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Anemia Flashcards

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1
Q

Define anemia

A

Low RBCs or hemoglobin

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2
Q

What are the 5 steps to anemia assessment?

A 
"See How Many Red Cells":
Signs and symptoms
Hemoglobin/hematocrit
MCV (avg RBC size)
RDW
Check - reticulocytes and likely deficiencies
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3
Q

What are the general symptoms of anemia?

A

CNS - fatigue, malaise, weakness, headache, dizziness, irritability, difficulty concentrating
Pallor (skin, eye, nail), vertigo
SOB on exertion
Palpitations, tachycardia, angina
Anorexia
Cold intolerance, loss of skin tone
(all related to low oxygen delivery to organs)

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4
Q

What is the Hgb level that indicates anemia (male & female)?

A

Male: Hgb <130 g/L
Female: Hgb <120 g/L

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5
Q 
Describe the expected lab values in iron deficiency anemia:
Hgb
MCV
MCH
MCHC
RDW
Reticulocytes
Serum ferritin
A 
Hgb -low
MCV - low
MCH - low
MCHC - low
RDW - high (variation of sizes)
Reticulocytes - low (impaired RBC production)
Serum ferritin - low
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6
Q

What are the specific symptoms for Iron deficiency anemia?

A 
Dry, rough skin
Brittle nails
Dry, damaged hair, or hair loss
Additional symptoms, if Hgb <90:
Reduced salivary flow
Pica
Pagophagia
Smooth tongue
Advanced tissue iron deficiency:
Chellosis (cracking corners of mouth)
Kollonychia (spoon fingernails)
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7
Q

What is TSAT%?

Is it high or low in iron def anemia?

A

The percentage of transferrin saturation with iron
= serum iron/TIBC
(normal = 14-50%)
Low in iron deficiency

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8
Q

What are the risk factors for IDA?

A 
Inadequate intake (adolescent, menorrhagia, pregnancy, vegetarians, endurance athlete, chronic renal failure)
Blood loss (blood donations, surgery, drugs - ASA, NSAIDs, anticoagulants)
Impaired absorption (low acid in stomach)
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9
Q

What are the goals of treating IDA?

A

Improve signs and symptoms

Restore Hgb and MCV to normal, replenish iron stores

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10
Q

What are the (4) options for replenishing iron stores?

A

Increased dietary iron
Oral iron supplement
IV iron supplement
Blood transfusions

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11
Q

What are the 2 types of iron found in food?

A

Heme (ferrous, Fe2+) and non-heme (ferric, Fe3+) iron

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12
Q

What foods do you find ferrous (heme) iron?

A

Meat, poultry, seafood

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13
Q

What foods do you find ferric (non-heme) iron?

A

Vegetables, fruits, dried beans, nuts, grains

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14
Q

Which type of iron is more absorbable?

A

Heme iron is 3x more absorbed than non-heme

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15
Q

How can you increase absorption of non-heme iron?

A

Increase acidity of stomach (vitamin C), have with heme iron

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16
Q

What is the usual dose of oral iron for IDA?

A

150-200 mg elemental iron/day (2-3mg/kg/day), usually divided BID/TID (can take all at night to avoid DI’s)

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17
Q

How should oral iron be taken?

A

Empty stomach for best absorption - 1h before/2h after meal

may need to take with meals to dec SE

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18
Q

What are the side effects of oral iron?

A

N/V, dyspepsia, constipation, diarrhea
Dark stools - make sure to tell pt so they don’t think it’s blood.
Generally dose related and improve over time (except dark stools)

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19
Q

What are the drug interactions with oral iron?

A

Decrease absorption of iron: antacids, PPIs, H2B, cholestyramine, calcium/milk
Decreased drug absorption of: levothyroxine, levodopa, quinolones, tetracyclines, bisphosphonates

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20
Q

Are SR/enteric coated iron formulations any good

A

no not really

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21
Q

List the elemental iron content for oral tabs of:
Ferrous gluconate
Ferrous sulphate
Ferrous fumarate

A

Gluconate: 11%, 35mg/300mg tab
Sulphate: 20%, 60mg/300mg tab
Fumarate: 33%, 100mg/300mg tab

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22
Q

Which iron supplement should be started?

A

Sulphate - lower iron content than fumarate (easier to tolerate), but only need 3 tabs per day (vs 6 for gluconate, 2 for fumarate) = good adherence

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23
Q

When would IV iron be considered?

A 
Iron malabsorption
Intolerance to oral
Significant blood loss, refuses blood transfusion
Chronic dialysis patients
Some chemotherapy patients with ESAs
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24
Q

side effects of IV iron

A

Transient N/V, pruritis, headache, flushing, pains

Hypersensitivity (rare)

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25
Issues with IV iron
has to be given by trained HCP in proper environment | Patients are monitored closely during administration
26
When are blood transfusions indicated?
Acute blood loss with hemodynamic compromise | Considered in severe anemia (Hgb <70-80 g/L)
27
What is 1mL of packed RBCs equivalent to for an iron dose?
1 mL PRBCs = 1mg iron | so 2 units = 500 mL = 500mg iron
28
Concerns about blood transfusions?
Bloodborne infections Autoantibody development Transfusion reactions Iron overload
29
Monitoring IDA - How much should Hgb increase?
Hgb increase 10g/L at therapeutic iron doses
30
How often do you do a CBC (Hgb) test? And for how long? | When should Hgb normalize?
Every month for 3-6 months | Hgb should icnrease by 2 weeks, normalize by 6-8 weeks
31
When should you measure ferritin (+/- TSAT)?
In 3-6 months
32
How long do you treat the anemia for?
3-6 months after anemia resolved to allow repletion of iron stores.
33
What are you monitoring for in general in regards to the patient?
Side effects | Symptom improvement
34
What are important symptoms that differentiate B12 deficiency anemia?
Neurologic symptoms - numbness, parasthesias Can progress to peripheral neuropathies, ataxia, imbalance, decreased vibratory sense and proprioception Also irritability, personality changes, memory impairment, dementia, depression, psychosis
35
Why is it so important to treat B12 deficiency?
The neurologic symptoms might not go away if left untreated.
36
``` What would you expect the levels to be in B12 deficiency anemia: Hgb MCV S-B12 Homocysteine MMA WBC, platelets Reticulocyte ```
``` Hgb - low MCV - high (macrocytic) S-B12 - low Homocysteine - high MMA - high WBC, platelets - low (impaired synthesis) Reticulocyte - low (impaired production) ```
37
What are the dietary sources of B12?
Meat, fish, poultry, dairy, fortified cereals
38
What are the 3 causes of B12 deficiency??
``` Inadequate intake (rare) Malabsorption Inadequate utilization (uncommon) ```
39
What are the causes of inadequate B12 intake?
Strict vegans Chronic EtOH Elderly
40
What are the causes of B12 malabsorption?
Pernicious anemia (no intrinsic factor) Cobalamin malabsorption (low gastric acid production) Acid suppressing meds (chronic) Overgrowth of gut bacteria that use B12
41
What are the causes of inadequate B12 utilization?
Lack of transport protein (transcobalamin II)
42
What is penicious anemia? What are the causes?
``` Absence of intrinsic factor (IF) Causes: Autoimmune destruction of parietal cells Atrophy of stomach mucosa Stomach surgery ```
43
What are the risk factors for pernicious anemia?
Age (>60; rare <35) Women>men Europeans, african americans
44
What is megaloblastic anemia?
B12 or Folate deficiency
45
What are common folate antagonists?
Phenytoin, carbamazepine, valproic acid MTX TMP
46
What are common drugs that reduce folate/B12 absorption?
``` EtOH Colchicine TMP/SMX H2Bs/PPIs Metformin Nitrofurantoin OCPs ```
47
2 options for treatment of B12 deficiency anemia?
SubQ/IM B12: 1000mcg/day x1-2 weeks 1000mcg/week until Hgb normal 1000mcg/month to maintain Oral B12: 1000-2000mcg/day
48
When is IM B12 recommended?
``` Neurologic symptoms- until resolved Hospitalized Poor GI absorption Unable to take PO V/D Non-compliant ```
49
How do you monitor B12 deficiency treatment?
Retics and hematologic improvement (Hgb, WBC, plts) in 5 days Deficiency should resolve in 3-4 weeks but neurologic symptoms may take 6 months+
50
What is the role of folic acid?
Production of DNA, RNA | Forms methylcobalamin, which converts homocysteine to methionine
51
What are the dietary sources of folic acid?
``` Fresh, green, leafy vegetables Citrus fruits Yeast Mushrooms Dairy products Animal organs (cooking >15m in water destroys lots of folate) ```
52
What are the causes of folic acid deficiency??
``` Inadequate intake (elderly, alcoholic, poor, chronic illness, poor diet) Decreased absorption (GI diseases, alcoholism, drugs) Hyperutilization (pregnancy, dialysis, inflammatory disorders) Altered metabolism (drugs: MTX, TMP, azathioprine, hydroxyurea) ```
53
What are the signs and symptoms of folic acid deficiency?
Similar to B12 but no neurologic symptoms
54
``` What would you expect to see in folic acid deficiency: Hgb MCV RBC folate Homocysteine MMA VitB12 ```
``` Hgb - low MCV - high (macrocytic) RBC folate - low Homocysteine - high MMA - normal VitB12 - normal ```
55
What MUST you rule out before treating folate deficiency?
B12 deficiency - worried about neurologic symptoms
56
Treatment for folic acid deficiency
1mg daily 5mg daily if impaired absorption continue until cause is corrected 4 months for RBCs to be cleared
57
Monitoring folate deficiency
Reticulocytosis in 2-3d Hgb, Hct increases within 2 weeks, normalizes in 2 months RBC folate in 4 months Symptoms improve early
58
What are common causes of anemia of chronic disease?
Chronic infection (HIV, UTIs, osteomyelitis) Malignancy Chronic inflammation CKD
59
what is normally the cause of anemia in CKD?
Erythropoetin deficiecny - kidney can't make enough, RBC lifespan shorter Can also have iron deficiency, from dec GI absorption, inflammation, frequent blood testing
60
How do you treat anemia of CKD?
ESA (erythropoiesis stimulating agents) - when hgb 90-100g/L (goal to prevent blood transfusions) Also require iron supplementation, due to increased demand from increased RBC production B12 and Folate supplementation - often depleted with renal diet and dialysis therapy (replavite)
61
What is a common reason for ESA resistance?
``` Iron deficiency (must treat before starting ESA) Underlying infection, inflammatory condition, malignancy ```
62
What should the target Hgb be for ESAs? Why?
<115g/L - higher causes strokes, thrombo events, CV events, increased cancer risk
63
Monitoring anemia in CKD
Every month for CBC Acceptable rise of 10-20 g/L Every 1-3 months Ferritin and TSAT

Clinical 2 (2 decks)

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