BLOOD + NUTRITION

Question 1

Types of anaemias

Answer 1

• sick cell anaemia
• G6PD Deficiency
• hypoplastic, haemolytic
• iron deficiency
• megoblastic anaemia
• aplastic
• eryhtropoeitic def

Question 2

Haemolysis

Answer 2

red blood cell destruction

Question 3

Sickle-cell anaemia

Answer 3

Deformed, less flexible red blood cells

Question 4

Severe complications of sickle-cell anaemia

Answer 4

• Acute complications: sickle-cell crisis → restricted blood supply to organs
• Hospitalisation → fluid replacement, analgesia, treat any infections

Question 5

Sickle cell anaemia - complications

Answer 5

anaemia, leg ulcers, renal failure, susceptibility to infections

Question 6

Sickle-cell anaemia - treatment

Answer 6

1. Vaccines
   - E.g. PCV, HiB, Influenza and possibly Hep B
2. Penicillins
   - E.g. phenoxymethylpenicillin
3. Folate supplementation- E.g. folic acid
   - Due to associated haemolytic anaemia and increased erythropoiesis
4. Hydroxycarbamide

Question 7

Hydroxycarbamide

Answer 7

• An antineoplastic
• Reduces the frequency of sickle-cell crisis
• The beneficial effect may not be evident for months
• SE: myelosuppression and skin reactions

Question 8

G6PD Deficiency

Answer 8

Glucose-6-phosphate dehydrogenase
* Susceptible to developing acute haemolytic anaemia

Question 9

Who is G6PD Deficiency more common in?

Answer 9

• Africa, Asia, Oceania, S Europe
• Males

Question 10

Drugs with definite risk of haemolysis in most G6PD-deficient individuals

Answer 10

1. Nitrofurantoin
2. Quinolones
   - e.g. ciprofloxacin
3. Sulfonamides
   - Co-Trimoxazole
   - Sulfadiazine
4. Dapsone and other sulfones
5. Methylthioninium
6. Niridazole
7. Pamaquin
8. Primaquin
9. Rasburicase

Question 11

Drugs with possible risk of haemolysis in some G6PD-deficient individuals

Answer 11

1. Aspirin
   - Acceptable up to 1g daily dose in MOST G6DP deficient individuals
2. Chloroquine
   - Acceptable in acute malaria and malaria chemoprophylaxis
3. Sulfonylureas
   - E.g. Gliclazide, Glimepiride
4. Quinine
   - Acceptable in acute malaria
5. Quinidine
   - Acceptable in acute malaria
6. Menadione

Question 12

What are three key points to bear in mind with G6DP deficiency?

Answer 12

1. A drug found to be safe in some G6DP deficient
   individuals may NOT be safe in other G6DP deficient individuals.
2. Manufacturers do NOT routinely test drugs for their effects in G6DP-deficient individuals.
3. The risk and severity of haemolysis is almost always dose-related.

Question 13

How do you treat Hypoplastic and haemolytic anaemias?

Answer 13

1. Anabolic steroids
2. Pyridoxine
3. Various corticosteroids
4. Rituximab (unlicensed)

Question 14

How do you treat aplastic anaemias?

Answer 14

1. Antilymphocyte immunoglobins
   - IV via central line.
   - Given for 12-18 hours each day for 5 days.
   - Severe reactions can occur in the first 2 days.
   - Profound immunosuppression can occur.
   - Rate response may increase if Ciclosporin is given as well.

Question 15

How do you treat erythropoietic deficiency?

Answer 15

1. Epoetin-beta
   - Babies
   - Low birth weight
   - DONT give any preparation containing benzyl alcohol
2. Darbepoetin alfa
   - Has a long half-life, so less frequent administration.

Question 16

Symptoms of iron deficiency

Answer 16

tiredness
sob
palpitations
pale skin

Question 17

What must you do before treating iron deficiency?

Answer 17

Must be able to show iron-deficiency to treat with iron preparation

Question 18

Before treating iron deficiency exclude serious underlying causes

Answer 18

• Gastric erosion
• GI cancer

Question 19

Prophylaxis with an iron appropriate in:

Answer 19

Malabsorption
Menorrhagia
Pregnancy
After subtotal or total gastrectomy
In haemodialysis patients
In the management of low birth-weight infants such as preterm neonates

Question 20

What is iron available as?

Answer 20

1. PO
   - IR or MR
2. Parenteral

Ferrous fumarate, gluconate, sulfate, sulfate (dried)

Question 21

Daily elemental iron dose

Answer 21

100 to 200 mg
* Usually as ferrous sulfate (dried) - can be MR preps too (reduces absorption)

Question 22

What oral iron is available and what is the equivalent elemental iron?

Answer 22

1. Ferrous Fumarate 200mg
   - 65mg
2. Ferrous Gluconate 300mg
   - 35mg
3. Ferrous Sulphate 300mg
   - 60mg
4. Ferrous Sulphate, dried
   200 mg
   - 65mg

Question 23

Which oral preparation of iron has the lowest elemental iron?

Answer 23

Ferrous Gluconate 300mg

Question 24

Side effects

Answer 24

• Constipation
• Diarrhoea (with MR)
• Black tarry stools

Question 25

When haemoglobin is in normal range

Answer 25

continued for 3 more months

Question 26

Iron - toxicity

Answer 26

treated with desferrioxamine

Question 27

Iron - c.diff

Answer 27

if pt has c.diff stop any iron preps can cause diarrhoea

Question 28

Iron - counselling points

Answer 28

Take after food to reduce side-effects Take before food for best absorption Best taken with orange juice, VIT C aids absorption

Question 29

Parenteral iron preparations

Answer 29

Iron dextran, iron sucrose, ferric carboxymaltose, or ferric derisomaltose.

Question 30

When is parenteral iron used?

Answer 30

* Oral therapy is not tolerated / doesn't work * Chemotherapy-induced anaemia * Chronic renal failure who are receiving haemodialysis

Question 31

MHRA Warning: Serious hypersensitivity reactions with intravenous iron

Answer 31

- Serious hypersensitivity reaction - Pt with allergies, Hx of severe asthma or eczema - Appropriately trained staff and resuscitation must be available - Monitor for hypersensitivity for at least **30 minutes** after every administration

Question 32

Megoblastic anaemia can be caused by either:

Answer 32

Can be either malabsorption of vitamin B12 or Folate deficiency (first step = establish cause)

Question 33

Which pt should receive B12 prophylactically

Answer 33

After - total gastrectomy or - total ileal resection

Question 34

Which drug can cause vit B12 deficiency?

Answer 34

Metformin

Question 35

B12 deficiency treatment

Answer 35

1. Cyanocobalamin - Given orally 2. Hydroxocobalamin - 1mg given every 3 months by IM injection

Question 36

Which of the two types of treatment for Vitamin B12 is largely used now and why?

Answer 36

- Hydroxocobalamin has replaced Cyanocobalamin - Hydroxocobalamin is retained in the body longer and administered MUCH less frequently than Cyanocobalamin

Question 37

Folate deficiency

Answer 37

- Poor nutrition - Pregnancy - AEDs

Question 38

Folic deficiency treatment

Answer 38

Daily folic acid supplementation for 4 months

Question 39

Megoblastic anaemia - emergency

Answer 39

Administer both while plasma assay results are awaited Don't give folic acid alone if undiagnosed → may cause neuropathy

Question 40

Folic acid - doses in pregnancy

Answer 40

* Regular pregnancy: 400mcg daily from before conception till week 12 of pregnancy * Risk of NTDs: 5mg daily from before conception till week 12 of pregnancy

Question 41

Folic acid doses in prevention of methotrexate induced SE

Answer 41

5mg once a week on diff day to metho

Question 42

Folic acid SE

Answer 42

- Vit B12 def - GI SE

Question 43

Risk factors of Neural Tube Defects:

Answer 43

* Smoking * Sickle cell anaemia * Diabetes * Obesity * Use of anti-epileptic drugs * Use of anti-malarial drugs