Nutrient Deficiency Anemias

Question 1

Iron
Transported by and stored by (2)

Answer 1

Transported by protein Transferrin in plasma
Stored as Ferritin or as hemosiderin in macrophages (spleen, liver, bone marrow)

Question 2

Vitamin B12 and Folate (Folic acid)

Answer 2

Both required from diet
Both necessary for DNA synthesis of RBCs (marrow) -S phase

Question 3

iron def. anemia

classification

Answer 3

Microcytic Hypochromic Anemia

Question 4

Question 5

Iron Deficiency Anemia

Pathogenesis (stages) and etiology

Answer 5

Stage 1—progressive loss of storage iron
Stage 2—exhaustion of iron storage pool
Stage 3—frank anemia

Inadequate intake
Increased need
Impaired absorption
Chronic blood loss

Question 6

iron anemia

Signs & Symptoms

Answer 6

Question 7

iron anemia

labs

Answer 7

Screening tests
complete blood count (CBC)
Blood smear

Diagnostic tests
Serum iron
Total iron-binding capacity (TIBC)
Transferrin saturation
Ferritin (iron stored)
Reticulocyte count

Question 8

high platelet count often seen with iron def. and it goes back down once corrected.

Question 9

iron anemia

Tx

Answer 9

• Treat underlying cause
• Oral supplementation
  Ferrous sulfate oral supplements
• Intravenous infusion
  Infed (Iron dextran) infusion
  Old standard
  Injectafer (Ferric Carboxymaltose)
  Ferrlecit (Sodium Ferric Gluconate Complex)
  Feraheme (Ferumoxytol)
  Venofer (Iron Sucrose)
• RBC transfusion
  Severe anemia

Question 10

advangtages and disadvantages of oral vs IV iron

Answer 10

Question 11

ferrous sulfate

MOA, Dosing, forms

Answer 11

MOA: Replaces iron, found in hemoglobin, myoglobin, and other enzymes

Dosing: 65mg of elemental iron daily
Previously recommended up to three times daily
Studies suggest no increased absorption with this dosing (but increased side effects)

Available as tablets or solutions
Recommend patients take with OJ and/or Vitamin C (aids in absorption)
Avoid enteric coated versions (poor absorption)
Take separately from antacids
Many medications can affect absorption

Question 12

ferrous sulfate

Adverse rxns

Answer 12

Adverse Reactions (more common)
Nausea
Darkening of stool
Constipation

Question 13

Question 14

iron anemia

follow up

Answer 14

Measure response to treatment 3-6 months into oral treatment
CBC
Iron Studies
Reticulocyte count

Patients with intravenous iron infusions
Follow up 6-8 weeks with
CBC
Reticulocyte count

Question 15

Iron dextran (infed) (IV)

dosing, indications

Answer 15

Dosing: Calculation based; intravenous

Indications:
Lack of response to or poor tolerability of oral iron
Poor GI absorption
Chronic kidney disease
Active inflammatory bowel disease
Cancer
Chronic or extensive blood loss

Question 16

Iron dextran (infed)

Adverse Rxns

Answer 16

Adverse Reactions
Risk of anaphylactic reaction
Need test dose prior to first administration
Delayed (1-2 days) infusion reaction
Arthralgia, back pain, chills, dizziness, fever, headache, malaise, myalgia, nausea, and/or vomiting)
Usually subside within 3-4 days
Flushing
Pruritus
Injection site skin discoloration Arthralgia

Question 18

Injectafer (Ferric Carboxymaltose)

MOA, dosing

Answer 18

MOA: A non-dextran formulation that allows for iron uptake (into reticuloendothelial system) without the release of free iron
IDA Dosing (used in pregnancy 2-3rd trimester):
≥ 50kg: 750mg IV weekly x 2 doses
< 50kg: 15mg/kg IV once

Question 19

Injectafer (Ferric Carboxymaltose)

adverse rxns

Answer 19

Adverse reactions
Hypersensitivity (not common)
Hypertension (during infusion)
Hypophosphatemia
Check level before administration
Usually resolves within 3 months
Extravasation may cause permanent skin discoloration

Question 20

Ferrlecit (Sodium Ferric Gluconate Complex)

MOA, indications, dosing

Answer 20

MOA: Supplies a source to elemental iron necessary to the function of hemoglobin, myoglobin and specific enzyme systems
Indications: IDA including hemodialysis patients (does not dialyze)
Dosing: 125mg IV infusion every 6 weeks (or with each dialysis session) for up to 8 doses

Question 21

Ferrlecit (Sodium Ferric Gluconate Complex)

adverse rxns

Answer 21

Adverse reactions
Hypersensitivity reaction (not common)
HTN
Nausea
Injection site discoloration
Muscle cramps

Question 23

Sideroblastic anemia

classification
And characterized by

Answer 23

Microcytic Anemia

Disorder of Hgb synthesis
Characterized by atypical nucleated RBCs
Ringed sideroblasts are present on the bone marrow aspirate smear
Helpful to know if anemia is macrocytic, normocytic, or microcytic

Question 24

sideroblastic anemia

causes

Answer 24

Causes
Hereditary forms very rare
Manifest in childhood

Toxins: lead, copper or zinc poisoning

Drug-induced: ethanol or isoniazid

Nutritional: pyridoxine (Vitamin B6) or copper deficiency

Diseases: Rheumatoid arthritis, multiple myeloma

Question 25

# Sideroblastic anemia Tx and prognosis

Answer 25

Tx Remove offending agent Some pts with hereditary form will respond to **pyridoxine (B6)** Prognosis variable If think it is typical iron deficiency anemia, but the history doesn’t fit, or there has been toxin or drug exposure, or the patient has RA…then it might be sideroblastic

Question 26

# Sources B12 / Folate general

Answer 26

Both play a critical role in DNA and RNA synthesis. Deficiencies may cause a cell to arrest in the DNA synthesis (**S) phase of the cell cycle**, make DNA replication errors, and/or undergo apoptotic death B12 Fish, meat, poultry, eggs, milk, milk products, fortified breakfast cereals Generally not present in plant foods Takes years to become deficient Folate (folic acid) Vegetables (esp dark green leafy), fruits, nuts, beans, peas, seafood, eggs, dairy products, meat, poultry, and grains. Spinach, liver, asparagus, and brussels sprouts have high folate levels. Weeks-months to become deficient

Question 27

B12 binds to

Answer 27

intrinsic factor

Question 28

# B12 deficiency causes

Answer 28

Vitamin B12 deficiency * Inadequate intake * Increased need * Impaired absorption Lack of intrinsic factor -**Pernicious anemia** Malabsorption -**Gastric bypass and/or bowel resection** -Pancreatic insufficiency -Crohn Disease -Prolonged **PPI use** Inherited errors of Vitamin B12 absorption and transport Competition for Vitamin B12 -Blind loop syndrome -Parasites

Question 29

# B12 anemia S/Sx 4 neuro

Answer 29

Expect the typical findings of anemia pallor, fatigue, SOB, palpitations, glossitis etc Neurological Findings Ataxia Decreased vibratory/positional sense + Romberg Test Cognitive impairment (also may occur in folate deficiency)

Question 30

Question 31

# B12 anemia labs

Answer 31

Screening tests Complete blood count (CBC) and reticulocyte count Blood smear examination RBC and WBC morphology WBC manual differential Vitamin B12 level Folate Methylmalonic Acid- In certain cases

Question 32

# megaloplastic erythropoiesis

Answer 32

few or no reticulocytes howell-jolly bodies macrocytes with pokilocytosis hypersegmentation of neutrophils.

Question 33

Question 34

# b12 and folate who to test?

Answer 34

**MCV >100 with or without anemia** Hypersegmented neutrophils on peripheral smear Gastric bypass surgery Unexplained neurologic symptoms/signs Alcoholics / malnourished / elderly Vegans, if no supplementation Patients on metformin with new onset neuropathy

Question 35

# Pernicious Anemia Deficiency (B12) Lab Features

Answer 35

Question 36

B12 **vs** Folate Deficiency

Answer 36

Question 37

# Vitamin B12 Deficiency Tx

Answer 37

Adults Vitamin B12 1000mcg PO daily 2000mcg daily if poor absorption concerns Vitamin B12 (Cyanocobalamin) 1000mcg IM inj. Once per week until deficiency corrected, then once a month May give up to 3-5 times per week if neurologic symptoms Children Vitamin B12 1000mcg PO daily x 1 week, QOD x 1 week, , twice weekly for 2 weeks, and once weekly for 3 months

Question 38

# Folate Deficiency Tx

Answer 38

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

Question 39

B12 Tx

Answer 39

Cyanocobalamin (B-12) 1000mcg IM daily x 1 week Then 1000mcg weekly x 1 month (usually once monthly x 2-3 months) 1000mcg monthly for life if specific conditions such as Pernicious Anemia Oral high dose 1-2 mg daily (usually labeled in mcg) As effective but less reliable than IM Sublingual, Nasal spray and gel formulations available