Treatement of Anemia

Question 1

First line therapy of IDA?

Answer 1

oral iron

Question 2

Drawbacks of oral therapy

2

Answer 2

1. Absorption is limited in malabsorptive states and in chronic kidney disease
2. May not be able to keep up with the bleeding in cases of ongoing blood loss

Question 3

70% non-compliance rate due to GI side effects. What are they?
7

Answer 3

Constipation
Nausea/vomiting
Diarrhea
Metallic taste
Thick green/black stool
May exacerbate inflammatory bowel disease

Question 4

Where are iron supplements absorbed?

Answer 4

Is not absorbed in the stomach but best in the duodenum and proximal jejunum

Question 5

How do you decrease the degree of side effects?

Answer 5

decrease the dose

Question 6

What are the kinds of formulas for oral iron administration?

Answer 6

Avoid enteric coated or sustained release

Question 7

When should we eat with iron supplementation?

What are the worst offenders?

Answer 7

1. Give on an empty stomach as most foods impair the absorption 2. (worst offenders are calcium containing foods, cereals, fiber, tea, coffee, eggs, milk)

Question 8

What meds should we avoid or take at a later time when taking oral supplementation?
2

Answer 8

1. Give 2 hours before or 4 hours post antacids
2. Calcium significantly impairs absorption
3. To increase absorption give with Ascorbic acid or orange juice

Question 9

What could you try if lowering the dose of the pills doesn’t work before going to IV therapy?

Answer 9

Ferrous sulfate elixir 44mg/5mL may be better tolerated than the tablets if patients have significant GI upset on the tablets
-rinse mouth out

Question 10

How much of elemental iron is recommened a day for adults?

Answer 10

150-200mg/day of elemental iron

Question 11

Whats the best option and how much elemental iron does it have?

Answer 11

Least expensive is ferrous sulfate 325mg tabs contain 65mg of elemental iron (varies from 300-325 iron salts and 60-65 elemental iron)

Question 12

HOw much elemental iron is in Ferrous fumerate?

Answer 12

67-106 mg

Question 13

How much elemental iron is in ferrous sulfate (325mg) ?

Answer 13

60-65 mg

Question 14

How much elemental iron is in ferrous gluconate 325mg?

How much elemental iron is in Elixir (ferrous sulfate)?

Answer 14

28-37 mg

44 mg/5mL

Question 15

Duration of therapy?

2

Answer 15

Some stop treatment when the Hgb normalizes

Others treat for 6 months after the Hgb has normalized

Question 16

Whats the advantages and disadvantagses of stopping when it normalizes?

Answer 16

could still have a low iron even though the HgB has normalized

Question 17

If youre giving the iron for pica or RLS how long will it take to go away?

Answer 17

often disappears right away

May feel better in a few days

Question 18

When will reticulocytosis go away with iron treatment?

Answer 18

7-10 days

Question 19

How long will it take for HgB to start getting better and nromalize?

Answer 19

Hgb increases slowly after 1-2 weeks of treatment and should rise 2 g/dL at 5 weeks, hgb should normalize in 6-8 weeks

Question 20

How long will it take for smooth tongue to go away with iron?

Answer 20

returns to normal in weeks to months

Question 21

Whats an alternative to pills and how should we take this?

3

Answer 21

1. 10 mL of iron sulfate elixir once daily (88 mg elemental iron)
2. mixed in a small glass of orange juice and taken
3. 30 min prior to breakfast (reduce the dose to 5 mL if irritation occurs, if unable to drink juice can give with 50-100 mg vitamin C (ascorbic acid)

Question 22

Indications for IV iron?

5

Answer 22

Excessive ongoing blood loss
Inflammatory bowel disease
Chronic kidney disease
Cancer patients
Inability to tolerate oral iron

Question 23

Why is iron IM not recommended?

4

Answer 23

1. PAINFUL,
2. can stain the skin at injection site,
3. mobilization of iron from IM sites is slow,
4. has been associated with gluteal sarcomas

Question 24

What are the kinds of IV iron?

4

Answer 24

Iron Dextran (INFeD) 
Ferris gluconate (ferriecit)
Iron sucrose aka saccharate (Venofer)
Ferumoxytol (Faraheme)

Question 25

If they have any asthma or drug allergy in their history or RA what do you have to medicate with?

Answer 25

prednisone

Question 26

What drug could alter MRI results?

Answer 26

Ferumoxytol

Question 27

Side effects of IV iron? | 5

Answer 27

``` 1. Life threatening adverse drug effects have been seen in all preparations SE – 2. fever, 3. arthralgias, 4. myalgias, 5. Rheumatoid arthritis flares ```

Question 28

How much folic acid should we take daily for a deficiency and for how long?

Answer 28

1-5 mg/day | Continue for 1-4 months

Question 29

Why do we need to rule out B12 deficiency before treating folate?

Answer 29

Can partially reverse some the hematologic abnormalities of B12 deficiency BUT the neurologic manifestations will progress!

Question 30

How should we treat permanenetly decreased ability to absorb detary B12? 3

Answer 30

1. IV 2. 1000mcg IM daily for 1 week 1000mcg IM weekly for 4 weeks 1000mcg IM once monthly 3. Or until corrected

Question 31

When is the most appropraite time to try oral replacement of B12? What kind of preparations that we should avoid?

Answer 31

after restoring deficiency with parenteral B12 (1000-2000mcg/day) Avoid sustained or time released preparations MUST MONITOR CLOSELY

Question 32

Effects fo therapy: When will they feel better? When will reticulocytes go up? When will HgB rise? When will neuro symptoms improve?

Answer 32

1. Patient may feel better within a few days 2. Reticulocytosis noted in 3-4 days 3. Hgb rises within 10 days and normalizes within 8 weeks 4. Neurologic abnormalities improve over 3 months and maximum improvement noted at 6-12 months

Question 33

Drugs used to stimulate RBC production? | 2

Answer 33

Epoetin alfa (Epogen, Procrit) Darbepoetin alfa (Aranesp)

Question 34

MOA for Erythropoiesis-Stimulating Agents?

Answer 34

1. Induces erythropoiesis by stimulating the division and differentiation of committed erythroid progenitor cells 2. Induces the release of reticulocytes from the bone marrow

Question 35

Patients disease state really matters when dosing RBC production drugs

Answer 35

LOOK them up

Question 36

Indications for Erythropoiesis-Stimulating Agents?

Answer 36

Used for the prevention of blood transfusion in the following causes of anemia

Question 37

Examples of when they would need Erythropoiesis-Stimulating Agents? 5

Answer 37

1. Chronic kidney disease hgb

Question 38

HgB level for EPS in Chronic kidney disease on dialysis?

Answer 38

below 10 and treat up to 11

Question 39

HgB level for EPS in Chronic kidney disease not on dialysis?

Answer 39

below ten and treat up tpt ten

Question 40

HgB level for EPS with cancer?

Answer 40

start with hgb

Question 41

HgB levl for EPS with HIV?

Answer 41

hgb levels should not >12 g/dL

Question 42

HgB level for EPS in presurgical patients?

Answer 42

>10 mg/dL ≤13 g/dL

Question 43

Dose adjustments in CKD: If Hgb increases by greater than 1 in 2 weeks what do we do?

Answer 43

Decrease dose by ≥25%

Question 44

Dose adjustments in CKD: If Hgb does not increase by greater than 4 weeks what do we do?

Answer 44

Increase dose by 25%

Question 45

If no response in HgB by how many weeks its not going to work?

Answer 45

12 weeks