IC7 - Anemia and Drug-induced hematologic disorder

Question 1

How are anemia classified?

Answer 1

1. Hypo-proliferative
2. Maturation disorder
3. Hemorrhage/ hemolysis

Question 2

What are the four common causes of anemia?

Answer 2

1. Iron-deficiency
2. Vitamin B12 or folic deficiency
3. Anemia of inflammation
4. Drug-induced

Question 3

What are the two physical examinations that may suggest anemia?

Answer 3

Pallor
Jaundice

Question 4

What are the laboratory evaluation that can be done for anemia?

Answer 4

1. Full blood count
2. Reticulocyte count
3. Peripheral Smear

Question 5

How is iron deficiency anemia diagnosed?

Answer 5

1. Low MCV > Low serum ferritin
2. Normal MCV > High reticulocyte count

Question 6

What are the causes for iron-deficiency anemia?

Answer 6

1. Decreased iron absorption
2. Blood/ iron loss

Question 7

How can iron-deficiency anemia be treated?

Answer 7

1. 1000 to 1500 mg of elemental iron for complete supplementation

Question 8

What is the duration of treatment for iron-induced anemia?

Answer 8

3 to 6 months

Question 9

How is anemia of chronic disease diagnosed?

Answer 9

1. Low MCV > Normal or high Serum ferritin > Low TIBC

Question 10

What causes anemia of inflammation?

Answer 10

Co-morbidities (IBD, Rheumatologic disorders, Renal insufficiency etc)

Question 11

What type of class of anemia does iron-deficiency anemia and anemia of inflammation belong to?

Answer 11

Microcytic

Question 12

Megaloblastic anemia are related to ______ and _____ disorders.

Answer 12

vitamin B12
folic acid

Question 13

MCV of megaloblastic anemias have _____ MCV.

Answer 13

high

Question 14

What are the three possible paths for megaloblastic anemia?

Answer 14

1. Decreased B12, normal folate
2. Normal B12, decreased folate
3. Normal B12 and folate

Question 15

How to treat pernicious anemia?

Answer 15

Parental (IM or SQ) 1000ug OD 1 week > 1000ug weekly 4 weeks > 1000 ug monthly for life

Question 16

How can cobalamin deficiency due to other causes be treated?

Answer 16

IV or oral B12 (1000ug or 2000ug daily)

Question 17

What is the common cause of folate deficieny?

Answer 17

Nutritional deficiency

Question 18

How can folate deficiency be treated?

Answer 18

1mg/d of folate (1 to 4 months or till hematologic recovery)

Question 19

Drug-induced haematologic disorders are due to _________ issues.

Answer 19

haematopoiesis

Question 20

How is aplastic anemia diagnosed?

Answer 20

Any of the following 2:
1. WBC ≤ 3500 cells/mm3
2. Platelet count ≤ 55000 cells/mm3
3. Haemoglobin value ≤ 10g/dL and reticulocyte count ≤ 30000 cells/mm3

Question 21

What can be done to treat aplastic anemia?

Answer 21

1. Remove offending drug
2. Start prophylactic antimicrobial if neutrophil less than 500 cells/mm3 OR broad spectrum if febrile neutropenia
3. Transfusion support with RBCs and platelets

Question 22

Over transfusion in aplastic anemia can be given _____ or ______.

Answer 22

deferxamine, deferasirox

Question 23

What is drug-induced neutropenia or agranulocytosis?

Answer 23

Absolute neutrophil count < 1500/ul

Question 24

What is the prototype drug for aplastic anemia?

Answer 24

Chloramphenicol

Question 25

What are the drugs that are associated with aplastic anemia?

Answer 25

Drugs causing bone marrow failure involved in processes such as radiation therapy or cytotoxic chemotherapy

Question 26

What are the three prototype drugs associated with agranulocytosis?

Answer 26

Anti-thyroid (i.e. propylthiouracil)
Clozapine and other phenothiazines
Penicillin

Question 27

How can agranulocytosis be managed?

Answer 27

1. Hold off offending drug
2. Start GSF (filgrastim) SQ if neutrophil nadir < 100 cells/mm3

Question 28

Penicillin can be restarted at ____ doses once neutropenia has been resolved without any recurrence of drug-induced agranulocytosis.

Answer 28

low

Question 29

How is hemolytic anemia diagnosed?

Answer 29

Direct and indirect Coombs’ test

Question 30

What is one cause of hemolytic anemia?

Answer 30

G6PD (Metabolic)

Question 31

What are some medications unsafe for people with G6PD deficiency and are associated with anemia?

Answer 31

Fluoroquinolones, primaquine, tafenoquine, sulfonylureas

Question 32

What are some chemical exposures and foods associated with hemolytic anemia and should be avoided in G6PD?

Answer 32

Fava beans, henna compounds, naphthalene

Question 33

Name a drug that is safe to be used in G6PD deficient patient and not associated with hemolytic anemia.

Answer 33

Chloroquine and hydroxychloroquine

Question 34

What are the medications associated with megaloblastic anemia?

Answer 34

Antimetabolite
Co-trimoxazole (esp when folate or B12 deficient)
Phenytoin and phenobarbital (inhibit folate absorption or catalyze folate catabolism)

Question 35

What is thrombocytopenia?

Answer 35

Platelet count ≤ 100000 cells/mm3 or greater than 50% reduction from baseline values

Question 36

Heparin induced thrombocytopenia is paradoxically associated with _____.

Answer 36

thrombosis

Question 37

What can be used in management of heparin induced thrombocytopenia?

Answer 37

DOACs

Question 38

What is the management for thrombocytopenia?

Answer 38

Hold off offending drug and KIV corticosteroids if severe

Question 39

How do one monitor for Heparin induced thrombocytopenia following major surgery?

Answer 39

4T score
Score of 4: intermediate
Score of 6: high

Question 40

What are the 4T in the 4T score?

Answer 40

Thrombocytopenia
Timing of platelet count fall
Thrombosis or other sequelae
Other causes for thrombocytopenia

Question 41

What should one do when 4T score is intermediate or high?

Answer 41

1. Stop heparin and start non-heparin
2. Conduct PF4/ heparin immunoassay

Question 42

What causes pernicious anemia?

Answer 42

1. Decrease absorption due to lack of intrinsic factor or gastric disruption
2. Nutritional
3. Other causes: PPI, H2RA, H.pyloric