Anemia

Question 1

What is anemia?

Answer 1

Loss of RBCs or low Hemoglobin

Question 2

How do I know if my patient has anemia?

Answer 2

Low hemoglobin
S/sx

Question 3

Signs and symptoms of anemia

Answer 3

Exertional dyspnea

Angina

Tachycardia

Fatigue

Pallor

May be asymptomatic, especially if developing slowly

Question 4

Normal hemoglobin levels

Answer 4

Male: 13.5-18 g/dL
Female: 12-16 g/dL

Question 5

Normal MCV

Answer 5

80-100 mm^3

Question 6

Normal RDW

Answer 6

11.5-14.5%

Question 7

Decreased RBC production

Answer 7

Chronic diseases: CKD, Cancer, CHF

Nutritional deficiencies: iron, folic acid, vitamin B12

Question 8

Increased RBC destruction

Answer 8

Drugs

Sickle cell anemia/thalassemia

Question 9

Increased RBC loss

Answer 9

Acute blood loss

Chronic NSAIDS/ASA

Question 10

Microcytic

Answer 10

MCV < 80

Iron deficiency, sickle cell, thalassemia

Question 11

Normocytic

Answer 11

MCV 80-100

Anemia of chronic disease, blood loss, hemolysis

Question 12

Macrocytic

Answer 12

MCV > 100

Folic acid and or B12 deficiency

Question 13

Consequences of anemia

Answer 13

Impaired cognitive function

Falls

HF

Afib

CV events

Increased mortality

Question 14

Iron deficiency anemia

Answer 14

Microcytic anemia

Low Hgb

Low MCV

High RDW

Low ferritin

Low TSAT

Question 15

Normal Ferritin

Answer 15

Iron deficiency is still likely for ferritin < 45 ng/mL

acute phase reactant- elevated in acute inflammation or chronic disease

Question 16

Normal TSAT

Answer 16

20-50%

Iron deficiency < 20%

Question 17

Causes of iron deficiency

Answer 17

Blood loss

Decreased absorption: maximal absorption in the duodenum

Vegetarian diet

Increased consumption (pregnancy)

Question 18

Additional symptoms for iron deficiency anemia

Answer 18

Spoon-shaped nails

Inflamed tongue

Pica: pagophagia–>ice

Question 19

Treatment of iron deficiency anemia

Answer 19

Oral is preferred

IV if: cannot tolerate, cannot absorb, ESRD, HF

Question 20

Oral iron

Answer 20

65 mg of elemental iron every other day

120-200 mg of elemental iron per day (often BID or TID)

Question 21

Why might every other day dosing be better?

Answer 21

Hepcidin is increased after a dose of oral iron for 24 hours and normalizes within 48 hours

Question 22

Counseling points for oral iron

Answer 22

Taken every other day to TID

Increased absorption on empty stomach

Causes stomach upset: take at bedtime or with food

Absorption is increased with vitamin C

Causes constipation

Causes dark stools: IMPORTANT IF PT IS ALSO ON BLOOD THINNER

Question 23

IV iron

Answer 23

ESRD, HF, failed oral iron, malabsorption

SE: hypotension, skin tattooing

Question 24

Vitamin B12 deficiency anemia

Answer 24

Macrocytic anemia

Low Hgb

High MCV

High RDW

Serum B12 is low ( < 200pg/mL

Question 25

Causes of Vitamin B12 deficiency

Answer 25

Diet: vegan/vegetarian, alcoholism Lack of intrinsic factor-->pernicious anemia Crohn's Metformin, PPI's

Question 26

Consequences of B12 deficiency anemia

Answer 26

Neurologic symptoms: weakness, numbness, cognitive dysfunction

Question 27

B12 supplements

Answer 27

Oral, IM or deep SC Oral: 1000-2000 mcg/day

Question 28

Folic acid deficiency anemia

Answer 28

Macrocytic Low Hgb High MCV High RDW Serum folate < 5ng/mL

Question 29

Causes of Folic acid deficiency

Answer 29

Malabsorption Malnutrition Alcoholism Medications: methotrexate, phenytoin, sulfasalazine, bactrim)

Question 30

Treatment of folic acid deficiency

Answer 30

Oral folic acid supplement 1 mg Never replace folic acid without checking Vitamin B12

Question 31

Anemia of chronic disease

Answer 31

CKD, HF, Cancer, HIV/AIDS

Question 32

Anemia of CKD

Answer 32

Decreased erythropoietin production Chronic inflammatory state Nutritional deficiencies

Question 33

Treatment of Anemia of CKD

Answer 33

Avoid blood transfusions Correct nutritional deficiencies Folate/B12 Iron -Use oral iron in stage 3-5 CKD if possible -Use IV iron in HD patients Target TSAT above 30% Do not target normal Hgb levels: > 10 ESA's should not be used

Question 34

Blood loss anemia

Answer 34

Stop the bleeding Transfuse packed RBCs when Hgb < 7

Question 35

Hemolytic anemia

Answer 35

RBCs are destroyed before 120 days Types: sickle cell anemia, G6PD anemia, drug induced

Question 36

Sickle cell anemia

Answer 36

RBC's are irregular shape

Question 37

Treatment of sickle cell anemia

Answer 37

Folic acid: 1 mg/day Blood transfusions: iron overload from frequent transfusions Hydroxyurea: 10-15 mg/kg/day Immunizations Pain control: NSAIDS/Tylenol, PCA