blood disorder agents

exam 1

cyanocobalamin brand names

B12, cobal

folic acid brand names

B9, FA-8

ferumoxytol brand

feraheme

ferumoxytol (feraheme) class

IV iron supplement

ferrous sulfate brand

feosol

ferrous sulfate (feosol) class

iron supplement

ferrous gluconate brand

fergon

ferrous gluconate (fergon) class

iron supplement

carbonyl iron brand

feosol

carbonyl iron class

iron supplement

iron sucrose brand

venofer

iron sucrose (venofer) class

IV iron supplement

ferrous fumarate brand

hemocyte

ferrous fumarate (hemocyte) class

iron supplement

what is anemia

group of disease characterized by low Hgb count OR a volume of red blood cells that result in decreased O2 binding capacity of the blood

normal Hgb men

13.5-17.5

normal Hgb women

12-16

severely low Hgb

<8

normal Hct

37-48

normal serum iron level

50-150

normal mean corpuscular volume (MCV)

50-150

acute symptoms of anemia

tachycardia, palpitations, hypotension, angina, lightheadedness

chronic symptoms of anemia

fatigue, weakness, dyspnea, vertigo, pallor, sensitivity to cold

MCV of microcytic anemia

<80

types of microcytic anemia

iron deficiency

thalassemia

sideroblastic anemia

MCV of normocytic anemia

80-100

MCV of macrocytic anemia

>100

what are the two types of macrocytic anemia

megaloblastic and nonmegaloblastic

4 common causes of iron deficiency anemia (micro)

1. inadequate dietary intake

2. blood loss

3. decreased iron absorption

4. increased iron requirement

what drugs can cause blood loss that can lead to iron deficiency anemia

NSAIDs, steroids, antiplatelets, anticoagulants

what can cause a decrease in iron absorption leading to iron deficiency anemia

PPIs, celiac disease, inflammatory bowel disease (IBD), gastric bypass

what can cause an increase in iron requirement leading to iron deficiency anemia

pregnancy and lactation, rapid growth in children and adolescents, infants

what is first line for iron deficiency anemia in pregnant patients

oral iron

what oral iron formulation has the highest amount of elemental iron per tab

ferrous fumarate

what oral iron formulation has the lowest amount of elemental iron per tab

ferrous gluconate

ADRs of oral iron

constipation, dark and tarry stool

oral iron boxed warning

accidental OD of iron — fatal poisoning in children

what is used for acute iron poisoning

deferoxamine

what is used for chronic iron overload

deferasirox

what is used for transfusion iron overload

deferiprone

effect of oral iron + antacids

decreased iron absorption — take iron 2h before or 4h after

effect of oral iron + H2RAs

decreased iron absorption — spacing does NOT help

effect of oral iron + vit C

increased iron absorption

what antibiotics are separated 2h before or 4-8h after oral iron

quinolones, tetracyclines, cefdinir

how long do you wait to take oral iron after taking a bisphosphonate

30-60 minutes

what IV iron can be used for iron deficiency anemia

iron sucrose, ferumoxytol, iron dextran complex, ferric gluconate, ferric derisomaltose

when is IV iron used for iron deficiency anemia

CKD pt on hemodialysis, CKD pt receiving ESA, pt unable to tolerate oral iron, pt loosing iron too fast, severe anemia

IV iron boxed warning

fatal anaphylaxis

boxed warning of ferumoxytol

angioedema, loss of consciousness

what class is used to treat thalassemia/MDS

erythroid maturation agents

erythroid maturation agent MOA

selectively binds TGF-B ligands to reduce Smad 2/3 signaling (signaling usually high in thalassemia/MDS)

why is Smad 2/3 unusually high in thalassemia or MDS

b/c ineffective production of RBCs

reblozyl class

erythroid maturation agent

erythroid maturation agent indications

anemia of thalassemia patients who require regular RBC transfusions

myelodysplastic syndrome/preleukemia

reblozyl (luspatercept) ADR

hypertension

what organ is responsible for 90% of erythropoietin production

kidney

what is erythropoietin (EPO)

hormone that stimulates bone marrow to produce red blood cells

what does a deficiency of EPO cause

anemia of CKD

kidneys make EPO so CKD= no EPO= decreased Hgb = anemia

treatment options for normocytic anemia

iron therapy

ESA/EPO

HIF-PHI

how doe erythropoietin stimulating agents (ESAs) work

induce erythropoiesis by stimulating division and differentiation of erythroid progenitor cells, inducing release of reticulocytes from bone marrow to become mature erythrocytes → increase Hct and Hgb levels

what drugs are ESAs

epoetin and darbepoetin

epoetin brand names

epogen, procrit

darbepoetin brand

aranesp

which ESA has a longer half life

darbepoetin — 2-3x of epogen

epoetin indications

cancer pts on chemo, pure red cell aplasia, progressive cancer, CKD

darbepoetin uses

cancer pts on chemo, CKD

ESAs side effects

arthralgia

ESA contraindications

uncontrolled HTN

ESA boxed warning

thrombotic complications if Hgb >11 → stroke, MI, worsening of CHF, HTN

what factors can limit the response to ESAs

iron and folic acid

vit C or B12 deficiency

infection

blood loss

aluminum overload

cancer, malnutrition

vadadustat MOA

decrease HIF degradation → increase HIF-a → increase endogenous EPO → increase RBCs

vadadustat class

hypoxia-inducible factor prolyl hydroxylase inhibitor (HIF-PHI)

vadadustat uses

CKD anemia (normocytic), dialysis >3 months

vadadustat ADRs

hypertension, diarrhea

vadadustat boxed warning

death, MI, stroke, VTE, vascular access thrombosis

when should you avoid using vadadustat

if Hgb >11

what can vadadustat do to statin levels

increase

what causes macrocytic anemia

low B12, low folate (B9), or both

what is required for diagnosis of macrocytic anemia

low Hgb and high MCV

what is first line treatment for macrocytic anemia

B12 injection

which type of anemia requires life long B12 injections

pernicious anemia

what is the function of B12

assist folate in biosynthesis of DNA, act as a coenzyme, amino and fatty acid metabolism, and promote cell and RBC growth

what is a deficiency of B12 called

pernicious anemia

what are s/s of B12 deficiency/pernicious anemia

weakness, numbness of hands or legs, bleeding gums, poor memory, depression, demyelination of CNS (dementia)

what is the function of B9

converted to TH4 → involved in RNA and DNA biosynthesis

coenzyme in hematopoietic cells in conversion of histidine to glutamate

what happens when there is a deficiency of B9

limited RBC division → megaloblastic anemia

drug interaction with folate

phenytoin

s/s of B9 overdose

mild GI upset

dosage forms of cyanocobalamin

IM injection (100-1000 mcg), PO, nasal (nascobal weekly)

drug interactions with cyanocobalamin

chloramphenicol and colchicine

B9 (folate) dosage forms

IM injection, oral

what should be monitored in B12 and B9 therapy

Hgb, Hct, and reticulocyte count

drug interactions with B9 (folate)

some chemo, phenytoin, green tea, sulfasalazine

what are some hematopoietic growth factors

G-CSF

GM-CSF

IL11

TPO

what drugs are G-CSF like/hematopoietic growth factors

filgrastim

pegfilgrastim

efbemalenograstim a

what does G-CSF stand for

granulocyte colony stimulating factor

what do G-CSF drugs treat

neutropenia — by stimulating WBC production

what drug is GM-CSF like/hematopoietic growth factor

sargramostim

what is sargramostim used for

neutropenia, stem cell transplantation — stimulate WBC production

what drug is IL11 like

oprelvekin