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Clinical 2 (Sam) > Anemia > Flashcards

Anemia Flashcards

1
Q

What is anemia?

A
  • decreased # of RBC or hemoglobin results in less oxygen binding
  • all the symptoms of anemia are related to the tissues having depleted oxygen stores
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2
Q

Describe the Anemia Assessment - 5 steps

A

See How Many Red Cells

S = Signs and Symptoms

H = Hemoglobin or hematocrit (if low = anemic)

M = MCV (indication of average RBC size)

R = RDW (or peripheral blood smear) - are all cells the same size?

C = Check reticulocytes and likely deficiencies

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3
Q

What are the 3 types of anemia?

A
  • Iron-deficiency
  • Folate-deficiency
  • B12-deficiency
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4
Q

Anemia symptoms:

CNS

A
  • fatigue
  • malaise
  • weakness
  • headache
  • dizziness
  • irritability
  • difficulty concentrating
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5
Q

Anemia symptoms:

HEENT (head, ears, eyes, nose, throat)

A

Pallor (skin, conjunctivae, nail beds), vertigo

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6
Q

Anemia symptoms:

RESP

A

dyspnea on exertion

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7
Q

Anemia symptoms:

CVS

A

Palpitations, tachycardia, angina

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8
Q

Anemia symptoms:

GI

A

Anorexia

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9
Q

Anemia symptoms:

Other

A

cold intolerance, loss of skin tone

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10
Q

What labs are typically ordered to assess anemia?

A
  • CBC: Hbg, Hct (including RBC indices: MCV, MCHC, RDW)
  • Iron indices (ferritin), vitamin B12 and folate levels
  • Reticulocyte index
  • Stool sample for occult blood (in older adults to rule out colon cancer)
  • +/- peripheral blood smear
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11
Q

What is the laboratory definition of anemia in males?

A

Hgb < 130 g/L

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12
Q

What is the laboratory definition of anemia in females?

A

Hgb < 120 g/L

*lower for females due to monthly menstruation

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13
Q

Microcytic anemia = what deficiency?

A

iron

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14
Q

Macrocytic anemia = what deficiency?

A

B12/folate

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15
Q

What MCV = microcytic ?

A

< 80

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16
Q

What MCV = normocytic ?

A

80-100

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17
Q

What MCV = macrocytic ?

A

> 100

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18
Q

see diagram on page 2

A

ok

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19
Q

What is the most common cause of anemia?

A

iron deficiency

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20
Q

What are the clinical presentations of iron deficiency anemia?

A
  • dry rough skin
  • brittle nails
  • dry, damaged hair or hair loss
  • restless leg syndrome

Other possible symptoms (unlikely unless Hgb < 90):

  • Glossal pain, smooth tongue (atrophy of tongue papillae)
  • Reduced salivary flow
  • Pica (compulsive eating of nonfood items - ex. clay, starch)
  • Pagophagia (compulsive eating of ice)
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21
Q

What are signs of advanced tissue iron deficiency?

A

Cheilosis - cracking at corners of mouth

Koilonychia - spooning of fingernails

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22
Q

What is Serum Ferritin?

A
  • Reflects tissue iron stores (liver, spleen, bone marrow)
  • Acute phase reactant - may be elevated in infection, inflammation, malignancy
  • If < 15-30, iron deficiency anemia is likely
  • If > 100, iron deficiency is unlikely
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23
Q

What is TSAT (%) ?

A

Serum iron/TIBC x 100

  • Amount of iron that is readily available
  • Normal range is 14-50%
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24
Q

What is TIBC?

A

indirect measure of iron-binding capacity of serum transferrin

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25
Q

What is Serum Iron?

A
  • concentration of iron bound to transferrin

- must be interpreted together with TIBC to obtain TSAT

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26
Q

Iron Deficiency Anemia:

Hgb

A

low

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27
Q

Iron Deficiency Anemia:

MCV

A

Low

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28
Q

Iron Deficiency Anemia:

MCH

A

Low

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29
Q

Iron Deficiency Anemia:

MCHC

A

Low

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30
Q

Iron Deficiency Anemia:

RDW

A

High (wide variation in size of RBCs)

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31
Q

Iron Deficiency Anemia:

Reticulocytes

A

Low

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32
Q

Iron Deficiency Anemia:

Serum Ferritin

A

Low

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33
Q

What are some risk factors for IDA (iron deficiency anemia)?

A

1) Inadequate intake/increased requirements:
- adolescents (poor diet, rapid growth)
- menorrhagia, pregnancy/lactation
- vegetarians (especially vegans)
- endurance runners/other athletes (increase RBC production, iron loss, through injury/”foot strike” damage to RBCs, sweat)
- Chronic renal failure patients

2) Blood loss:
- Regular blood donors
- Surgery
- Drugs (ex. ASA/NSAIDs, anticoagulants - GI blood loss)

3) Genetic:
- Family Hx of hematologic disorders
- Ethnicity (first nations, indo-Candian)

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34
Q

What are the goals of treatment?

A
  • To improve clinical signs and symptoms of anemia

- To restore Hgb levels and MCV to normal and replenish iron stores

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35
Q

What are the principles of treatment?

A
  • Determine cause of iron deficiency and treat underlying disease if possible
  • Fecal occult blood test (FOBT) to check for GI bleeding/colon cancer screening
  • Replenish iron stores
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36
Q

What are some options for treatment?

A
  • Increase dietary iron
  • Oral iron supplementation
  • IV iron supplementation
  • Blood transfusions
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37
Q
  • Menses
  • GI neoplasms
  • Blood donations
  • Bleeding disorder
  • UC(ulcerative colitis)/IBD
  • Peptic ulcer
  • Hemorrhoids
  • Diverticulosis
  • Drugs (ASA, NSAIDs, anticoagulants)

All examples of what cause ?

A

Increased iron loss

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38
Q
  • Rapid growth, infancy, adolescence
  • Pregnancy
  • EPO deficiency

All examples of what cause ?

A

Increased demand for iron

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39
Q
  • Inadequate diet
  • Gastric surgery
  • Crohn’s disease
  • Celiac disease
  • Achlorhydria
  • Acute or chronic inflammation
  • H. pylori infection

All examples of what cause ?

A

Decreased iron intake/absorption

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40
Q

You need ____ in the stomach to absorb iron.

A

acid

*so antacids affect iron absorption

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41
Q

Examples of Heme Iron (ferrous iron)

A
  • Meat, poultry, seafood
  • 3x more absorbable vs. non-heme iron
  • Absorption decreased by content of calcium in meal (Ca2+ supplements, dairy)
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42
Q

Examples of Non-Heme Iron (ferric iron)

A
  • Vegetables, fruits, dried beans, nuts, grains

- Absorption increased by gastric acid and ascorbic acid-rich foods, heme iron

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43
Q

What decreases non-heme iron absorption?

A
  • Phytates (bran, oats, rye, fibre)
  • Tannins (herbal teas)
  • Phosphates
  • Polyphenols (tea/coffee)
  • Calcium supplements
  • Milk/dairy
  • Antacids, PPI, H2Bs
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44
Q

What is the recommended dose of iron for IDA for adults and elderly?

A

Adults: 150-200 mg elemental FE/day (or 2-3 mg/kg/day) usually divided BID/TID

Elderly: lower 15-50mg/day dose may be effective

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45
Q

How should iron be spaced from food?

A
  • on an empty stomach or at least 1 hr before meal or 2 hrs after meals
  • may need to take with meals to decrease GI SE (decreases absorption of iron though)
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46
Q

SE of iron?

A
  • nausea, vomiting, dyspepsia, constipation, diarrhea, dark stools, metallic taste
  • generally dose related and resolve with time (except dark stools)
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47
Q

How do you start iron?

A

Start with 1 tab and work up gradually (every 3-7 days) to improve GI tolerability

Start low and titrate up

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48
Q

Liquid preps of iron may do what?

A

Stain teeth

-Mix with juice/water & drink through straw, rub teeth with baking soda)

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49
Q

Drug interactions with iron?

A
  • Antacids, PPIs, H2B, cholestyramine, calcium/milk (decrease absorption of Fe)
  • Levodopa, levothyroxine, quinolones, tetracyclines, bisphosphates (also decrease absorption) - Take iron at least 3 hours before or 2 hours after these drugs
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50
Q

Consider holding iron until _______ completed

A

antibiotics

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51
Q

Describe the differences between oral preparations

A
  • Various iron salts contain different amounts or iron (all absorbed similarly)
  • SR formulations (no controlled studies to indicate less GI SE, slow release past duodenum may decrease chance for absorption
  • Enteric coated (more poorly absorbed than standard film-coated)
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52
Q

gluconate

A

green

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53
Q

sulphate

A

red

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54
Q

% of elemental iron in Ferrous Gluconate ?

A

11%

35/300 mg tab

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55
Q

% of elemental iron in Ferrous Sulphate ?

A

20%

60/300 mg tab

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56
Q

% of elemental iron in Ferrous fumarate ?

A

33%

100/300 mg tab

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57
Q

When should you consider parenteral iron?

A
  • Evidence of iron malabsorption
  • Intolerance to oral iron
  • Patient with significant blood loss who refuses blood transfusion and cannot take oral iron
  • Chronic dialysis patients
  • Some patients receiving chemotherapy and erythropoiesis stimulating agents (ESAs)
58
Q

All parenteral iron preparations carry a risk for ______ rxns

A

anaphylactic

59
Q

What is the formula for calculating IV iron dose?

A

Dose of iron (mg) = weight (kg) x (140-Hgb) x 0.22

  • An additional quantity of iron to replenish stores should be added (about 600 mg for women and 1000 mg for men)
  • Usually given in divided doses
60
Q

Can you give oral and IV iron together?

A

No way man

-Don’t give IV and oral iron together bc GI absorption would be impaired

61
Q

What are the transient side effects of IV iron that usually resolve within 48 hours ?

A
  • nausea, vomiting, pruritus, headache and flushing
  • myalgia, arthralgia
  • back and chest pain
62
Q

What are some other side effects of IV iron?

A
  • Hypersensitivity reactions (rare)
  • Severe or life-threatening reactions (rare). Risk factors: rapid infusions, history of atopy and drug allergy
  • Must be given by trained HCP in an environment with access to resuscitation equipment.
  • Patients are monitored closely during administration
63
Q

How much iron is in 1 mL of packed RBC’s?

A

1 mg iron

64
Q

How many mL is in 2 units of PRBC’s?

A

500 mL = 500 mg iron

65
Q

How much does 1 unit of PRBC increase Hgb by ?

A

10 g/L

66
Q

Describe the concerns with safety and availability of blood transfusions?

A

Bloodborne infections, development of autoantibodies, transfusion reactions and iron overload

67
Q

Who are blood transfusions considered for?

A

severe anemia with Hgb < 70-80 g/L

68
Q

IDA:
Therapeutic doses of iron should increase Hgb by ____g/L per week

*Response of < 20 g/L over 3 weeks - further evaluation

A

10

69
Q

When are CBC, Ferritin, and may eTSAT ordered?

A

CBC every month and 3-6 months

Ferritin +/- TSAT in 3-6 months

70
Q

When do reticulocytes rise?

A

5-7 days after iron therapy started, reaching a max on day 10-14, then decreases

71
Q

How long should you treat IDA for after anemia is resolved?

A

For 3-6 months after anemia resolved to allow for repletion of iron stores and prevent relapse (approx 6-12 months)

72
Q

Which 2 tests are used to differentiate between B12 deficiency and folate deficiency?

A
  • Homocysteine
  • MMA (methylmalonic acid)
  • Both are high in B12 deficiency
  • Only homocysteine is high in folate deficiency
73
Q

Which symptoms can help you differentiate between B12 deficiency and folate deficiency?

A

Neurologic symptoms:
-If present = B12 deficiency

*Folic acid deficiency does not cause neurologic symptoms

74
Q

What are neurologic symptoms?

A

parasthesias, numbness, tingling

75
Q

What is the role of vitamin B12 (cobalamin) ?

A
  • Required along with folic acid in synthesis of DNA, RNA
  • Essential for maintaining integrity of NEUROLOGIC system
  • Role in fatty acid synthesis and energy production
76
Q

Dietary sources of Vitamin B12

A

meat, fish, poultry, diary, fortified cereals

77
Q

B12 deficiency takes several years to develop due to efficient ??

A

enterohepatic circulation and body stores

78
Q

B12 Deficiency Anemia:

Hgb

A

Low

79
Q

B12 Deficiency Anemia:

MCV

A

High (microcytic)

80
Q

B12 Deficiency Anemia:

Serum vitamin B12

A

Low

81
Q

B12 Deficiency Anemia:

Homocysteine

A

High

82
Q

B12 Deficiency Anemia:

MMA

A

High

83
Q

B12 Deficiency Anemia:

WBC, platelets

A

Low (mild)

84
Q

B12 Deficiency Anemia:

Reticulocyte count

A

Low

85
Q

In additional to general symptoms of anemia:

What neurologic symptoms are there for B12 deficiency anemia?

A

Early: numbness & paresthesias

Later: peripheral neuropathy, ataxia, imbalance, decrease vibratory sense, decreased proprioception

86
Q

In additional to general symptoms of anemia:

What neuropsychiatric symptoms are there for B12 deficiency anemia?

A

Irritability, personality changes, memory impairment, dementia, depression, psychosis (uncommon)

87
Q

In additional to general symptoms of anemia:

What GI symptoms are there for B12 deficiency anemia?

A
  • glossitis (inflammation of tongue)
  • dysphagia (difficulty swallowing)
  • anorexia
88
Q

In additional to general symptoms of anemia:

What MSK symptoms are there for B12 deficiency anemia?

A

muscle weakness

89
Q

Patients with unexplained ____ should be evaluated for vitamin B12 deficiency

A

neuropathies

90
Q
  • Strict vegans (and their breast-fed infants)
  • Chronic EtOH
  • Elderly (tea and toast diet)

Are all types of what cause of Vitamin B12 deficiency?

A

inadequate intake (rare)

91
Q
  • Pernicious anemia (no intrinsic factor)
  • Cobalamin malabsorption (inadequate gastric acid production)
  • Rx acid suppression (chronic use)
  • Overgrowth of bacteria in the bowel that use vitamin B12

Are all types of what cause of Vitamin B12 deficiency?

A

Malabsorption

92
Q
  • Lack of transport protein
  • Transcobalamin 2 deficiency

Are all types of what cause of Vitamin B12 deficiency?

A

Inadequate utilization (uncommon)

93
Q

Pernicious anemia is a type of _____ deficiency anemia

A

B12

94
Q

Pernicious anemia is absence of ?

A

absence of intrinsic factor

95
Q

Causes of pernicious anemia?

A
  • Autoimmune destruction of gastric parietal cells
  • Atrophy of gastric mucosa
  • Stomach surgery
96
Q

Risk factors for pernicious anemia?

A
  • age (increase over age 60)
  • women > men
  • europeans of northern descent, african americans
97
Q

Pernicious anemia:

What antibodies are positive in 50%

A

anti-intrinsic factor antibodies

98
Q

Pernicious anemia:

What is the Schilling test? (no longer used)

A

Oral dose of ratio-labelled B12, then IM injection of non-labelled B12 to saturate plasma transport proteins, 24 hour urine collection

99
Q

List some common drugs that can cause drug-induced megaloblastic anemia

A
  • carbamazepine
  • phenytoin
  • valproic acid
  • colchicine
  • H2B, PPIs
  • metformin
  • oral contraceptives
100
Q

Describe the treatment for vitamin B12 deficiency anemia (SC/IM)

A

SC/IM vitamin B12 (cyanocobalamin):

  • 800-1000 mpg daily for 1-2 weeks to saturate stores then;
  • 100-1000 mpg weekly until Hgb/Hct normal then;
  • 100-1000 mpg monthly to maintain normal erythrocyte count

*only really need 100mcg but pack size is 1000 mcg so you give that and then the rest will be excreted in the urine

101
Q

Describe the treatment for vitamin B12 deficiency anemia (oral)

A

Oral vitamin B12 (cyanocobalamin or methylcobalamin):

  • Treat early to reduce risk of irreversible neurologic damage
  • Life time therapy if underlying cause not corrected
102
Q

Why do you want to treat vitamin B12 deficiency early?

A

to reduce risk of irreversible neurologic damage

103
Q

Is oral B12 as effective as IM for hematologic/neurologic response even in pernicious anemia?

A

Yes

104
Q

Who is IM B12 injection recommended for?

A
  • Neurologic symptoms, until resolved, then switch to PO
  • Inadequate evidence for use of PO B12 if severe neurologic impairment
  • Hospitalized patients
  • Poor GI absorption (ex. ileectomy)
  • Unable to take PO
  • Diarrhea/vomiting
  • Noncompliance
105
Q

What do you need to monitor for B12 deficiency anemia? Include timeframes.

A
  • Reticulocytosis in 3-5 days (peaks at 7 days)
  • Hematologic improvement (Hgb, WBC, platelets) in 5-7 days (normal by 1-2 months)
  • Hypersegmented PMNs persistent for 2 weeks
  • MMA, homocysteine decreases start at 1-2 weeks
  • Vitamin B12 deficiency resolves in 3-4 weeks
  • Improved strength and well-being within a few days
  • 6 months or longer required for improvement of neurologic signs/symptoms
106
Q

What is the role of folic acid?

A
  • Production of DNA and RNA
  • Necessary to form methylcobalamin which converts homocysteine to methionine
  • Humans unable to synthesize sufficient folate - dietary sources needed
107
Q

What are dietary sources of folic acid?

A
  • fresh green leafy vegetables
  • citrus fruits
  • yeast
  • mushrooms
  • dairy products
  • animal organs
108
Q

Does cooking foods increase or decrease amount of folate in foods?

A

decrease

109
Q

Folic acid:

5-10 mg mainly in ____ (4-6 month supply of folic acid)

A

liver

110
Q

Folic acid:

Severely deficient diet can result in clinically significant deficiency within __ weeks

A

6

111
Q

Causes of folic acid deficiency anemia?

A
  • Inadequate intake
  • Decreased absorption
  • Hyperutilization (increased requirement)
  • Altered metabolism
112
Q

Who is at risk of folic acid deficiency anemia caused by inadequate intake?

A

elderly, alcoholics, poverty, chronic illness/dementia, teenager (junk food diet)

113
Q

Who is at risk of folic acid deficiency anemia caused by decreased absorption?

A

Chron’s disease, celiac disease, alcoholism, drugs (ex. phenytoin)

114
Q

Who is at risk of folic acid deficiency anemia caused by hyper utilization (increased requirement)?

A

pregnancy, hemolytic anemia, malignancy, chronic dialysis, chronic inflammatory disorders

115
Q

Who is at risk of folic acid deficiency anemia caused by altered metabolism?

A

Drugs: folate antagonists (methotrexate, trimethoprim), DNA synthesis inhibitors (azathioprine, hydroxyurea, zidovudine)

116
Q

What are the signs and symptoms of folic acid anemia?

A

Exact same as B12 deficiency anemia (except neurological symptoms)

117
Q

Folic Acid Deficiency Anemia:

Hgb

A

Low

118
Q

Folic Acid Deficiency Anemia:

MCV

A

High (macrocytic)

119
Q 
Folic Acid Deficiency Anemia:
RBC folate (reflects total body stores)
A

Low

120
Q

Folic Acid Deficiency Anemia:

Homocysteine

A

High

121
Q

Folic Acid Deficiency Anemia:

MMA

A

Normal !!!

122
Q

Folic Acid Deficiency Anemia:

Vitamin B12

A

Normal !!!

123
Q

Folic Acid Deficiency Anemia:

Must rule out ?

A

vitamin B12 deficiency

124
Q

What is the treatment for Folic Acid Deficiency Anemia?

A

Oral folic acid (folate)

  • 1 mg daily
  • 5 mg daily if absorption compromised (ex. EtOH)
125
Q

How long is the treatment continued for Folic Acid Deficiency Anemia?

A
  • until cause of deficiency is identified and corrected (ex. improve diet)
  • 4 months therapy in order for folate-deficient RBCs to be cleared (life span of RBC)
126
Q

What happens if you accidentally treat pernicious anemia with folate?

A
  • Anemia symptoms will improve
  • Partial hematologic response
  • Neurologic symptoms WILL NOT BE REVERSED - may progress or become irreversible if not treated

*Remember that pernicious anemia is B12 deficiency

127
Q

What do you need to monitor for Folic Acid Deficiency Anemia?

A
  • Reticulocytosis in 2-3 days (peaks at 5-8 days)
  • Hgb, Hat increases within 2 weeks, normalizes in 2 months
  • RBC folate after 4 months (life cycle of RBC)
  • Symptomatic improvement (increase altertness, increase appetite) occurs early
128
Q

Anemia of Chronic Disease (ACD):

Is it microcytic or macrocytic?

A

Neither - normocytic

129
Q

Anemia of Chronic Disease (ACD):

Usually a diagnosis of _____

A

Exclusion

  • non-specific symptoms
  • important to rule out IDA and blood loss
130
Q

Anemia of Chronic Disease (ACD):

Common causes?

A
  • Chronic infection (HIV, chronic UTIs, osteomyelitis)
  • Malignancy
  • Chronic inflammation (RA, lupus)
  • CKD
131
Q

Anemia of Chronic Disease (ACD):

Generally develops when?

A

after 1-2 months of sustained disease

132
Q

Anemia of Chronic Disease (ACD):

Goal?

A

treat underlying cause if possible

133
Q

Anemia of Chronic Disease (ACD):

AKA ?

A

anemia of inflammation

134
Q

What is erythropoietin ?

A

hormone made by the kidney that signals for more RBCs to be made

135
Q

Anemia of Chronic Disease (ACD):

Desired outcomes?

A
  • increased oxygen carrying capacity of blood
  • decrease signs and symptoms of anemia
  • improve QOL
  • decrease need for blood transfusions
136
Q

Anemia of Chronic Disease (ACD):

Treatment?

A

1) Iron supplementation
- Required by most patients receiving ESAs due to increased iron demand resulting from stimulation in RBC production

2) Erythropoiesis Stimulating Agents (ESAs)
- Consider when Hgb between 90-100 g/L
- And in non-dialysis patients when rate of Hgb decline indicates likelihood of requiring a RBC transfusion, goal of avoiding transfusions due to risk of alloimmunization or other RBC-transfusion-related risks

3) Vitamin B12 and folate supplementation
- Vitamins B, C and folic acid (water-soluble vitamins) often depleted with renal diet and hemodialysis therapy (replavite/jamplavite)

137
Q

If on ESA, need to be on _____ as well

A

iron

138
Q

What are some ESAs?

A

1) Epoetin alfa (Eprex)
- Given SC or IV 1-3 times per week
- 25% increase dose for IV vs SC

2) Darbopoetin alfa (Aranesp)
- SC or IV q1-2 weeks (can be extended up to every 3-4 weeks)

3) ESA dosage adjustments
- Usually 25% dosage increments (round to nearest prefilled syringes)

139
Q

What contributes to ESA resistance ?

A
  • Iron deficiency/folic acid or B12 deficiency
  • Underlying infection, inflammatory condition or malignancy temporarily impair activity of ESA
  • Blood loss; hemolysis
  • Underlying hematologic disease
  • Aluminum toxicity
  • Hyperparathyroidism
  • Catheter insertion
  • Malnutrition
  • Pure Red Cell Aplasia - very rare
140
Q

What are high targets of ESAs associated with ? (>120 g/L)

A
  • strokes
  • thromboembolic events
  • CV events
  • possible increased risk of cancer (if Hx of cancer)
141
Q

When should iron be started in relation to ESA for CKD anemia?

A

All CKD patients on ESAs should have adequate iron stores before initiation/increasing dose of ESA

142
Q

Avoid giving IV iron to patients with active systemic _____

A

infections

*bacteria need iron to grow so you may worsen the infection if you give iron supplements during an acute infection

Clinical 2 (Sam) (18 decks)

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