A 48 year-old woman who had been taking aspirin for a flare of rheumatoid arthritis presented with mild epigastric pain. A CBC was ordered, and a guaiac test for occult blood was performed. The guaiac test was negative. The CBC revealed a normocytic anemia (hemoglobin 10.5 g/dL; hematocrit, 32 percent MCV, 90 fL), with a red blood cell distribution width of 44 fL (normal range: 39 to 47 fL). A reticulocyte count and “draw and hold” specimens were ordered. The corrected reticulocyte index was 1.0 percent. Ferritin and serum iron levels were obtained from the stored specimens. These tests revealed an elevated ferritin level and a low serum iron level. Which of the following types of anemia is supported by these findings?
A. Iron deficiency anemia
B. Anemia of chronic disease
C. Macrocytic anemia
D. Pernicious anemia
E. Aplastic anemia
B. This patient has normocytic anemia and most likely has anemia of chronic disease associated with her rheumatoid arthritis.
A father suspects that his toddler may have taken a few of his iron tablets. He is not sure, and has brought the child into the local pharmacy. The pharmacist looks at the child, who is playing with a toy and looks fine. What is the proper recommendation to the parent?
A. Watch the child for the next hour; if he appears to look sullen, or ill, take him to the hospital right away.
B. Watch the child for at least 12 hours; if he appears to look sullen, or ill, take him to the hospital right away.
C. Administer syrup of ipecac when you return home.
D. Administer activated charcoal when you return home.
E. Take the child to the emergency room now.
E. The child can appear asymptomatic (initially) or have already developed severe nausea, vomiting, gastrointestinal bleeding (most often vomiting blood), and diarrhea. If a parent suspects their child took iron pills or liquid, they should be directed to the nearest emergency room immediately-whether symptomatic or not. Left untreated, iron overdose will damage most organs, including the brain, and can be fatal.
A patient with renal insufficiency is going to begin self-injecting Aranesp. She can be instructed to inject the medicine in which of the following areas? (Select ALL that apply.)
A. The abdomen but not within two inches of the navel
B. The deltoid on the upper arm, above the elbow
C. The front of the middle thighs
D. The outer area of the buttocks
E. The chest
A, C, D. Each of these sites are acceptable except for the chest and deltoid (this is the common site for an intramuscular injection-erythropoietin is subcutaneous, unless it is given at dialysis into the port.)
A pharmacy in a hospital has an order for injectable vitamin B12. What medication should be ordered?
E. Nicotinic acid
nicotinic acid (B3)
Anemia is a disease characterized by a decrease in hemoglobin or red blood cells (RBCs). This can happen when a patient is bleeding, with certain diseases, and when the red blood cells are not functional. Which of the following nutrients are required for optimal red blood cell function? (Select ALL that apply.)
B. Vitamin E
C. Folic Acid
D. Vitamin D
E. Vitamin B12
A, C, E. Iron, folic acid and vitamin B12 are essential nutrients for optimal RBC function.
Charlene's doctor orders lab work and finds she has low vitamin B12. The physician orders a test to determine if her body absorbs vitamin B12. What is the name of the test that may be ordered to determine if she has adequate vitamin B12 absorption?
A. Coombs test
B. Urine protein electrophoresis
C. Amylase test
D. Schilling test
E. Trypsin-like immunoreactivity
D. The Schilling test is used to determine whether the body absorbs vitamin B12. It indicates that the person is lacking in intrinsic factor, cannot absorb vitamin B12 and therefore has pernicious anemia. Most physicians no longer order the Schilling test; they just order injectable vitamin B12 if the level is low. This can be administered in the physician's office or self-injected subcutaneously by the patient.
Choose the correct statement concerning iron supplementation:
A. The majority of patients who need iron replacement are able to receive an injection twice yearly to replace iron stores.
B. The majority of patients who receive iron by injection are alcoholics or have a malabsorption condition, such as celiac disease or Crohn's.
C. The preferred oral iron replacement product is polysaccharide iron complex (such as Niferex-150).
D. The majority of patients who need iron replacement are able to use ferrous sulfate tablets.
E. Iron supplementation is only recommended in patients with severe anemia (Hgb
D. The majority of patients who receive iron by injection are ESRD patients on dialysis. Most patients who have microcytic anemia use oral iron tablets, primarily ferrous sulfate.
Erythropoietin stimulating agents are commonly used in patients with ESRD who are on dialysis. Which of the following statements concerning erythropoietin stimulating agents are correct? (Select ALL that apply.)
A. Patients must monitor blood pressure with these agents. They are likely to have arthralgia, and may experience bone pain.
B. Erythropoietin stimulating agents will not work well in patients who are iron deficient.
C. There is a risk of thrombosis with these agents.
D. Once patients have started the medication, the hemoglobin does not need to be monitored before subsequent doses.
E. The advantage of darbepoetin is less frequent dosing and can normalize the patient's blood values more quickly.
A, B, C. Joint achiness is called arthralgia. In ESRD patients, Aranesp is dosed weekly or every two weeks (versus about three times weekly-or at every dialysis-for the older epo formulations), however, it does not normalize hemoglobin levels any quicker than other formulations. Never dose unless the hemoglobin warrants it (less than 10 g/dL); hemoglobin needs to be monitored.
Gustavo has been diagnosed with iron-deficiency anemia and is beginning to use iron supplements. He asks how long he has to take the iron. What is a reasonable response?
A. At least one week; your doctor will test your blood and tell you when to stop.
B. At least three weeks; your doctor will test your blood and tell you when to stop.
C. At least a month; your doctor will test your blood and tell you when to stop.
D. At least several months; your doctor will test your blood and tell you when to stop.
E. At least a year; your doctor will test your blood and tell you when to stop.
D. The effect of iron supplementation may be seen in about 3 weeks and the treatment should last until 3-6 months after RBCs, iron stores, and other labs have normalized.
Gustavo is purchasing store-brand ferrous sulfate. Which of the following is a correct counseling point for iron supplements?
A. Take with your heaviest meal of the day, as iron causes nausea.
B. This will cause loose stools.
C. If you become constipated, use a psyllium product, such as Metamucil.
D. If you become constipated, use a stool softener such as docusate.
E. Iron makes the stool light, or chalky colored.
D. Although iron causes stomach upset, it is recommended to take iron on an empty stomach because food decreases absorption by up to 50%. If the patient cannot tolerate the iron and they must take with food, it will take longer to replenish the iron stores and they may need more frequent dosing. The other major side effect of oral iron, in addition to nausea, is constipation. Although fiber is the usual first-line therapy for constipation, a stool softener such as docusate is often recommended because iron causes hard, compact stools and it is difficult for fiber to "mix in" to the stool and make it spongy.
Gustavo uses a variety of different medicines and over-the-counter supplements. Which of the following will interact with iron supplements? (Select ALL that apply.)
B. Tetracycline and quinolone antibiotics
C. Clopidogrel and other similar antiplatelets
D. Antacids and other agents that increase pH
B, D. Antacids and agents that raise pH (H2RAs, PPIs) decrease iron absorption by increasing pH. Antibiotics, mainly tetracycline & quinolones, can decrease iron absorption through chelation (take iron 2 hours before or 4 hours after).
Gustavo went to his doctor complaining of weakness. He had pallor and was tachycardic. The CBC had the following values: WBC 4.5 cells/mm³, Hgb 10.2 g/dL, PLT 350/mm³ and MCV 76 µm³. A peripheral smear showed hypochromic, microcytic RBCs. The patient had no history of GI symptoms, and endoscopic exams were unremarkable. He was diagnosed with iron-deficiency anemia and given oral iron supplementation. Gustavo went to the pharmacy and asked for a recommendation for an iron supplement. What should the pharmacist recommend for this patient?
B. Ferrous sulfate
C. Iron sucrose
B. Ferrous sulfate is the usual recommendation for oral iron replacement. There is no particular advantage over other (generally more expensive) formulations, although ferrous bisglycinate might cause less nausea in some patients and carbonyl iron is more concentrated. Fer-In-Sol are iron-only drops for infants. Poly-Vi-Sol are infant drops with iron and vitamin D--both of which are required by breast-fed babies. Ferumoxytol and iron sucrose are injectable iron formulations.
Intravenous iron administration commonly causes this side effect:
D. Migraine headache
C. Slowing the rate of infusion and spreading out the doses may help reduce hypotension.
IV iron can cause anaphylaxis. Which of the following IV iron preparations has the highest risk for anaphylaxis and requires a test dose prior to administration?
A. Iron sucrose (Venofer)
B. Sodium ferric gluconate complex (Ferrlecit)
C. Ferumoxytol (Feraheme)
D. Iron dextran (INFeD, Dexferrum)
E. Ferric carboxymaltose (Injectafer)
D. Iron dextran requires a test dose, due to the potential for anaphylaxis. The patient is given a small dose and monitored for adverse reactions for 15-20 minutes. IV iron can cause delayed reactions (arthralgias, myalgias, fever, dizziness, nausea). Some patients receive prophylaxis for these reactions with NSAIDs or steroids. All the IV iron preparations have a boxed warning for anaphylaxis risk; iron dextran has the highest risk.
Keith has severe anemia. In addition to the classic symptoms of anemia, what symptoms might be present in a patient with a severe case? (Select ALL that apply.)
B. Chest pain, angina, heart attack
A, B, C, D, E. More severe symptoms include chest pain, angina, heart attack, fainting, and tachycardia. Pallor, or pale skin, and glossitis (an inflamed tongue) may be noticeable. Koilonychias, or thin, concave, spoon-shaped nails, brittle nails and restless leg syndrome may be present.
Megan is purchasing ferrous fumarate tablets. She asks the pharmacist how much elemental iron is in each tablet. The pharmacist should respond:
C. Ferrouse fumarate contains 33% elemental iron. Ferrous sulfate contain 20% elemental iron, unless it is exsiccated which contains 30% elemental iron. You should know the percent elemental iron in ferrous sulfate for the exam, since it is the most commonly used.
Mary has a low hemoglobin and hematocrit. The physician needs to determine the anemia type. What lab value is used to distinguish between microcytic and macrocytic anemia?
A. Mean corpuscular volume (MCV)
B. Mean Corpuscular Hemoglobin Concentration (MCHC)
C. Total Iron-Binding Capacity (TIBC)
D. Serum ferritin
E. Total Reticulocyte count
A. The symptoms may be similar for both macrocytic or microcytic, but the mean corpuscular volume, or MCV, will differ. The MCV is small (less than 80) in microcytic anemia due to a small cell size from a lack of iron. The MCV is large (greater than 100) in macrocytic anemia, due to folate and/or vitamin B12 deficiency.
Parenteral iron therapy is as effective but can be more dangerous and is much more expensive than oral therapy. All of the following clinical situations may warrant IV iron administration except:
A. Patients donating large amounts of blood for autoinfusion
B. GI tract absorption condition (such as Crohn's) that is causing poor oral absorption
C. Anyone unable to tolerate iron orally, or if losing the iron too rapidly
D. A patient who wants to get her iron levels up rapidly in order to enter a marathon in a few weeks
E. Hemodialysis patients
D. Hemodialysis patients are the most common users of intravenous iron. The National Kidney Foundation (NKF) guidelines state that to achieve and maintain a hemoglobin level of 11 to 12 g/dL, most hemodialysis patients will require IV iron on a regular basis.
Patients with end stage renal disease develop anemia due to a lack of this hormone, which is produced by healthy kidneys:
C. Erythropoietin stimulates the bone marrow to produce RBCs. In renal disease the deficiency results in the bone marrow making fewer red blood cells. Erythropoietin can be given by injection (generally subcutaneous) or via a dialysis port.
Sandra has been using erythropoietin for six months. She woke up yesterday from pain in her left leg, below the knee. She was surprised to see her leg was swollen. She had difficulty walking on the leg. What is the likely complication that Sandra is having?
C. Deep vein thrombosis
E. Multiple myeloma
C. The erythropoietin stimulating agents (ESAs) increase the risk for thrombosis. Blood clots (most commonly deep vein thrombosis) are uncommon, but can occur and patients should be told to call the physician if they have pain in the legs (with or without swelling) or chest pain or trouble breathing (possible pulmonary embolism). Rarely, the use of ESAs can cause seizures.
Sandra has been using Procrit for quite some time. She has heard that there is a similar agent that requires less frequent dosing. Which formulation is given weekly (or every other week) due to a longer drug half-life?
D. Darbepoetin (Aranesp) works similary to epoetin alfa, but requires less frequent dosing.
Sandra has chronic kidney disease and has been prescribed erythropoietin (Epogen, Procrit). Counseling points for self-injection of this medication should include which of the following? (Select ALL that apply.)
A. Store the vials in the refrigerator (do not freeze).
B. Allow the medicine to reach room temperature; shake well prior to drawing up the medication.
C. Each needle is to be used only once. Do not re-enter the multidose vial with with the same needle and syringe.
D. Draw up the medicine in a subcutaneous syringe; knock out any large air bubbles to ensure you get the right amount of medicine.
E. Your blood pressure may increase with the use of this medicine; it is important to monitor your blood pressure.
A, C, D, E. It is important to allow the medicine to reach room temperature but do NOT shake hormones or proteins that are used as injectable drugs-this damages the drug. Follow the recommended (local) instructions for safe needle disposal.
Sandra has chronic kidney disease and has been prescribed erythropoietin (Epogen, Procrit). How does erythropoietin work?
A. It helps the decreased number of red blood cells that are still being produced operate more efficiently.
B. It makes the kidneys produce more endogenous erythropoietin.
C. It is converted into red blood cells.
D. It stimulates red blood cell production in the bone marrow.
E. It increases the amount of iron available for binding to red blood cells.
D. Normally, erythropoietin is produced by the kidneys. In this patient, her kidneys are failing and are not able to produce adequate erythropoietin. This hormone stimulates RBC production (erythropoiesis) in the bone marrow.
Sandra has SLE-induced nephropathy with an estimated creatinine clearance of 22 mL/min. She injects weekly epoetin alfa. Lab values include Hgb 11.4 g/dL, Hct 34.2 g/dL and LDL 146 mg/dL. Her blood pressure averages 156/92 mmHg. Using her current lab values, should she receive an injection of epoetin alfa?
A. Yes, because the goal Hgb level is below 11 g/dL.
B. Yes, because the goal Hgb level is below 12 g/dL.
C. No, she is at the goal Hgb level.
D. No, epoetin alfa is no longer recommended for use in renal failure.
E. No, the drug has been removed from the market due to cardiovasular risk.
C. For chronic renal failure start ESA therapy when the hemoglobin is less than 10 g/dL and reduce or stop when near 11 g/dL. Use the lowest possible dose and do not give more than is necessary. Higher levels increase the risk for cardiovascular events, stroke and death.
Susan lacks adequate secretion of intrinsic factor. The lack of intrinsic factor can put her at risk for what type of anemia?
A. Iron deficiency anemia
B. Aplastic anemia
C. Folic acid deficiency anemia
D. Vitamin B12 deficiency anemia
E. Anemia of chronic disease
D. Intrinsic factor is required for adequate vitamin B12 absorption in the small intestine.
The most common type of anemia is iron-deficiency anemia. Which statement concerning iron-deficiency anemia is correct?
A. It is generally treated with intravenous iron.
B. It is indicated by a MCV greater than 100.
C. This type of anemia is called macrocytic.
D. The hemoglobin and hematocrit will both be low.
E. It takes 1-2 weeks to treat in most cases.
D. Iron-deficieny anemia is diagnosed by a low hemoglobin/hematocrit, and MCV less than 80 (microcytic anemia). A normal MCV is between 80 and 100. Iron-deficiency anemia is generally treated with over the counter iron products. It takes a long time to replenish iron stores.
What are causes of macrocytic, or megaloblastic, anemia? (Select ALL that apply.)
A. Chronic alcoholism
B. Iron deficiency
C. Crohn's or celiac disease
D. Poor nutritional intake
E. Lack of intrinsic factor
A, C, D, E. Macrocytic anemia is due to a vitamin B12 or folate deficiency, or both.
What is pica?
A. Craving and eating substances with poor nutritional value such as ice, clay or paper
B. Consuming excessive amounts of fluids and eating constantly without the ability to stop
C. Falling asleep suddenly and not recalling the event
D. Painful muscle spasms in the lower extremities making it difficult to walk
E. Picking at one's fingernails incessantly in a nervous manner
A. Pica is sometimes present in patients with iron-deficiency anemia. Children can occasionally have pica at some point while growing up (without anemia); it generally goes away.
What is the leading cause of poisoning deaths among young children?
E. Household cleaners
A. All of these cause accidental poisonings, but iron poisoning is the leading cause of poisoning deaths among young children. Very young children (with no teeth) can be excited to find iron pills that look like M&Ms and can quickly ingest a toxic amount-it does not take much.
What is the antidote for iron overdose?
D. The antidote for iron overdose is deferoxamine (Desferal). Iron pills are now routinely packaged in unit-dose blister packs to reduce the risk of accidental childhood ingestion.
What is the name for B12 deficiency macrocytic anemia when caused by a lack of intrinsic factor?
A. Anemia of chronic disease
B. Thrombotic anemia
C. Recidivist anemia
D. Pernicious anemia
E. Anemia of secondary disease
D. Pernicious anemia is a common type of macrocytic anemia that results in low B12 levels due to a lack of instrinsic factor, which is required for adequate B12 absorption in the small intestine. Since gut absorption is impaired, pernicious anemia requires lifelong vitamin B12 replacement, most often using injections. Some patients can get enough supplementation with high-dose tablets of oral vitamin B12 while many receive injections.
Which lab values are indicative of macrocytic, or megaloblastic, anemia? (Select ALL that apply.)
A. Low hemoglobin
B. High hematocrit
C. MCV D. Low hematocrit
E. MCV > 100
A, D, E. In both microcytic and macrocytic anemia the hemoglobin and hematocrit are low, but in macrocytic the MCV is greater than 100 and in microcytic the MCV is less than 80.
Which of the following are classic symptoms of anemia? (Select ALL that apply.)
B. Oily skin
E. Shortness of breath
A, C, D, E. In anemia, the tissues are not getting enough oxygen-rich blood. This results in the classic anemia symptoms of fatigue, weakness, shortness of breath (SOB), lightheadedness and palpitations. Skin can become dry, and hair can become thin.
Which of the following groups of people are not likely to require iron supplementation?
A. Pregnant women
B. Teenage girls with heavy menstrual bleeding
C. Breast-fed babies
D. Women using birth control pills that contain estrogen
E. Crohn's and celiac patients
D. Women taking hormone contraception experience less bleeding during their periods and therefore have a lower risk of developing an iron deficiency. Breast-fed babies need 1 mg/kg/day from 4-6 months old and until they are consuming iron-rich foods. Occasionally vegetarians need iron replacement.
Which of the following statements concerning vitamin B12 are correct? (Select ALL that apply.)
A. B12 can be poorly absorbed and is generally given as an injection.
B. B12 is called pyridoxine.
C. B12 is used to treat microcytic anemia.
D. B12 is called cyanocobalamin.
E. A typically starting dose would be 1,000 mg.
A, D. Vitamin B12 (cyanocobalamin) is generally given as an injection because macrocytic (not microcytic) anemia can be caused by poor oral B12 deficiency. It is dosed in mcg, not mg.