Anemia definition
decreased hemoglobin and hematocrit conc below normal levels
Immature RBC’s
reticulocytes
mature RBC
erythrocytes
lifespan of RBC
120 days
Recycled by spleen
Common causes of anemia
iron, folate, b12 deficiencies
CKD
Malignancy
Symptoms of anemia
Fatigue weakness SOB exercise intolerance HA dizziness anorexia
Specific symptoms of iron deficiency anemia
glossitis (inflamed, sore tonuge)
thin, concaved nails
pica (craving and eating non-foods (ie chalk) WTF
Specific symptoms of B12 anemia
neurologic symptoms
psychiatric symptoms
What lab value is used to determine the type of anemia?
Mean corpuscular volume (MCV) - size of RBCs
Low MCV - microcytic
High MCV- macrocytic
Normal MCV value
80 - 100
Microcytic anemias
iron
Macrocytic anemias
Folate of Vit B12
Normocytic anemias
caused by some comorbid condition
CKD, cancer, etc
recommended dose for iron deficiency anemia
100- 200 mg elemental iron per day
Things that decrease iron absoprtion
food (take on empty stomach unless GI upset occurs)
acid suppressing agents (PPIs)
% elemental iron of ferrous gluconate
12%
% elemental iron of ferrous sulfate
20 %
% elemental iron of ferrous fumurate
33%
% elemental iron of carbonyl iron/polysaccharide iron complex
100 %
Main side effects of oral iron therapy
nausea, stomach upset
constipation
Dark and tarry stools
Preferred agent to treat iron-induced constipation
docusate
Antidote for iron overdose (common in children)
deferoxamine (Desferal)
Coadmin of iron and antacids/PPIs/H2RAs
take iron 2 hours before or 4 hours after antacids
Drug classes that should be separated from iron
quinolones and tetracycline (2 hrs before 4-8 hrs after)
bisphosphonates (take iron 60 mins after)
Levothyroxine (2-4 hrs after)
What can increase the absorption of iron?
Vit C –> creates more acidic environment in stomach
When might IV iron be used?
Pts with CKD on hemodialysis
Ferrlecit
sodium ferric gluconate IV
Venofer
Iron sucrose IV
Feraheme
ferumoxytol IV
Pernicious anemia definition
most common cause of B12 anemia
lack of intrinsic factor – decr absorption of vit b 12
Long-term (> 2 yrs) use of which drugs decr B12 absorption?
metformin
H2RAs
PPIs
Folic acid/B 12 anemias are classified as what type of anemia?
Macrocytic anemia
MVC > 100 (large RBCs)
Which anemia can lead to serious neurlogic issues if not treated?
B 12 deficiency
What admin route is first line for treating B 12 anemia with severe deficiency or neurologic symptoms?
IM or deep SC injection
Don’t have to worry about variable oral absorption
Dose of cyanocobalamin injection
1000 mcg
dose of oral cyanocobalamin
1000- 2000 mcg daily
Vit b12 nasal spray
Nascobal
500 mcg in one nostril once weekly
folic acid dose
0.4-1 mg daily
Underlying cause of anemia in CKD
deficiency of erythropoietin, which is produced by the kidneys and stimulates bone marrow to produce RBCs
Epogen
Procrit
epoetin alfa
When would you initiate Epogen?
when HGB is < 10
When would you decr or stop dose of Epogen
when Hgb > 11 (on HD)
WHen Hgb > 10 (not on HD)
How often can you increase the dose of Epogen?
Every 4 weeks
How often is Epogen dosed?
Usually 3X/week
Darbepoetin
Aranesp
How often is Aranesp dosed?
once weekly (longer t 1/2)
Aranesp and Epogen are classified as….
Erythropoiesis-stimualting agents (ESAs)
ESAs are still effective if Iron stores are low (t/f)
False
most supplement iron too
1st line iron treatment for pts on HD?
IV iron
Aplastic anemia
bone marrow does not make enough RBCs, WBCs, platelets
What medications can be used to treat aplastic anemia?
immunosuppressants
stem cell transplant/ blood transfusion
Eltrombopag (Promacta) - incr platelet coount
Hemolytic anemia
develops when RBCs are prematurely destroyed
commonly drug-induced or autoimmune
Test for hemolytic anemia
Coombs test
detects antibodies that bind to RBCs
Genetic cause of hemolytic anemia
G6PD deficiency
G6PD - protects RBCs from being destroyed by reactive oxygen species and more
Various drugs that can cause hemolytic anemia
Beta-lactamase inhibitors Cephalosporins penicllins rifampin platinum based chemo Levodopa Methyldopa isoniazid