allergy or multiple drug allergies may increase this risk.

Contraindications:

Warnings:
All parenteral iron products carry a risk for hypersensitivity reactions (including anaphylaxis)

Side Effects:
hypotension, chest tightness, peripheral edema, muscle aches, flushing, tachycardia,

Monitoring:
Hgb, iron studies, reticulocyte count, vital signs, signs and symptoms of anaphylaxis

Pearls/Notes:
*Feraheme is stable in NS or D5W
*All parenteral iron products are stable in NS
- give by slow IV injection or infusion to decrease the risk of hypotension

Drug-Drug/Food interactions:

71
Q

Triferic

class:

MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:

A

ferric pyrophosphate citrate

Indications: is only indicated for iron replacement in patients with hemodialysis-dependent CKD; it should be added to the bicarbonate concentrate of the hemodialysis for patients receiving hemodialysis

MOA:

Dosage forms: parenteral iron

Dosing:

Boxed Warning: Serious and sometimes fatal anaphylactic reactions have occurred with the use of iron dextran or ferumoxytol; all patients receiving iron dextran should be given a test dose prior to the first full therapeutic dose; fatal reactions have occurred even in patients who tolerated the test dose; a Hx of drug allergy or multiple drug allergies may increase this risk.

Contraindications:

Warnings:
All parenteral iron products carry a risk for hypersensitivity reactions (including anaphylaxis)

Side Effects:
hypotension, chest tightness, peripheral edema, muscle aches, flushing, tachycardia,

Monitoring:
Hgb, iron studies, reticulocyte count, vital signs, signs and symptoms of anaphylaxis

Pearls/Notes:
*Feraheme is stable in NS or D5W
*All parenteral iron products are stable in NS
- give by slow IV injection or infusion to decrease the risk of hypotension

Drug-Drug/Food interactions:

72
Q

Macrocytic anemia =

A
  • is anemia caused by vitamin B12 or folate deficiency or both
  • when MCH > 100fL
73
Q

Pernicious anemia =

A

is the most common cause of vitamin B12 deficiency that occurs due to lack of (IF) intrinsic factor.

74
Q

What is intrinsic factor (IF) required for?

A

adequate absorption of vitamin B12 in the small intestine. Without IF, vitamin B12 deficiency will occur

75
Q

In pernicious anemia, ____________is required

A

lifelong parenteral vitamin B12 replacement

76
Q

Diagnosis of pernicious anemia used to be with a ____________ but now having a positive test for ___________

A

Schilling test

autoantibodies to IF intrinsic factor

77
Q

Other causes of macrocytic anemia include:

A
  • alcoholism
  • poor nutrition
  • GI disorder (Crohn’s, celiac, IBS)
  • long term use > or = 2 years of metformin, H2RAs or PPIs can decrease the absorption of vitamin B12
78
Q

Vitamin B12 deficiency can result in ________

A

serious neurologic dysfunction, including cognitive impairment and peripheral neuropathies.

79
Q

Normocytic anemia:

cause:

Tx:

A

Anemia of Chronic Kidney Disease (CKD)
- deficiency in erythropoietin (EPO)

-low Hgb and low Hct
- MCV is within normal range

  • Treatment with iron AND Erythropoiesis-Stimulating Agents (ESAs)
    IV iron first line in hemodialysis patients
    -ESAs maintain Hgb levels and decrease need for blood transfusions (requires sufficient iron stores)
80
Q

(ESA) erythropoiesis-stimulating agents

Boxed warning:

Side effects:

A

thrombosis, MI, stroke, death, tumor progression (cancer patients)

-Risk of death increased when Hgb > 11g/dL

include: hypertension, fever, HA, arthralgias, rash

81
Q

Dodex

class:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:

A

cyanocobalamin (Vitamin B12)

82
Q

Nascobal

class:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:

A

cyanocobalamin (Vitamin B12)

83
Q

FA-8

class:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:

A

folic acid (vitamin B9)

84
Q

-
-
-

A

Diagnosis:
- low Hgb & Hct
- elevated MCV
- low Vitamin B12 levels AND/OR low folate (vitamin B9) levels
- low reticulocyte levels

85
Q

-
-
-

A
  • Cyanocobalamin (Vitamin B12)
  • parenteral treatment (IM or deep SC)
    -Nasal solutions (Nascobal) - administer in one nostril once weekly
  • Folic acid
    0.4-1 mg daily
86
Q

What are the common reference ranges for Hemoglobin (Hgb):

A

Females: 12-16 g/dL

Males: 13.5-18 g/dL

87
Q

What are the common reference ranges for Hematocrit (Hct):

A

Females: 36% - 46%

Males: 38% - 50%

88
Q

What is the common reference range for Mean Corpuscular Volume (MCH)?

A

80-100 fL

89
Q

what is the common reference range for Folic acid (folate) (vitamin B9):

A

5 - 25 mcg/L

90
Q

what is the common reference range for Vitamin B12:

A

> 200 pg/mL

91
Q

What is the common reference range for Reticulocyte count:

A

0.5 - 2.5%

92
Q

Erythropoietin (EPO):

A

is a hormone produced by the kidneys that stimulates the bone marrow to produce RBCs.

93
Q

a deficiency of erythropoietin causes _______________

A

anemia of chronic kidney disease (CKD) aka “normocytic anemia”

94
Q

what is the common reference range for EPO

A

2 - 25 mIU/mL

95
Q

(ESAs) Erythropoiesis Stimulating Agents, help maintain ____________ and reduce the need for __________. But these agents are ineffective if __________________

A

Hgb levels

blood transfusions

iron stores are low

96
Q

KDIGO

A

Kidney Disease Improving Global Outcomes

97
Q

KDOQI

A

Kidney Disease Outcomes Quality Initiative

98
Q

KDIGO guidelines/criteria for initiating ESAs:

A
99
Q

KDOQI guidelines/criteria for initiating ESAs:

A
100
Q

ESAs:

criteria for use:

A

Start when Hgb < 10 g/dL
Stop when Hgb nears or is > 11 g/dL

101
Q

Epogen

class:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:

A

epoetin alfa

class: (ESA) Erythropoiesis Stimulating Agent

MOA: “acts like the hormone Erythropoietin” and stimulates the bone marrow to produce red blood cells. This increases the volume of rbc’s.

Dosage forms: single dose & multi dose vials

Dosing:
For Chronic Kidney Disease: 50 - 100 units/kg IV or SC 3x weekly***
Initiate when Hgb < 10 g/dL
Stop when Hgb nears or is > 11 g/dL (CKD on HD= hemodialysis)

For (taking chemotherapy)
150 units/kg SC 3x weekly or 40000 units SC weekly
Initiate when Hgb < 10 g/dL & when at least 2 additional months of chemotherapy are planned.

(All Indications) - * *Titrate dose up or down based on Hgb levels; do not increase the doe more frequently than once every 4 weeks.

Boxed warnings:
- *increased risk of death, MI, stroke, thrombosis
(Use the lowest effective dose to reduce the need for blood transfusions)

  • *Chronic Kidney Disease: increased risk of death, serious cardiovascular events and stroke when Hgb level > 11 g/dL
  • *Cancer: shortened overall survival and/or increase risk of tumor progression or recurrence in clinical studies of patients with some cancers. Not indicated when the anticipated outcome is cure. discontinue when chemotherapy is complete.
  • Perisurgery (epoetin alfa): DVT prophylaxis is recommended due to increased risk of DVT

Contraindications:

-uncontrolled hypertension, pure red cell aplasia (PRCA) that begins after treatment.
-epoetin alfa: multidose vials contain benzyl alcohol (contraindicated in neonates, infants, pregnancy and lactation)

Warnings:
hypertension*, seizures, serious allergic reactions, serious skin reactions (SJS/TEN)
epoetin alfa: contains albumin from human blood (remote risk for transmission of viral diseases)

Side Effects:
arthalgia/bone pain, fever, headache, pruritis/rash, N/V, cough

Monitoring:
***Hgb, Hct, TSAT, serum ferritin, blood pressure

Pearls/Notes:

  • have to use these agents in a small Hgb rangeCriteria for use

-ESA’s help maintain Hgb levels and reduce the need for blood transfusions. But, these drugs are ineffective if iron stores are low.

  • Do Not shake
  • Store in the refrigerator; protect from light; discard multidose vials 21 days after initial entry
  • IV route is recommended for patients on hemodialysis

Drug-Drug/Food interactions:

102
Q

Procrit

class:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:

A

epoetin alfa

class: (ESA) Erythropoiesis Stimulating Agent

MOA: “acts like the hormone Erythropoietin” and stimulates the bone marrow to produce red blood cells. This increases the volume of rbc’s.

Dosage forms: single dose & multi dose vials

Dosing:
For Chronic Kidney Disease: 50 - 100 units/kg IV or SC 3x weekly**
Initiate when Hgb < 10 g/dL
Stop when Hgb nears or is > 11 g/dL (CKD on HD= hemodialysis)

*For (taking chemotherapy)
150 units/kg SC 3x weekly or 40000 units SC weekly
Initiate when Hgb < 10 g/dL & when at least 2 additional months of chemotherapy are planned.

(All Indications) - * *Titrate dose up or down based on Hgb levels; do not increase the doe more frequently than once every 4 weeks.

Boxed warnings:
- *increased risk of death, MI, stroke, thrombosis
(Use the lowest effective dose to reduce the need for blood transfusions)

  • *Chronic Kidney Disease: increased risk of death, serious cardiovascular events and stroke when Hgb level > 11 g/dL
  • *Cancer: shortened overall survival and/or increase risk of tumor progression or recurrence in clinical studies of patients with some cancers. Not indicated when the anticipated outcome is cure. discontinue when chemotherapy is complete.
  • Perisurgery (epoetin alfa): DVT prophylaxis is recommended due to increased risk of DVT

Contraindications:

-uncontrolled hypertension, pure red cell aplasia (PRCA) that begins after treatment.
-epoetin alfa: multidose vials contain benzyl alcohol (contraindicated in neonates, infants, pregnancy and lactation)

Warnings:
hypertension*, seizures, serious allergic reactions, serious skin reactions (SJS/TEN)
epoetin alfa: contains albumin from human blood (remote risk for transmission of viral diseases)

Side Effects:
arthalgia/bone pain, fever, headache, pruritis/rash, N/V, cough

Monitoring:
***Hgb, Hct, TSAT, serum ferritin, blood pressure

Pearls/Notes:

  • have to use these agents in a small Hgb rangeCriteria for use

-ESA’s help maintain Hgb levels and reduce the need for blood transfusions. But, these drugs are ineffective if iron stores are low.

  • Do Not shake
  • Store in the refrigerator; protect from light; discard multidose vials 21 days after initial entry
  • IV route is recommended for patients on hemodialysis

Drug-Drug/Food interactions:

103
Q

Which agent is a biosimilar to epoetin alfa?

A

Retacrit

104
Q

Aranesp

class:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:

A

darbepoetin

class: (ESA) Erythropoiesis Stimulating Agent

MOA: “acts like the hormone Erythropoietin” and stimulates the bone marrow to produce red blood cells. This increases the volume/viscosity of rbc’s.

Dosage forms: single dose vial & single dose prefilled syringe

Dosing:
Criteria for use:
Start when Hgb < 10 g/dL
Stop when Hgb nears or is > 11 g/dL

*For Chronic Kidney Disease:
-(HD) Hemodialysis: 0.45mcg/kg IV or SC weekly OR
0.75mcg/kg IV or SC every 2 weeks

-Non-HD: 0.45mcg/kg IV or SC every 4 weeks

*For Cancer (taking chemotherapy)
2.25mcg/kg SC weekly or 500 mcg SC every 3 weeks

*(All Indications) - * *Titrate dose up or down based on Hgb levels; do not increase the doe more frequently than once every 4 weeks.

Boxed warnings:
- *increased risk of death, MI, stroke, thrombosis
(Use the lowest effective dose to reduce the need for blood transfusions)

  • *Chronic Kidney Disease: increased risk of death, serious cardiovascular events and stroke when Hgb level > 11 g/dL
  • *Cancer: shortened overall survival and/or increase risk of tumor progression or recurrence in clinical studies of patients with some cancers. NOT INDICATED WHEN THE ANTICIPATED OUTCOME IS CURE. discontinue when chemotherapy is complete.

Contraindications:

-uncontrolled hypertension, pure red cell aplasia (PRCA) that begins after treatment.

Warnings:
hypertension*, seizures, serious allergic reactions, serious skin reactions (SJS/TEN)

Side Effects:
arthalgia/bone pain, fever, headache, pruritis/rash, N/V, cough

Monitoring:
***Hgb, Hct, TSAT, serum ferritin, blood pressure

Pearls/Notes:

  • have to use these agents in a small Hgb rangeCriteria for use

-ESA’s help maintain Hgb levels and reduce the need for blood transfusions. But, these drugs are ineffective if iron stores are low.

  • Do Not shake
  • Store in the refrigerator; protect from light; discard multidose vials 21 days after initial entry
  • IV route is recommended for patients on hemodialysis
  • **darbepoetin t1/2 is 3-fold longer than epoetin alfa (it can be given weekly)

Drug-Drug/Food interactions:

105
Q

what is first line in normocytic anemia patients that have hemodialysis?

When would we initiate ESAs?

A

IV iron

if Hgb drops below 10 g/dL

106
Q

Aplastic anemia:

what are these patients at increased risk for?

A
  • occurs when the bone marrow fails to make enough red blood cells (RBCs), white blood cells (WBCs) and platelets.

“Complete bone marrow failure”

  • infections & bleeding
107
Q

Aplastic anemia can be caused by:

A
  • drugs
  • infectious diseases
  • hereditary conditions
  • autoimmune conditions
108
Q

Treatment of Aplastic anemia:

A
  • immunosuppressants
  • (Promacta) eltrombopag if unresponsive to immunosuppressive therapy (increases platelets)
  • blood transfusions
  • stem cell transplant
109
Q

Promacta

class:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:

A

eltrombopag

class: thrombopoietin nonpeptide agonist

indications: approved for the treatment of severe aplastic anemia in patients who are unresponsive to immunosuppressive therapy.

MOA: increases platelet counts

Dosage forms:

Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:

110
Q

Hemolytic anemia:

How is it caused?

A
  • develops when RBCs are destroyed and removed from the bloodstream before their normal lifespan of 90-120 days.
  • can be ACQUIRED (drug-induced or associated with an immune disorder) or INHERITED (sickle cell disease, G6PD deficiency)
111
Q

-
-
-
-
-

  • Not necessarily have to be avoided in G6PD deficiency

Not all medications that can cause drug-induced hemolysis are prohibited in patients with G6PD deficiency. If a high-risk medication is used, ________

A
  • penicillins
  • cephalosporins
  • isoniazid, rifampin
  • levodopa
  • methyldopa
  • cisplatin and other platinum-based drugs
  • quinidine, quinine, ribavirin

“drugs most often bind to the RBC surface and this triggers the development of antibodies that attack the red blood cells”

“a Coombs test is used to identify if antibodies are stuck to the surface of red blood cells”

  • monitor closely and discontinue immediately if hemolysis develops.
112
Q

Glucose-6-phosphate dehydrogenase deficiency:

(G6PD deficiency)

A

is an X-linked inherited disorder that most commonly affects persons of african, asian, mediterranean or middle eastern descent.

Without sufficient levels of G6PD, RBCs hemolyze (break apart) 24-72 hours after exposure to oxidative stress.

113
Q

Drugs to AVOID with G6PD deficiency:

A
  • dapsone
  • methylene blue
  • nitrofurantoin
  • pegloticase
  • primaquine, chloroquine
  • rasburicase
  • sulfonamides
  • probenecid
114
Q

direct Coombs test:

A

is used to detect antibodies that are stuck to the surface of RBCs

115
Q

Oral iron: counseling points

A
  • take on an empty stomach
  • if stomach upset occurs, it can be taken with food BUT AVOID cereals, tea, coffee, eggs, milk, and high fiber products, as these decrease iron absorption
  • can cause dark stools, which is expected
  • constipation
    drug interactions due to:
  • Binding
  • High gastric pH

Notes/Facts/Brand vs Generic (23 decks)

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