Hematological Parameters

what is an utility in obtaining and evaluating CBC?

a) evaluate effectiveness and /or adverse effects of some medication therapies

b) confirms diagnosis of folic acid deficiency anemia

c) evaluate renal function in a patient

d) evaluate potassium level in a patient

a) evaluate effectiveness and /or adverse effects of some medication therapies

the patient has started a new medication that is associated with thrombocytopenia. which lab test should be ordered to evaluate the patient’s platelet count?

a) Chem 7

b) CBC

c) CBC with differential

d) iron studies

b) CBC

what is analyzed in a CBC?

• RBC count

• Hgb

• Hct (hematocrit)

• red blood cell indices

• WBC count

• platelet count

what is analyzed in a CBC with differential?

• CBC + % of types of WBC

describe the steps of erythropoiesis

1. kidneys sense decrease in oxygen (hypoxia)

2. kidney releases erythropoietin (EPO)

3. EPO stimulates release of reticulocytes from bone marrow

4. reticulocytes → erythrocytes

5. increases erythrocytes turn off EPO stimulation

what are the 4 building blocks of RBC ?

1. pyridoxine (B6)

2. iron

3. cycanobalamin (B12)

4. folic acid

what is the normal hematocrit range for females?

• 36% - 46%

what is the normal hematocrit range for males?

• 37%-49%

what does hematocrit measure?

• volume occupied by RBC (percent of total volume)

what is the normal range of hemoglobin for females?

• 12-16 g/dl

what is the normal range of hemoglobin for males?

• 13-18 g/dl

what is TIBC?

• total iron binding capacity

• amount of iron that can bind to transferrin

• less iron = increased TIBC

what is MCV? what does it look at?

• mean corpuscular volume

• looks at average size of RBC

  • microcytic, normocytic, macrocytic

what is the management dose of iron for pregnant patients? 

27 mg/day 

what is the management dose of iron for lactating patients? 

• 9-10 mg/day 

what is thrombocytopenia?

• low platelet count

• increases risk for bleeding

what is leukocytosis

• increased WBC count

what is leukopenia?

• decreased WBC count

  • bone marrow failure ?

if there is an increase in bands (a shift to the left), what might it indicate?

• infection

increased eosinophils is characteristic of…

• parasitic + allergic diseases

increased basophils may indicate

• allergic reactions

what does the Hb concentration in the blood need to be for men to indicate anemia?

• <13 g/dl

what does the Hb concentration in the blood need to be for women to indicate anemia?

• <12 g/dl

what are the 2 approaches to finding the cause of anemia? describe each briefly

1. kinetic

   • decrease in Hb

2. morphologic

   • RBC size + reticulocyte

which lab tests to order to further evaluate underlying cause of anemia?

• iron panel

• folic acid + B12 levels

what is the most common cause of anemia?

• nutritional deficiencies

  • iron, vit. B12, folic acid

what are 3 causes of iron deficiency?

1. increase demand

2. increased loss (blood loss)

3. decrease intake/absorption

what are some symptoms of iron deficiency anemia?

• fatigue

• pallor

• Koilonychia (spoon nails)

• pica

T/F: calcium helps with absorption of iron

• false

  • inhibits both forms of iron

T/f: low iron can lead to increased absorption 

• true

when laboratory findings show low Hgb with a low MCV, it is most likely what type of anemia? 

• iron-deficiency 

how does the source of heme iron differ from non-heme iron

• heme

  • meat, fish, poultry 

  • more absorbable (ferrous 2+)

• nonheme 

  • vegetables fruit 

  • ferric (3+)

SATA: improve absorption of nonheme iron

a) gastric acid

b) ascorbic acid

c) vitamin c

d) calcium

a) gastric acid

b) ascorbic acid

c) vitamin c

T/F: the elemental iron content is the same across all iron agents

• false

  • differs between formulations

  • can not be interchanged with the same dose (mg per mg)

what type of oral iron is recommended? dose?

• ferrous sulfate 325 mg once daily 

T/f: some iron formulation has an advantage over the other

• false 

  • cost + patient preference based

how should oral iron be dosed? 

• low + slow 

  • hard to tolerate iron 

• once daily or every other day

• 1 hour before or 2 hours after meals (empty stomach)

• can be taken with vitamin c

T/F; % Fe absorbed decreases as the dose increases, absolute amount of Fe absorbed increases

true

what is a common side effect of iron

• constipation 

• GI side effects

failure of oral iron

1. malabsorptive states 

2. inflammatory bowel disease 

3. heavy blood loss and gastric bypass 

4. dialysis/cancer patients on erythropoiesis-stimulating agents 

when is IV iron given?

• not properly responding / intolerant

• continued blood loss

• CKD

• IBD

• cancer

• heart failure

what factors influence what type of IV iron formulations are given?

• what is available / on formulary 

• insurance coverage 

megaloblastic anemia is also known as …

• folic acid deficiency anemia 

what are some causes of folic acid deficiency anemia? 

• inadequate intake (major cause)

• increased need

• impaired metabolism

• malabsorption

what medications interfere with folic acid metabolism?

• trimethoprim (bactrim)

  • weak inhibitor of dihydrofolate reductase

• phenytoin 

  • blocks folate absorption

• methotrexate 

  • inhibits dihydrofolate reductase

• pyrimethamine 

  • Inhibits parasitic dihydrofolate reductase

what are the symptoms for folic acid deficiency anemia?

• usually asymptomatic 

• GI symptoms

• sore tongue/painful swallowing

• stomatitis

if laboratory findings find low Hgb, high MCV, low folate it might indicate…

• folic acid deficiency anemia

what is the recommended dietary allowance for adults, pregnant women, and lactating women to prevent folic acid deficiency anemia?

• 400 mcg/day = adults 

• pregnant = 600 mcg/day 

• lactating = 500 mcg/day 

therapeutic folic acid for pregnant women? 

1mg/day 

T/F: 1mg folic acid is rx

• true

what doses of folic acid are available OTC?

• 400 mcg 

• 800 mcg 

T/F: prenatal vitamins usually have a higher amount of folic acid vs general multivitamins

• true 

how long is folic acid administered?

• until underlying problem corrected (~4 months) 

• long-term therapy for chronic conditions w/ increased folate requirements 

is folic acid well tolerated?

• yes 

Kelly is a young female in her mid 20th presenting to your pharmacy and asking for folic acid as she is trying to get pregnant. what dose should she receive? 

• 400 mcg (adult dose)

Kelly returns to your pharmacy in 4 months announcing she is pregnant. what dose of folic acid should she receive? 

• 600 mcg/day

what is the etiology for vit b12 deficiency anemia?

1. inadequate intake 

2. malabsorption (MOST COMMON) 

3. inadequate utilization

what is the most common reason for vit b12 deficiency anemia?

1. malabsorption

• loss of intrinsic factor 

• GI disorders 

• competition for B12 

• drug interactions/effects

what type of medications interfere with vitamin b12?

• prolonged use of PPIs 

  • absence of gastric acid secretions

• prolonged use of H₂RA 

  • absence of gastric acid secretions

• metformin 

  • calcium dependent ileal membrane antagonism

  • can be reversed with supplemental calcium

what are the only sources of vit b12 in humans?

• meat, poultry, eggs, dairy

what type of damage can vit b12 deficiency anemia cause if not treated?

• neurological damage (progressive)

  • can be permanent

how is vit b12 absorbed?

• peptic digestion in acidic environment of the stomach

• free b12 → b12 binder (intrinsic factor) in duodenum 

• absorbed at terminal ileum 

what are the symptoms for vit b12 deficiency

• fatugue

• impaired membory memory

• dyspnea

• paresthesias

• children: poor brain development w/ prolonged deficiency

what is the recommended dietary allowance of vit b12 for adults ?

• 2 mcg/day

what is the recommended dietary allowance of vit b12 for pregnant/lactating women ?

• 2.6 mcg/day

what is the oral therapeutic dosage for vit b12?

• 1000-2000 mcg/day

what is the IM/deep SC therapeutic dosage for vit b12?

• 1000 mcg/day once a week → weekly for a month → monthly for maintenance

TF: vit b12 is only available in prescriptions

• false

  • oral = otc

what is pernicious anemia 

• vit b12 deficiency anemia 

  • cant not absorb vit b12 because lack of intrinsic factor 

how long is vitb12 given for patients with pernicious anemia?

• for life 

is vitamin b12 well tolerated?

• yes 

vit b12 can have some drug interactions with …

• colchicine 

• ethanol

what are 2 examples of combination products?

• ferrex-150 forte (RX only)

• Multigen (RX only) 

if patient has ab above normal MVC and tingling in his hands and feet, which anemia would you suspect?

• vit b12 deficiency anemia 

Jack = 70 yo old male

numbness in hands + feet, fatigue + recent forgetfulness

lab values: Hgb 12 g/dL, MVC 109, 

what is a possible diagnosis? possible causes? treatment?

• vit b12 deficiency anemia 

• treatment: 

  • neurological complication → injection IM/SC1000 mcg 

Which of the following parameters is more reliable in determining the status of RBC on CBC?
a. Reticulocyte count
b. Ferritin
c. Hgb
d. Hct

c. Hgb

Which of the following hormones is important in the production of RBC?
a. Erythropoietin
b. Thyroid Stimulating Hormone
c. Homocysteine
d. RES

a. Erythropoietin

You are rounding with the Internal Medicine team and an intern states that patient has "shift to the left". What does it indicate?
a. Anemia
b. Inflammation
c. Kidney Disease
d. Infection

d. Infection

You are verifying medication orders, and as part of your monitoring, you need a basophil count. Which test will you ask the doctor to order?
a. CBC
b. CBC with differential
c. Chem 7
d. WBC

b. CBC with differential

Patient is a 31 y.o. female who comes to your pharmacy for advice on oral iron repletion therapy. She was just advised by her doctor to start ferrous sulfate for her anemia. While helping patient select the right oral iron product, patient mentions that she is 9 weeks pregnant and craves milk and ice cream. What counseling points can you provide to this patient?
a. Separate administration of iron supplements and dairy products
b. Administer iron supplements with breakfast and a glass of milk to increase absorption
c. Administer iron supplements with a glass of grape juice to increase absorption
d. Administer iron supplements with yogurt to increase absorption

a. Separate administration of iron supplements and dairy products

what is the hallmark lab finding for folic acid deficiency?

• elevated MCV

Which of the following laboratory findings might be elevated in patients presenting with folic ccid deficiency anemia?
a. WBC
b. Hct
c. MCV
d. Ferritin

c. MCV

Patient is a 53 y.o. female with a PMH significant for hypertension type II DM, and rheumatoid arthritis. Patients is currently taking alendronate, metformin, glipizide, methotrexate, ibuprofen,Vitamin D, prednisone, and calcium carbonate. Patient recently presented to their primary care
provider with complaints of fatigue and was diagnosed with folate deficiency anemia. What is a potential cause of Vitamin B9 deficiency in this patient?
a. Use of methotrexate
b. Use of calcium carbonate
c. Use of ibuprofen
d. Use of metformin

a. Use of methotrexate

• folate antagonist 

85-year-old male patient presents to his primary care provider, accompanied by his daughter. The daughter reports that her father has been complaining of numbness in his fingers and toes, as well as difficulty performing daily tasks. The patient has been living alone since his wife
passed away about 4 years ago. He has been diagnosed with Vitamin B12 deficiency anemia, and the primary care provider is consulting a clinic pharmacist for the best management strategy.
a. Initiate folic acid 1 mg daily
b. Initiate cyanocobalamin 1000mcg po daily
c. Initiate cyanocobalamin 2000mcg po daily
d. Initiate cyanocobalamin 1000 mcg IM daily x 1week, then weekly x 1month, then monthly for maintenance

d. Initiate cyanocobalamin 1000 mcg IM daily x 1week, then weekly x 1month, then monthly for maintenance

• neurological symptoms (numbness, tingling, difficulty with dialy tasks) 

You are reviewing your patient's lab results before their clinic visit. The patient's CBC reveals the following:
• RBC: 5.8 × 10⁶/μL (normal: 4.2–5.4 × 10⁶/μL)
• Hgb: 10.1 g/dL
• Hct: 30.3%
• MCV: 72 fL (80–100 fL)
• MCH: 22 pg/cell (27–31 pg/cell)
• RDW: 16% (11.5–14.5%)
• Platelets: 385 × 10⁹/L (150–450 × 10⁹/L)
• WBC: 7.5 × 10³/μL (4.5–11 × 10³/μL)
Which of these laboratory findings suggest that the patient may have iron deficiency anemia?
a. WBC
b. Plt
c. MCV
d. Hgb

c. MCV

A patient presents to your pharmacy with complaints of stomach upset and constipation. During your consultation, you learn that they were recently started on oral iron supplementation for iron deficiency anemia. What recommendations can you provide to help manage these side
effects?
a. Limit amount of fiber you consume daily
b. Initiate laxative and increase fluid intake
c. Discontinue taking your iron supplements
d. Change to a different iron formulation, like Slow FE

b. Initiate laxative and increase fluid intake

Which one of the following patients with iron deficiency anemia would be a great candidate for IV iron therapy vs oral iron supplementation?
a. 53 y.o. patient who is admitted for the management of alcohol withdrawal and has Hgb of 10.5 g/dl
b. 31 y.o. patient who is presenting with mild iron deficiency anemia and is currently trying to get pregnant
c. 48 y.o. patient with a history of inflammatory bowel disease and has Hgb of 7.8 g/dl
d. 28 y.o. patient with iron deficiency anemia and a strict vegan, currently not taking any supplements. Patient had a great response to oral iron therapy in a past.

c. 48 y.o. patient with a history of inflammatory bowel disease and has Hgb of 7.8 g/dl

A 32-year-old patient contacts their primary care provider, reporting persistent fatigue and the need for naps during the day to complete daily tasks. Patient has been taking ibuprofen 800 mg three times daily for the past 3 months due to a torn meniscus and difficulty walking. A nurse
ordered a CBC and iron studies, revealing iron deficiency anemia. What treatment recommendations would you provide for managing iron deficiency anemia in this patient?

a. No treatment is needed at this time and patient should have CBC repeated in 8 weeks and a consultation with a gastroenterologist to evaluate for GI bleeding
b. Initiate ferrous sulfate 325mg po daily
c. Initiate ferric gluconate 325mg 3 times daily
d. Initiate IV iron ( Iron dextran) 1000mg x once

b. Initiate ferrous sulfate 325mg po daily

what is RBC indices? 

• MCV 

• MCHC

what is normocytic MCV value? microcytic? macrocytic?

• normocytic = 78-100

  • micro= <78

  • macro = >100

what is the therapeutic dose of folic acid for pregnant women? 

1 mg/day 

what is therapeutic dose of folic acid for women who previously had babies with neural tube defects?

4 mg/day

what is the therapeutic dose of folic acid for patients with deficiency due to malabsorption?

• 1-5 mg/day

why is sustained/delayed release iron not as effective as immediate release?

• iron = best in acidic environment (duodenum + proximal jejunum)

• sustained → absorbed later in ileum = less absorption

T/F: therapeutic iron can cause thick, dark green stool

• true

what is the standard dose of folic acid? 

1 mg po daily