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Naplex > Anemia > Flashcards

Anemia Flashcards

1
Q

What is anemia?

A
  • Anemia is a decrease in hemoglobin (Hgb) and hematocrit (Hct) concentrations below normal range for age and gender
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2
Q

What is Hgb and what does it do in the body?

A
  • Hgb is an iron-rich protein found in RBCs
  • Hgb’s main purpose is to carry oxygen from the lungs to the tissues
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3
Q

RBCs are formed in the ______ where they take up ____ and ____ before being released into the circulation as ____ , known as ____.

Fill in the blanks

A
  • Bone marrow
  • Hgb
  • Iron
  • Immature RBCs
  • Reticulocytes
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4
Q

What can cause anemia?

A
  • Nutritional deficiencies (e.g., iron, folate, vitamin B12)
  • CKD
  • Malignancy
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5
Q

What are the symptoms of anemia?

A
  • Fatigue
  • Weakness
  • SOB
  • Exercise intolerance
  • Headache
  • Dizziness
  • Anorexia and/or pallor
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6
Q

What are symptoms of iron deficiency anemia?

A
  • Glossitis (inflamed, sore tongue)
  • Koilonychias (spoon-shaped nails)
  • Pica (eating non-foods like clay/chalk)
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7
Q

T/F: Vitamin B12 deficiency can present with neurologic symptoms, including peripheral neuropathies

A

TRUE

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8
Q

What is used to determine the type of anemia and the possible underlying cause?

A
  • The mean corpuscular volume (MCV); size or average volume of RBCs
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9
Q

What does low MCV and high MCV mean?

A
  • Low MCV: RBCs are smaller than normal (microcytic)
  • High MCV: RBCs are larger than normal (macrocytic)
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10
Q

What are microcytic, normocytic and macrocytic MCV values and their likely causes?

A

~~~
```Microcytic: MCV <80 fL
* Iron deficiency

Normocytic: MCV 80-100 fL
* Acute blood loss

  • CKD
  • Bone marrow failure (aplastic anemia)
  • Hemolysis

Macrocytic: MCV >100 fL
* Vitamin B12

  • Folate deficiency
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11
Q

What laboratory tests are used to further evaluate microcytic and macrocytic anemia?

A
  • Microcytic: Iron studies
  • Macrocytic: Vitamin B12 and folate levels
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12
Q

A reticulocyte count measures the production of RBCs and it is low in ____ due to iron, folate or B12 deficiency and with ______.

Fill in the blanks

A
  • Untreated anemia
  • Bone marrow suppression
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13
Q

What are common laboratory tests in anemia?

A

Relevant CBC Components
* Hgb

  • Hct
  • RBC count
  • Reticulocyte count

RBC Indices
* MCV

  • MCH
  • Mean Corpuscular Hemoglobin Concentration (MCHC)
  • Red Blood Cell Distriburion Width (RDW)

Iron Studies
* Serum iron

  • Serum ferritin
  • Total Iron Binding Capacity (TIBC)
  • Transferrin Saturation (TSAT)

Additional Tests
* Serum folate

  • Serum vitamin B12
  • Methylmalonic acid
  • Homocysteine
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14
Q

```

~~~

What are the causes of iron deficiency?

A

Inadequate Dietary Intake
* Iron poor diets (e.g., vegetarian, vegan)

  • Malnutrition
  • Disease-related (e..g., dementia, psychosis)

Blood Loss
* Acute (GI hemorrhage)

  • Chronic (heavy menses, blood donations, PUD, IBD)
  • Drug-induced (NSAIDs, steroids, antiplatelets, anticoagulants)

Decreased Iron Absorption
* High gastric PH (e.g., PPIs)

  • GI diseases (celiac disease, IBD, gastrectomy, gastric bypass)

Increased iron Requirements
* Pregnancy

  • Lactation
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15
Q

What are the laboratory findings for iron deficiency anemia?

A
  • ↓ Hgb, MCV <80 fL, ↓ RBC production (low reticulocyte count)
  • ↓ Serum iron, ferritin and TSAT
  • ↑ TIBC
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16
Q

How do you treat iron deficiency?

A
  • Iron therapy: 100-200 mg elemental iron/day *
  • Take iron on an empty stomach **
  • Avoid H2RAs and PPIs; seperate from antacids
  • Sustained-release or enteric-coated formulations cause less GI irritation but are not recommended due to poor absorption

*One oral formulation is not better than the other if dosed appropriately based on elemental iron needs.

** 1hr before or 2 hrs after meals; can be taken with food if GI upset occurs

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17
Q
  1. Ferrous gluconate: %
  2. Ferrous sulfate: %
  3. Ferrous sulfate, dried: %
  4. Ferrous fumarate: %
  5. Carbonyl iron, polysaccharide iron complex, ferric maltol: %

Give % of elemental iron in each of the listed oral products

A
  1. 12%
  2. 20%
  3. 30%
  4. 33%
  5. 100%
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18
Q

What are the treatment goals in iron deficiency anemia?

A
  • ↑ in serum Hgb by 1 g/dL every 2-3 weeks; continue treatment for 3-6 months after anemia has resolved until iron stores return to normal
19
Q

Most IDA is adequately treated with ___ supplements. Parenteral iron is primarily used in ___.

Fill in the blanks

A
  • Oral iron
  • Dialysis
20
Q

Ferrous sulfate/Ferrous sulfate, dried - dosing, BW, SEs

A

Ferrous sulfate: 325 mg (65 mg elemental iron) PO daily to TID.

Ferrous sulfate, dried: 160 mg (50 mg elemental iron) PO daily to TID.

Boxed Warning
* Accidental overdose of iron-containing products is a leading cause of fatal poisoning in children under 6; go to emergency department or call poison control center asap (even if asymptomatic)

Side Effects
* Constipation (dose-related)

  • Dark and tarry stools
20
Q

T/F: A stool softener such as docusate is recommended to prevent iron-induced constipation

A

TRUE

21
Q

What is the antidote for iron overdose?

A
  • Deferoxamine (Desferal)
22
Q

Oral iron - DDIs

A

Antacids, PPIs and H2RAs ↓ iron absorption by ↑ gastric PH
* Patients should take iron 2 hours before or 4 hours after taking antacids

Iron is a polyvalent cation that can ↓ the absorption of other drugs by binding with them GI tract. Seperate administration iron with:
* Quinolone and tetracycline antibiotics - take iron 2 hrs before or 4-8 hrs after
* Bisphosphonates - take iron 60 min after oral ibandronate or 30 min after alendronate/risedronate

  • Levothyroxine - seperate from iron 2-4 hrs

Vitamin C ↑ the absorption of iron. Giving iron with ascorbic acid may enhance the absorption to a minimal extent

23
Q

Which patient population IV iron is restricted to? Why?

A

Due to the severe ADRs and the cost of therapy, IV iron is restricted to patients who are;

  • CKD on hemodialysis (most common IV iron use)
  • CKD receiving erythropoiesis-stimulating agent (ESAs)
  • Unable to tolerate oral iron or failure of oral therapy (e.g., IBD, celiac disease, certain gastric bypass procedures, achlorhydria and H.pylori)
  • Religious reasons
24
Q

IV iron - BWs, SEs, brand/generic names

A

Iron sucrose (Venofer)
Ferumoxytol (Feraheme)
Iron dextran complex (INFeD)

Boxed Warning
* Anaphylactic reactions with iron dextran and ferumoxytol - all patients receiving iron dextran should be given test dose prior to first full dose

Side Effects
* All parenteral iron products carry a risk for hypersensitivity reactions

25
Q

What is the only indication for IV ferric pyrophosphate citrate (Triferic)?

A
  • Iron replacement in patients with hemodialysis-dependent CKD
  • It should be added to the bicarbonate concentrate of the hemodialysate for patients receiving hemodialysis
26
Q

Pernicious anemia, the most common cause of vitamin B12 deficiency, occurs due to a lack of ____.

Fill in the blank

A
  • Intrinsic factor (IF)
27
Q

T/F: Pernicious anemia requires a lifelong parenteral vitamin B12 replacement

A

TRUE

28
Q

What are the other causes of macrocytic anemia?

A
  • Alcoholism
  • Poor nutrition
  • GI disorders (e.g., chrons disease, celiac disease)
  • Pregnancy
29
Q

The long term use (>= __ years) of ___, ___ or ___ can decrease the the absorption of vitamin B12.

A
  • 2
  • Metformin
  • PPIs
  • H2RAs
30
Q

Vitamin B12 deficiency can result in serious neurologic dysfunction, including ___ neuropathies. If left undiagnosed, neurologic symptoms can become ___.

Fill in the blanks

A
  • Peripheral
  • Irreversible
31
Q

Folic acid deficiency does not cause neurologic symptoms; it causes ___ of the tongue and oral mucosa and changes to skin, hair and fingernail pigmentation

Fill in the blank

A
  • Ulcerations
32
Q

T/F: Macrocytic anemia = low Hgb, high MCV

A

TRUE

33
Q

How do you treat macrocytic anemia?

A

Cyanocobalamin, vitamin B12
* First-line

  • IM or deep SC: 100-1,000 mcg daily/weekly/monthly
  • Nascobal: 500 mcg in one nostril once weekly

Folic acid, folate, vitamin B-9

34
Q

What is erythropoietin (EPO)?

A
  • EPO is a hormone produced by kidneys that stimulates the bone marrow to produce RBCs
35
Q

What happens if EPO is deficient?

A
  • Anemia of CKD
36
Q

How is anemia of CKD treated?

A
  • Erythropoiesis-stimulating agents (ESAs) should be initiated
37
Q

How do ESAs work in the body?

A
  • ESAs help maintain Hgb levels and reduce the need for blood transfusions
  • They are ineffective if iron stores are low
38
Q

Epoetin alfa, Darbepoetin - brand/generic names, dosing

A

Epoetin alfa (Epogen, Procrit)
* CKD: 3x/week, initiate when Hgb <10 g/dL ↓ or interrupt dose when Hgb approaches or exceeds 11 g/dL (CKD on HD)

  • Cancer (taking chemo): initiate when Hgb <10 g/dL

Darbepoetin (Aranesp)
* CKD: IV or SC weekly

  • t1/2 is 3-fold longer than epoetin alfa (it can be given weekly)
39
Q

ESAs - BWs, SEs, warnings, monitoring, storage/use

A

Boxed Warning
* ↑ risk of death, MI, stroke, VTE, thrombosis

  • Use the lowest effective dose to reduce the need for blood tranfusions
  • CKD: ↑risk of death when Hgb >11 g/dL
  • Cancer: not indicated when the anticipated outcome is cure

Side Effects
* Arthralgia

Warnings
* HTN

Monitoring
* Hgb, Hct, TSAT, serum ferritin, BP

Storage/use:
* Store in the refrigerator

  • Do not shake
40
Q

What is the cause of hemolytic anemia?

A
  • Acquired (e.g., drug-induced)
  • Inherited (e.g., G6PD deficiency)
41
Q

T/F: The direct coombs test is used for hemolytic anemia

A

TRUE

42
Q

List drugs that can cause hemolytic anemia

A
  • Cephalosporins
  • Dapsone -
  • Isoniazid
  • Levodopa
  • Methyldopa
  • Methylene blue -
  • Nitrofurantoin -
  • Pegloticase -
  • Penicillins
  • Primaquine -
  • Quinidine
  • Rasburicase -
  • Rifampin
  • Sulfonamides -

-Avoid in G6PD deficiency

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