fava iron b12 folic acid

anemia is characterized by which blood work factors

- decrease in hemoglobin

- decrease in RBC volume

(leads to lower blood oxygen carrying capacity)

what are the normal Hb levels in males and females?

anemia?

males: 14-18 (anemia<13)

female: 12-16 (anemia<12)

macrocytic anemia

- due to folic acid or vit b12 deficiency

- RBCs larger than normal

general anemia risk factors/ etiology

1. chronic disease/ inflammation

2. autoimmune/ bone marrow disorder

3. blood loss

4. cancer

5. CKD

6. drug induced

7. pregnant

8. vitamin/mineral/nutrient deficiencies

what are some clinical presentations of anemia

fatigue, weakness, headache, orthopnea, faintness, cold, pallor

which biomarker is the earliest and most sensitive predictor of IDA

ferritin (stores iron)

TSAT

what does it measure?

what happens in anemia?

transferrin saturation= % of iron-binding sites occupied on transferrin

-TSAT decreases in anemia

TIBC

what does it measure?

what happens in anemia?

Total iron binding capacity= measures the ability of transferrin to bind iron

- TIBC increases in anemia (has a higher capacity to bind)

an iron deficiency anemia is categorized by

a. hypochromic microcytic anemia

b. hypochromic macrocytic anemia

c. normochromic microcytic anemia

d. normochromic macrocytic anemia

a. hypochromic microcytic anemia

(pale and small)

note: b12 and folate are normochromic macrocytic

etiology/risk factors for IDA anemia

1. age: <2 or >65 (growth or reduced intake)

2. teen girls (periods)

3. celiac disease (less absorption)

4. pregnant and lactating (greater demand)

5. blood loss

clinical presentations specific to IDA

- brittle/ spoon shaped nails

- sore tongue

- angular stomatitis

- coldness/numbness of extremeties

non pharm treatment for IDA

1. address underlying cause

2. eat iron rich foods (beans, red meats, etc)

how is iron best absorbed? what hinders absorption?

best= acidic environment/ Vit C foods (oranges, bell peppers, tomatoes...)

worst= milk, tea, acid suppressors

what are 3 possible OTC iron supplements and their percent elemental iron?

gold standard?

1. ferrous sulfate- 20% (GOLD STANDARD)

2. ferrous gluconate- 12%

3. ferrous fumarate- 33%

(last 2 are good options if theres GI upset with ferrous sulfate)

the goal dose of elemental iron is _____________ for IDA patients

150-200mg

t/f: it is acceptable to take 3 tabs ferrous sulfate all at once with food to increase pt compliance and meet goal dose of 150-200mg

false. do not take all at once as it causes GI upset and is poorly absorbed. give in divided dose

should patients take iron with food?

yes: take at least 1hr before a meal to reduce GI upset

or

no: food reduces iron absorption (acidic environment preferred)

(so you may do either, just know caveats)

t/f: it is necessary to eventually titrate up to desired goal dose or iron levels will not return to normal

false. you do not have to meet the goal dose, but it will take longer to replace iron stores

a rise in hemoglobin is typically initially seen in ________

should continue to increase to normal levels within _________ months

therapy should continue for ______ months even after reaching normal levels

initial: 2 weeks

rise: 2 months

continue: 3-6 months (prevent relapse and replete iron stores)

adverse effects of oral iron

GI upset-> abdominal pain, nausea, constipation, dark stools

which drugs chelate with iron, decreasing absorption of both the drug and iron

Vampires Crave Blood Leaving Folks Tired

antiretroVirals

carbidopa/levidopa

bisphosphonates (alendronate)

Levothyroxine

Fluoroquinolones (ciprofloxacin)

Tetracyclines

which drug is ok to be taken with oral iron

a. ranitidine

b. lorazepam

c. Mylanta

d. risedronate

b

t/f: iron may be potentially lethal if taken at a high enough dose

true. counsel about children eating it. note its hard to overdose on Vit B, that one has lower risk

exclusions for self care for IDA

1. complete intolerance to oral therapy

2. malabsorption syndromes (IBS, gastric bypass)

3. long term non-adherence

4. blood loss/symptoms-> emergency care

-> depends on how severe: cancer and CKD

how should a pt taking an acid suppressor and oral iron tablets be counseled

separate iron and acid suppressor by at least 4 hours

what is the purpose of vitamin B12 and folic acid in hematology

essential for DNA synthesis- rapidly dividing cells like those in the bone marrow responsible for producing red blood cells (RBCs)

which type of pathophysiology is seen in B12 deficiency anemia

a. normocytic

b. microcytic

c. macrocytic

c. macrocytic

(contrast to IDA, which is microcytic)

etiology/risk factors for B12 deficiency anemia

1. poor intake

2. malabsorption (gastritis, surgery, autoimmune-> pernicious)

3. H. pylori infection

4. poor gastric acid production (disease or drug induced)

5. metformin

which drug is often linked to B12 deficiency anemia

a. antiretrovirals

b. carbidopa/levidopa

c. doxycycline

d. metformin

d. metformin

pernicious anemia

vitamin b12 deficiency anemia

- lack IF needed to absorb B12 bc antibodies against it

clinical presentations specific to vitamin B12 deficiency anemia

neurological

1. bilateral paraesthesia in extremities (tingling)

2. deficits in proprioception and vibration

indications for treatment of B12 deficiency anemia

1. lab confirmed megaloblastic anemia

2. other hematological abnormalities + neurological symptoms

key is to treat early! neurological symptoms may be irreversible!

what is the general pharm treatment option for VitB12 deficiency with no neurological symptoms? with symptoms? severe?

none: 1000mcg PO daily

neurological: 1000mcg IM/SC once daily x 1 week, one weekly, then one a month

severe: 1000mcg once weekly

avoid time release! no benefit, just more expensive

why should time release vit b12 be avoided

theres no clinical benefit, its just more expensive

generally, 1000mcg of folate are recommended. what is the exception?

pregnant women with history or family history of offspring with neural tube defects

1000-4000mcg PO daily

describe general RBC size for the following deficiencies

-IDA

-B12 anemia

- folic acid anemia

IDA: microcytic

B12: macrocytic

folate: macrocytic

FA deficiency anemia etiology/risk factors

1. low intake (elders, teens, ill, poor)

2. malabsorption/ alcoholism

3. increase folate demand

-pregnant

-malignancy

- chronic inflammation

-burn patients

- growth spurt

which drugs could lead to folate deficiency (via antagonism, absorption, etc)

5-fluorouracil

6-mercaptopurine

azathioprine

hydroxyurea

zidovudine

methotrexate

triamterene

trimethoprim

alcohol

carbamazepine

divalproex

phenytoin

primidone

valproic acid

clinical presentations specific to FA deficiency anemia

decreased appetite, irritable, diarrhea

t/f: when assessing FA deficiency anemia, it is necessary to test for B12 deficiency anemia due to their similarity in clinical presentation and lab findings

true

pharm treatment for FA deficiency

folic acid 1000mcg PO daily

about 4 months

t/f: if 400mcg of folic acid are all that are available, it is acceptable to take 3

true. even tho dose is 1000mcg, taking more is acceptable