Anemia edited Flashcards
1
Q
What’s hemoglobin?
A
iron rich protein in RBC that carries oxygen to tissues
2
Q
What’s the normal lifespan of RBC?
A
About 120 days
3
Q
List the main causes of anemia
A
Impaired RBC production
Increased RBC destruction (hemolysis)
Blood loss
Underlying causes: nutritional deficiency (iron, B`12, folate) medical disorders (CKD, malignancy, etc)
4
Q
What’s the main cause behind sx experienced in anemia?
A
Tissue hypoxia (tissues not getting enough oxygen-rich blood)
5
Q
List the sx of anemia.
A
Fatigue
Weakness
SOB
exercise intolerance
Headache
Dizziness
And/or
Pallor
6
Q
When does a pt typically NOT experience sx of anemia (asymptomatic)?
A
In mild anemia or in beginning stages
7
Q
What’s sx are experienced in acute blood loss?
A
Chest pain
Angina
Fainting
Palpitations
Tachycardia
8
Q
List the unique sx that may develop in iron deficiency anemia
A
Glossitis
Koilonychias
Pica
9
Q
What’s Glossitis?
A
An inflamed, sore tongue
10
Q
What’s Koilonychias?
A
Thin, concave, spoon-shaped nails
11
Q
What’s Pica?
A
Craving and eating non-foods such as chalk or clay
12
Q
How is anemia xterized?
A
Low hemoglobin (Hgb) and low hematocrit (Hct) levels
13
Q
What’s the most common way to classify the type of anemia?
A
Mean corpuscular volume (MCV)
Or
Average volume of RBCs
14
Q
While the sx of both microcytic and macrocytic anemia are similar, how can they be differentiated?
A
MCV
15
Q
Define microcytic anemia
A
low hgb, MCV is small (< 80fl) dis to small cell size from a lack of iron
16
Q
Define macrocytic anemia
A
low hgb, MCV is large (> 100fl) due to folate or Vit b12 deficiency
Also called Megaloblastic anemia
17
Q
What’s normocytic anemia? How does it normally occur?
A
low hgb, normal MCV (80-100 fL)
From acute blood loss (surgery or trauma)
18
Q
What’s the normal range of MCV?
A
80 - 100 fL
19
Q
What’s erythropoietin?
A
Hormone secreted by the kidneys that stimulates bone marrow to produce RBCs
anemia of CKD is primarily due to defieciency in erythropoietin (EPO)-kidneys aren’t working-they aren’t producing it
20
Q
What’s essential for hemoglobin formation?
A
Iron
21
Q
What should be done b4 initiation of erythropoietin therapy (ESAs)? Why?
A
Iron levels need to be checked
If iron stores are low, erythropoietin-stimulating agents (ESAs) will NOT work
ESAs help maintain Hgb levels and reduce the need for blood transfusions
22
Q
What’s the mainstay of anemia tx?
A
Iron therapy
ESAs
23
Q
What does majority of pts needing iron replacement use?
A
Oral iron supplement
24
Q
Why would a pt need iron by injection as replacement?
A
IV iron is first line for CKD-hemodialysis patients
non-HD CKD pts can be treated with oral iron supplements
25
Iron studies
Used to further evaluate microcytic anemia:
serum iron (bound to transferrin)
serum ferritin (iron stores)
TSAT-transferrin saturation (amount of transferrin binding sites occupied by iron)
TIBC-total iron binding capacity (amount of transferrin binding sites available for binding-unbound iron binding sites)
26
What's the list common type of anemia?
Iron-deficiency anemia
iron deficiency is the most common nutritional deficiency in US
27
Which is more easily absorbed? Heme or non-heme iron?
Heme iron (from meat & seafood) is more readily absorbed than non-heme (from nuts, grains/cereals, beans, and veggies)
non-heme is affected by gastric pH and other foods being consumed
28
Why may vegetarians still need iron supplement even if they are consuming enough iron?
Because their iron is non-heme, which is less absorbable form
29
What's the first-line tx of iron deficiency anemia?
oral iron therapy
100-200 mg elemental iron per day
one oral formulation is not superior to another as long as dose appropriately based on elemental iron needs
30
Which is more readily absorbed, ferrous iron (Fe2+) or ferric (Fe3+)?
Ferrous iron (Fe2+)
31
Duration of iron replacement?
3-6 months AFTER anemia has resolved (to allow for iron stores to return to normal and prevent relapse)
32
What formulations of iron replacement is NOT recommended as initial therapy? Why?
Sustained-release formulations or Enteric coated formulation
released in he alkaline environment of small intestine-cause less GI upset but also have decreased absorption
33
In what gastric environment is absorption of iron enhanced?
Acidic (low pH)
avoid PPIs and H2RAs-prolong pH increase
separate from antacids
34
What may be used with iron to enhance absorption, to a minimal extent?
Ascorbic acid (Vit C 200mg)
35
Should iron be taken with food? Why or why not?
Food will DECREASE iron absorption
Take iron at least 1 hr before or 2 hours after meals
*can be taken with meals if GI upset occurs
36
What's the dosing of ferrous sulfate (most commonly prescribed and least expensive)?
325 mg PO daily to TID
(65 mg elemental iron)
20% elemental iron
37
What's the brand name of ferrous sulfate, dried controlled release? Dose?
ER tablet-not recommended for initial therapy
Slow Fe,Slow Iron
160mg PO daily to TID
(50 mg elemental iron)
30% elemental
38
What's the leading cause of fatal poisoning in children under 6?
Accidental overdose of iron-containing pdts
39
Side effects of oral iron replacement therapy?
Nausea
Stomach upset
Constipation (dose related)
Dark and tarry stools
40
Why are enteric-coated and delayed-release pdts not recommended?
Decresaes iron absorption
41
What's recommended for iron-induced constipation?
Docusate (stool softener)
| Although, fiber is 1st line tx for constipation, Docusate is 1st line here
42
What's unique about carbonyl iron and polysaccharide iron complex?
Highest amt of iron (100% elemental iron)
43
Effects of antacids and agents that raise pH on iron absorption?
They decrease iron absorption (remember, iron needs acidic gastric environment)
44
Effects of iron on antibiotics?
Quinolones and Tetracyclines (less concern with Doxycycline and Minocycline) bind with the polyvalent iron cation to form a non-absorbable complex.
iron+these antibiotics leads to a decrease in absorption of both iron AND antibiotic
45
Which tetracyclines are of less concern wrt reducing iron absorption?
Doxycycline
Minocycline
46
How to take iron if pt is also on Tetracycline or Quinolones?
Take iron 2 hrs BEFORE
OR
4-8 hrs AFTER antibiotic
47
How much Vit c is needed to increase gastric acidicity t4 enhance iron absorption?
About 200mg or Ascorbic acid
48
By how much does food decrease iron absorption?
About 50%
49
List the drugs that iron interacts with and DECREASES their levels. How should they be separated?
Seperate doses by 2-4 hrs:
Levothyroxine
Levodopa
Methyldopa
Cefdinir
Dolutegravir
bisphosphonates:
take iron 1 hr AFTER oral ibandronate
take iron 30 minutes after alendronate or risendronate
50
T/F? If a parent finds that their kid has swallowed iron tablet, they should be directed to the ER?
True
Take to ER or call poison control even if asymptomatic
51
How much iron do kids need to overdose on iron?
As little as 5 tablets of iron can lead to over dose
52
What's the antidote for oral iron overdose?
Deferoxamine (Desferol)
53
What's the antidote for transfusional iron overdose?
Deferiprone (Ferriprox)
54
What conditions may require Parenteral iron therapy?
Hemodialysis (most common use of IV iron)
Unable to tolerate oral iron OR losing iron too fast for oral replacement
Intestinal malabsorption, such as Crohn's
Pts donating large amts of blood for autoinfusion
55
List IV (Parenteral) iron supplements
Iron dextran
Sodium ferric gluconate
Iron sucrose
Ferumoxytol
Ferric carboxymaltose
ferric pyrophosphate citrate
56
What's the brand name of iron dextran?
INFeD
57
What's the brand name of Sodium Ferric Gluconate?
Ferriecit
58
What's the brand name of iron Sucrose?
Venofer
59
Which IV iron supplement has a black box warning?
Iron Dextran (INFeD) and ferumoxytol (Feraheme)
anaphylaxis risk
iron dextran-give a test dose prior to 1st full therapeutic dose
Note: all have risk for hypersensitivity rxs including anaphylaxis
60
What's the black box warning assoc. with iron dextran? How is it prevented?
Risk of anaphylactic rxns
A test dose should be given to ALL pts prior to 1st therapeutic dose
61
What factors may be of concern, even if the test dose was tolerated by a pt?
fatal reactions have occurred even if pt tolerated test dose
Hx of drug allergy or multiple drug allergies may increase this risk
62
How should IV iron be given? Why?
By slow IV injection or infusion
To reduce risk of hypotension
63
What's macrocytic anemia?
Is due to either Vit B12 or Folate deficiency OR both
64
What's the concern with long-term untreated macrocytic anemia?
Pt is at risk of NEUROLOGICAL consequences including
Cognitive dysfunction (dementia)
AND
Peripheral neuropathies
65
What's Pernicious anemia?
Most common cause of b12 deficiency
Occurs due to lack of INSTRINSIC factor (required for sm intestine absorption of B12)
Dx: pernicious anemia can be diagnosed by Schilling test
66
What's the tx duration for those with pernicious anemia?
Forever!
They req lifelong parenteral Vit B12 replacement therapy
67
Which dosage form of Vit B12 is preferred? Why?
Vit B12 injections (to bypass absorption barriers) followed by oral B12
Injection is 1st line for anyone with severe deficiency or neurologic symptoms
68
List the other causes of macrocytic anemia.
Alcoholism
Poor nutrition
GI disorders (Crohn's dx, Celiac dx)
pregnancy
```
long term use of (2 years or more):
metformin
H2RAs
PPIs
(these can decrease B12 absorption)
```
69
How is macrocytic anemia diagnosed?
LOW hemoglobin and HIGH mean corpuscular volume (MCV) >100fL
70
What other values are considered in diagnosing macrocytic anemia?
Vit B12 and/or serum folate levels will be LOW
B12 is used is enzymatic reactions involving methylmalonic acid and homocysteine-so they can accumulate and be high when b12 is low
homocysteine can also be elevated in folate deficiency
71
What's used to diagnosed Vit B12 deficiency specifically?
Schilling test
Can pick up lack of intrinsic factor (needed for absorption of Vit B12 in the small intestine )
72
What's the tx of macrocytic anemia?
Tx usually starts with Vit B12 injections and follow with oral supplements
73
List drugs used to treat macrocytic anemia
Cyanocobalamin, Vit B12
given IM or deep SC
can be daily/weekly/monthly
Nasocobal is a nasal solution give in one nostril once weekly
Folic acid (folate)
74
What's contraindication to use of cyanocobalamin?
Cobalt allergy
75
What's formulation of b12 isn't used?
Sustained-release B12 supplements as the absorption is not adequate
76
What's the dose of Folic acid (folate) used in macrocytic anemia?
0.4-1mg daily
1mg (Rx)
0.4, 0.8mg (OTC)
77
What's the SE of Folic acid (folate)?
Bronchospasm
Flushing
Rash
Pruritus
*all are rare
78
What's the monitoring for both Vit B12 and Folic acid (folate)?
Hgb
Hct
Folate
Vit B12
reticulocyte count (immature RBCs)
79
List drugs that may reduce the absorption of Vit B12
Chloramphenicol
Colchicine
Ethanol
Long-term tx with Metformin
80
List drugs that Folic acid may reduce efficacy of?
Raltitrexed-chemo agent (avoid concurrent use)
81
What's the effect of CKD on iron?
CKD causes anemia due to deficiency in erythropoietin, a hormone produced by healthy kidneys
82
How should ESAs be used in chronic renal failure?
At lowest possible dose that reduces need for blood transfusion
83
When should ESA be started and stopped (or reduced)?
Start - when hgb < 10 g/dL
Reduce or Stop - when hgb is near or over 11 g/dL in HD-CKD or over 10 in non-HD
84
List agents that fall under ESA
Epoetin alfa (Epogen, Procrit)
Darbepoetin (Aranesp)
85
Whats the brand name of Epoetin alfa (ESA)?
Epoetin
Procrit
86
Whats the brand name of Darbepoetin (ESA)?
Aranesp
87
What's the black box warning on ESAs (Epoetin and Darbepoetin)? When is this a concern?
In CKD: ESAs increase the risk of death, cardiovascular events, and stroke when hgb > 11g/dL
In cancer: shorten overall survival and increase risk of tumor progression DON'T use if anticipated outcome is a CURE
Postsurgery: increase risk of DVT
88
What's the hgb target in CKD pts?
over 10 for non-HD
| 11 for HD-CKD... Black box warning comes in
89
Effect of ESA on cancer survival?
ESA shortens overall survival and/or increased risk of tumor progression or recurrence in pts with some cancers
90
What's ESA APPRISE?
Oncology program to prescribe and/or dispense agents (Epoetin and Darbepoetin) to cancer pts
91
When should ESA be used in cancer pts?
Hgb less than 10 AND at least 2 additional months chemo are planned
92
T/F? In cancer pts, ESA (Epoetin, Darbepoetin) is not recommended when the outcome is cure?
True
93
T/F? D/c ESA following chemotherapy course?
True
94
ESA and perisurgergy?
Increases risk of DVT, t/4 DVT prophylaxis is recommended
95
List contradictions to ESA (Epoetin and Darbepoetin) use
Uncontrolled HTN
Pure red cell aplasia (PRCA) that begins after tx
Multi-dose Epoetin vials have BENZYL alcohol- contraindicated in neonates, infants, pregnancy, and lactation
96
SE of ESA
Hypertension, seizures, serious allergic rxs
```
Fever
Headache
Arthralgia/ bone pain
Pruritus/ rash
Nausea/vomiting
Cough
Injection site pain
Edema
Chills
Dizziness
```
97
What's the monitoring parameters of ESA?
Hgb
Hct
Transferrin saturation
Serum ferritin
BP
98
What's the preferred route of ESA for pts on hemodialysis?
IV route
99
Where should ESA be stored?
In the refrigerator, protect from light
100
ESA dosing
epoetin alfa IV or SC 3x/week
darbapoetin IV or SC weekly, q 2 weeks, q 3 or 4 weeks
t1/2 of darbapoetin is 3x longer than epoetin alfa so it is dosed less frequently
101
Should the ESA bottle (vial) be shaken?
No- do not shake vial or syringe-it will ruin the medication
102
List sites of injections of ESA
Outer area of upper arms
Abdomen (except 2inches around navel)
Front of the middle thighs
Upper outer area of buttocks
103
What's aplastic anemia?
occurs when bone marrow fails to make enough RBCs, WBCs, and platelets
caused by drugs, infections, hereditary conditions, or autoimmune
104
What's hemolytic anemia?
when RBCs are destroyed and removed from bloodstream before 120 days
caused by
drug-induced-drug binds RBC surface and triggers antibodies to attack RBC
immune disorder
or inherited (sickle cell or G6PD deficiency)
105
Coombs test
detects antibodies stuck to RBC surface (which leads to hemolytic anemia)
106
G6PD
an enzyme that protects RBCs from harmful substances
without the enzyme RBCs hemolyze 24-72 hours after oxidative stress
107
G6PD deficiency
most patients don'y require treatment for deficiency but should avoid certain high risk meds
```
chloroquine
dapsone
methylene blue
nitrofurantoin
primaquine
probenecid
rasburicase
sulfonamides
```
108
drugs that can cause hemolytic anemia
```
beta-lactamase inhibitors (clavulanate, sulfbactam, tazobacatam)
penicillins (esp piperacillin)
cephalosporins (especially ceftriaxone & cefotetan)
isoniazid
methyldopa
levodopa
-platins
quinidine
quinine
ribavirin
rifampin
```
109
elemental iron values
```
ferrous gluconate 12%
ferrous sulfate 25%
ferrous sulfate, dried 30%
ferrous fumarate 33%
carbonyl iron, polysaccharide iron complex
100%
```
110
ferumoxytol brand
Feraheme
111
ferric pyrophosphate citrate
Triferic
only indicated for CKD-HD
should be added to bicarbonate concentrate of hemodialysate
112
parenteral iron stability
ALL ARE STABLE IN NS
ferumoxytol (Feraheme) is stable in NS and D5W
