Anemia Part 2

Anemia: Hb concentration in the blood is below a defined level,

resulting in a reduced oxygen-carrying capacity of RBCs

for men vs for women

Hb <13 g/dL; for women Hb <12 g/dL

causes of anemia

• mechanism for the decrease in Hb concentration

kinetic approach

causes of anemia

• alterations in RBC size and reticulocyte response

morphological approach

Kinetic Approach

• Nutrient deficiency

  •Disorders of bone

  marrow

  •Suppression of bone

  marrow

  •Low levels of trophic

  hormones

decrease RBC production

Kinetic Approach

• Nutrient deficiency

  •Disorders of bone

  marrow

  •Suppression of bone

  marrow

  •Low levels of trophic

  hormones

increase RBC destruction

kinetic approach

• Obvious bleeding

  •Occult bleeding

  •Induced bleeding

  •Surgical procedure

  •Use of anticoagulants

blood loss

Morphological approach
•Reduced iron

availability

•Disorders of heme

synthesis

•Reduced globin

production

microcytic mcv<80 fl

Morphological approach

• •Hemorrhage

  •Anemia of chronic

  disease

  •Hemolytic anemia

normocytic mcv 80-100 fl

Morphological approach

• Reticulocytosis

  •Abnormal nucleic acid

  methabolisms

  •Abnormal RBC

  maturation

  •EtOH abuse

  •Liver disease

  •Hypothyroidism

macrocytic mcv >100 fl

symptoms of ____

• Most patients are asymptomatic

  Physical examination

  Laboratory evaluation

  Symptoms:

  • decrease O2 delivery to tissues:

  • Dyspnea, fatigue, palpitations

  • Severe: lethargy, confusion, arrhythmia, MI

  • Acute blood loss:

  • Dizziness, lethargy, hypotension, shock

anemia

nutritional deficiencies of _____ are common causes of anemia

iron, vitamin B12, or folic acid

some causes include increase deman, increase loss, or decrease intake

Iron deficiency anemia

Laboratory finding for anemia

• ____ are increase

• ______ are decreased

TIBC (increase) vs Hgb MCV Serum Iron, Serum Ferritin (decreased)

Management of iron deficiency anemia: correct underlying cause and reverse parameters

• maintenance dose: pregnant vs lactating

27mg vs 10 mg

Management of iron deficiency anemia: correct underlying cause and reverse parameters

maintenance dose: supplement

18mg/day

Management of iron deficiency anemia: correct underlying cause and reverse parameters

• therapeutic dose

100-200 mg/day

Iron come from diet

• ______ increase iron absorption

gastric and ascorbic acid (200mg VitC per 30mg Fe)

Iron come from diet

______ decrease iron absorption

calcium and tea

treatment reccs for iron def in Jane?

Ferrous Sulfate 325 mg qd

administer oral iron on _____ because food can reduce absorption

empty stomach

anatacids, H, RA, PPI, Ca can ____

inhibit iron abosorption

Vit C or orange juice can ____

increase iron absorption

Failure of oral iron → inability to absorb oral iron

malabsorptive state

Failure of oral iron → worsening of

underlying disease, poorly absorbed and ineffective

Inflammatory bowel disease

Failure of oral iron → amount absorbed not sufficient to replete

Heavy blood loss and gastric bypass

Failure of oral iron→ unable to fully utilize oral iron

Dialysis/cancer patients on erythropoiesisstimulating agents

iron toxicity

• ____ associated with sever iron overload = liver/heart failure

hemochromatosis

iron toxicity

• ____ to treat iron overload

chelation therapy

Folic acid deficiency anemia aka “Megaloblastic anemia”

folic acid = folate = vitamin B9

________________ is storage site of folic acid → limited space

liver

Folic Acid is essential for DNA synthesis and red blood cell formation. A deficiency can lead to _____ characterized by the presence of large, immature red blood cells.

megaloblastic anemia

Folic Acid Deficiency Etiology (what causes the deficiencies)

inadequate intake, increased need, impaired metabolism, malabsorption

Medication interfering with folic acid metabolism

• weak inhibitor of dihydrofolate reductase

trimethoprim

Medication interfering with folic acid metabolism

• blocks folate absorption and increase utilization

phenytoin

Medication interfering with folic acid metabolism

• inhibit dihydrofolate reductase

methotrexate

Medication interfering with folic acid metabolism

• used for treatment of malaria and toxoplasmosis

• inhibits parasitic dihydrofolate reductase

pyrimethamine

Symptom of ____

Usually asymptomatic

• GI symptoms

• Nausea/vomiting/ abdominal pain especially after a meal

• Weight loss

• Sore tongue or pain when swallowing

• Stomatitis

folic acid deficiency

Folic Acid Deficiency Lab

• ____ increase

• ____ decrease

MCV (increase) vs RBC, HgB, Reticulocytes, Serum Folate (decrease)

maintenance dose of folic acid

• _____ in adults 

400 mg

maintenence dose of folic acid in pregnant vs lactating

500 mcg vs 600 mcg

therapeutic dose of folic acid: including pregnant who are considered deficient

• ____ 

1 mg/day

therapeutic dose of folic acid: women who previously had babies with neural tube defects 

• ____

4 mg/day

therapeutic dose of folic acid: deficiency due to malabsoprtion

1-5 mg/day

vernacular “megaloblastic anemia”

risk increase with age

large storage in liver → will take years to develop

neurological damage is progressive and may be pernament

Vitamin B12 Deficiency Anemia

____ Etiology

• Inadequate intake → rare

• Malabsorption → most common

  • Loss of intrinsic factor

  • GI disorders

  • Competition for B12

  • Drug interactions and effects

• Inadequate utilization

Vitamin B12 Deficiency

Medication interfering with Vitamin B12

• ____ → impaired release of B12 from food due to absence of gastric acid secretions

prolong use of PPIs and H2RA

Medication interfering with Vitamin B12

• ____ → reduce B12 absorption due to calcium-dependent ileal membrane antagonism

• can be reversed with supplemental calcium

Metformin

Symptoms:

• Pica: Eating ice for something with no nutritional value.

• may also be caused by severe blood loss, which can present as dizziness, lethargy, hypotension, or shock (in acute blood loss), or as occult (hidden) bleeding, such as a gastric intestinal bleed or bleeding ulcer from NSAID use

Iron Deficiency Anemia (IDA)

Symptoms:

• may present with GI symptoms.

  • Sore tongue or pain when swallowing.

  • Stomatitis.

  • Nausea, vomiting, or abdominal pain, especially after a meal.

  • Weight loss.

Folic Acid Deficiency Anemia

Symptoms:

• Neurological symptoms:

  ◦ Numbness .

  ◦ Weakness .

  ◦ Impaired memory .

  ◦ Tingling on the arm or leg → paresthesias
  poor brain developement in children. 

Vitamin B12 Deficiency Anemia

Lab finding for Vitamin B12 deficiency anemia

• increase ____

• decrease ____

MCV (increase) vs RBC, HgB, Reticulocyte, Serum B12 decrease

Vitamin B12 RDA (recommended daily allowance)

• adults

• pregnant/lactating females

2mcg/day vs 2.6 mcg/day

Vitamin B12 therapeutic dose

• oral ___

• Im/SubQ ____

1000-2000 mcg/day vs 1000 mcg daily/week, weekly/1month, maintenance monthly