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Flashcards in Anemia&Chemo Drugs Deck (74):
1

Normal Hb levels of a male and female?

Male: 13.5-17.5 g/dL
Female: 12 - 16 g/dL

2

How is anemia defined?

Hgb < 12 g/dL

3

Mild anemia =
Moderate anemia =
Severe anemia =

Mild = hgb 10-12

Mod = hgb 8-12

Severe = hgb < 8

4

Which is a better test? Hemoglobin or hematocrit? Why?

Hemoglobin because hematocrit is sensitive to fluid shifts

5

Macrocytic (megaloblastic) anemia is associated with what types of deficiency?

Folic acid and B12 deficiency

6

Iron deficiency is d/t what 5 possible etiologies?

1. Inadequate iron intake
2. Inadequate iron absorption
3. Increased iron demand
4. Blood loss
5. Chronic disease

7

Presentation of Anemia: Symptoms of acute onset v. chronic onset

Acute = tachycardia, light-headedness, breathlessness

Chronic = Fatigue, HA, vertigo, faintness, cold sensitivity, pallor, loss of skin tone

These symptoms can overlap

8

Lab values needed to diagnose anemia

CBC (WBC, Hgb, HCT, Platelets)
RBC Indicies (MCV, MCHC, MCH)
Reticulocyte count
Peripheral blood smear
Stool guiac

9

Normal Iron Panel levels:
--Serum Iron
--Serum ferritin
--Transferrin
--Total iron binding capacity
--Transferrin saturation (Serum iron/TIBC)

Serum Iron = 50-160 mcg/dL

Serum ferritin = Males 30-300, Females 15-200

Transferrin = 200-360 mg/dL

TIBC = 250-400 mcg/dL

Transferrin sat = Males 20-50%, Females 15-50%

10

Normal folic acid levels

1.8 - 16 ng/mL

11

Normal vitamin B12 levels

100-900 pg/mL

12

Normal Erythropoietin levels

0 - 19 mu/mL

13

Homocysteine levels

3.3 - 10.4 umol/mL

14

Methylmalonic acid levels

0.07 - 0.27 umol/mL

15

Goals of Iron Deficient Anemia (4)

1.) Alleviate symptoms
2.) Correct iron deficiency
3.) Increase Hgb
4.) Prevent recurrence

16

Iron deficient lab values:
-MCV
-MCH, MCHC
-Serum ferritin
-Transferrin
-TIBC
-Transferrin saturation

Low MCV, MCH, MCHC

Low serum ferritin

High transferrin

High TIBC

Low transferrin saturation

17

Tx options for Iron Deficiency: Oral Iron Supplements dosage

*How much iron in mg/day is the goal?

Ferrous Sulfate
--> 300mg = 60mg elemental

Ferrous Gluconate
--> 300mg = 37mg elemental

Ferrous Fumarate
--> 100mg = 33mg elemental

Polysaccharide iron complex
--> 150mg = 100% elemental iron

18

What should you counsel a pt with iron deficiency on how to change their diet?

Eat meat, fish, poultry

Plant sources are more difficult for body to extract iron

19

How many tablets a day should one take ferrous sulfate?

5

Why? Because a 300mg tablet has 60mg elemental iron and you want a pt to consume 200mg of elemental iron/day.

So...a tablet has 20% elemental iron

20

When would parenteral iron be used (3 instances)

1. Iron malabsorption
2. Intolerant of oral therapy
3. Chronic non-compliance

21

What is an important consideration when giving iron dextran?

Give a test dose of 25mg to assess for anaphylaxis (wait 30-60 min to assess)

22

Besides iron dextran, what are the other 3 parenteral iron products that are much less likely to cause anaphylaxis?

1. Sodium ferric gluconate (Ferriecit)

2. Iron sucrose (Venofer)

3. Ferumoxytol (Feraheme)

23

Side effects of iron therapy

1. Nausea
2. Abdominal discomfort
3. Constipation or diarrhea
4. Black stools

24

How should you be monitoring iron deficiency anemia

-Weekly Hgb
-CBC
-Iron Panel

25

With proper iron tx you should expect to see what in the reticulocyte count?

Increase in ret count within 7 days (usually 4-5) d/t increased RBC synthesis

26

When treating iron how much of an increase should you expect to see weekly of Hgb

1-2 g/dL/week Hgb increase

27

Symptoms of Vitamin B12 Deficiency

- Typical symptoms of anemia
- Neuropsychiatric abnormalities
- Paresthesias
- Ataxia
- Memory Loss

28

What do the following look like in Vitamin B12 Deficiency?
- MCV
- Hgb
-Serum B12
-Schilling test
- Homocysteine
-Methylmalonic Acid

MCV = macrocytosis
Hgb = low
Serum B12 = low
Schilling Test = assess level of intrinsic factor
Homocysteine = increased
Methylmalonic Acid = increased

29

Treatment goals of B12 Deficiency

1. Resolve symptoms
2. Inc. Hgb
3. Prevent recurrence

30

First line treatment for B12 deficiency

Cyanocobalamin 1000mcg PO daily

31

Second line tx for B12 deficiency

Cyanocobalamin 1000mcg IM or SC daily for 1-2 weeks until acute symptoms subside

Then weekly doses of 1000mcg IM/SC x4 weeks or until Hgb/HCT are normalized

Then 1000mcg IM/SC monthly indefinitely (for life!)

32

When would you give Nascobal (nasal spray B12)?

Weekly for maintenance treatment of patients who have responded to oral/IM/SC vitamin B12 tx

**Must be aministered 1 hr before or after ingestion of hot foods to ensure absorption

33

Rare adverse effects of Vitamin B12 therapy

1. Hyperuricemia
2. Hypokalemia
3. Sodium retention

34

How should the ret count and Hgb respond to vitamin B12 treatment?

Ret count = begins to increase after 2-5 days

Hgb = Should begin to rise within 1-2 weeks and normalize 1-2 months

35

Folic acid antagonist medications

Sulfamethoxazole/trimethoprim (Bactrim)

Methotrexate

36

Causes of folic acid anemia

1. Increased demand
2. Poor absorption from small intestine
3. Alcoholism
4. Use of folic acid antagonist meds

37

How do you distinguish between folic acid anemia and Vitamin B12 anemia?

Folic acid has normal MMA levels, no psychiatric symptoms and normal B12

38

Treatment of folic acid anemia

Oral folic acid 1-5 mg IV/PO daily for approx 4 months

**1mg is usually adequate

39

Maintenance dose of oral folic acid tx if a pt requires it

0.4 mg

40

Ret count and Hgb response to folic acid tx

Ret count and Hgb respond within 1-2 weeks

Should normalize within 2 months

41

Drugs that contribute to folic acid deficiency

1. Methotrexate
2. Nitrofurantoin
3. Alcohol consumption

42

These drugs use the folic acid pathyway and therefore alter metabolism leading to reduced serum levels (3)

1. Fosphenytoin
2. Phenytoin
3. Phenobarbital

43

Causes of anemia of chronic disease

1. Renal failure
2. Cancer
3. HIV

44

Red Blood Cell Transfusions: disadvantages

- Limited resource
- Immunologic concerns
- Expensive (8000-1000/unit)
- Short term tx
- Infection risk
- Dated shelf life (good for only 28 days)

45

Types of Erythropoiesis Stimulating Agents

Darbepoetin (Aranesp)
Epoetin alfa (Epogen, Procrit)

46

Type of ESA indicated in Cancer:

Aranesp, Epogen, Procrit

47

Type of ESA indicated in renal disease

Aranesp or Epogen

48

Type of ESA indicated in drug induced anemia:

Aranesp, Epogen, Procrit

49

MOA of Erythropoiesis stimulating agents

Mimic endogenous erythropoietin and circulate through the vasculature and into the bone marrow

In the bone marrow these agents bind to receptors on hematopoietic stem cells

Stimulus results in an increase in erythrogenesis (formation of new RBCs)

50

Is there a difference in efficacy between darbepoetin and epoetin?

No!

51

Darbepoetin brand names

Aranesp

52

Epoetin brand names

Epogen
Procrit

53

Which has a longer half life? Darbepoetin or Epoetin?

Darbepoetin (Aranesp)

54

Oncology dose of darbepoetin v. Epoetin

Darbepoetin = 500mcg q3weeks

Epoetin = 40,000 untis q/week

55

What is the best way to minimize the risks of ESAs

Lowest dose needed to avoid red blood cell transfusions

56

Max epoetin dose in oncology

60,000 units / week

57

Max darbepoetin dose in oncology

500 mcg q3weeks

58

What program should providers be enrolled in in order to give cancer patients ESAs?

APPRISE Program

59

Patient criteria for using ESAs

1. Anemic
2. Chemotherapy induced anemia or other approved indication
3. Cure of cancer unlikely

60

Is hypertension or hypotension a side effect of ESA treatment?

Hypertension

61

Response to HCT or Hgb may not be seen for how long when monitoring responses to ESAs

For 2-6 weeks in renal pts

For 4-8 wks in oncology pts

62

___% of oncology patients respond to ESA therapy

60%

63

Most common type of abnormal hemoglobin

Hgb-S

64

Why do cells sickle?

- Cells containing Hgb-S have an impaired ability to maintain potassium and water balance

- When these cells become dehydrated the concentration of Hgb-S increases leading to molecular interactions

65

When do you usually start seeing symptoms of sickle cell anemia?

at 4-6 months of age when Hgb-F begins to decline

66

Sickle Cell anemia early sx

Pain
Swelling in hands/feet
Splenomegaly

67

Sickle cell anemia chronic sx

Anemia
Fever
Pallor
Arthralgia
Scleral icterus
Abdominal pain
Weakness
Anorexia
Fatigue
Cardiomegaly
Hepatomegaly
Hematuria

68

Sickle Cell Crisis can be triggered by:

- Infection
- Dehydration
- Hypoxia
- Acidosis
- Sudden temp changes

69

Four types of Sickle Cell Crises

1. Vaso-occlusive crisis (most common)

2. Aplastic Crisis

3. Hemolytic Crisis

4. Splenic Sequestration

70

Complications of sickle cell disease

Acute chest syndrome

End organ damage

71

Goals of tx in sickle cell disease

1. Dec. frequency and duration of crises

2. Prevent or delay long term complications

3. Improve quality of life

72

Supportive and preventive tx in Sickle Cell Disease

1. Folic acid

2. Vaccinations (H. influenzae type B and pneumococcal)

3. Prophylactic PCN up to 5 years old
--> 125 mg PO BID for < 3yrs old
--> 250 mg BID 3-5 years old

4. Hydroxyurea

73

Treating the complications of Sickle Cell Anemia - 2 main ways

1.) RBC transfusions
--> reserve for life-threatening situations

2.) Hematopoietic Stem Cell Transplantation
--> Only potentially curative tx

74

Management of Sickle Cell Anemia

- Hydration
- Pain management
- Tx infections
- RBC transfusions
- Spenectomy