Anemia

Anemia

-Group of diseases characterized by a decrease in either hemoglobin (Hgb) or the hematocrit (Hct)

-Results in reduced oxygen-carrying capacity of the blood

13

Anemia is defined by the (WHO) as Hgb < _____ in men

12

Anemia is defined by the (WHO) as Hgb < _____ in women

hypoproliferative anemia

-marrow damage

-iron deficiency

-decreased stimulation (renal disease, inflammation, metabolic disease)

maturation disorders in anemia

Cytoplasmic defects

-thalassemia

-iron deficiency

-sideroblastic

Nuclear maturation defect

-folate deficiency

-vitamin B12 deficiency

-refractory anemia

hemorrhage/hemolysis anemia

blood loss, intravascular hemolysis, autoimmune disease, hemoglobinopathy, metabolic/membrane defect

asymptomatic

Anemia is often ________

chronic anemia

Fatigue, weakness, HA, orthopnea, DOE, vertigo, sensitivity to cold

acute onset anemia

Palpitations, angina, orthostatic lightheadedness, breathlessness, tachycardia, hypotension

no not always

Does the severity of the symptoms of anemia correlate with degree of anemia?

CBC

What lab should you do first in anemia?

MCV

If you get back the CBC in an anemic patient and the Hgb is decreased what should you evaluate next?

MCV

used to determine which additional labs may be needed

normocytic anemia

MCV 80-100 fl

Microcytic Anemia

MCV < 80 fl

Macrocytic Anemia

MCV > 100 fl

iron-deficiency anemia (IDA)

• Most common nutritional deficiency

• Results from prolonged negative iron balance

• Presents as a microcytic anemia

-inadequate dietary intake

-blood loss

-decreased iron absorption

-increased iron requirements

What are the causes of iron deficiency?

inadequate dietary intake cause of IDA

-iron-poor diets (vegetarian, vegan)

-malnutrition

-disease related (dementia, psychosis)

blood loss cause of IDA

-acute (GI hemorrhage)

-chronic (heavy menses, blood donation, peptic ulcer disease, inflammatory bowel disease)

-drug induced (NSAIDs, steroids, antiplatelets, anticoagulants)

decreased iron absorption of IDA

-high gastric pH

-GI disease (like celiac diseases, IBD, gastrectomy, gastric bypass)

increased iron requirements of IDA

-pregnancy or lactation

-rapid growth in adolescence or infants

Pica

Patients with IDA may present with ______

at risk groups for IDA

-Age:

-Adolescent girls

-Pregnant/lactating females (low-dose iron supplements recommended for pregnant women)

iron

is essential for Hgb formation, electrontransport and energy metabolism within cells

transferrin

transport protein for iron

ferritin

stores iron

patho of IDA

1. Iron stores are reduced without reduced serum iron levels

• Pt is at risk for developing anemia but supply is still able to meet demand

2. Iron stores are depleted

• Reduced transferrin saturation and increased TIBC but "normal" Hgb

3. Anemia develops

Mean Cell Volume (MCV) in IDA

-Average volume of RBC

-↓ (microcytic)

serum iron in IDA

-Concentration of iron bound to transferrin

-↓

ferritin in IDA

-Storage iron *best indicator of iron deficiency or overload

-↓

total iron binding capacity (TIBC) in IDA

-Iron binding capacity of serum transferrin

-↑

-increase dietary intake

-oral iron

-parenteral iron

What is the tx for IDA?

8 mg

What is the daily recommended allowance of iron in adults?

18 mg

What is the daily recommended allowance of iron in menstruating females?

reduce

Milk, tea, calcium, grains can ______ absorption

good sources of iron

-Meat/fish/poultry

-Fortified cereals

-Broccoli/Spinach

-Potatoes

-Lentils/Beans

-Animal liver

-Eggs

150-200 mg divided into 2-3 doses to maximize tolerability for adults

What is the recommended dose of elemental iron orally daily?

1 hour prior to meals because food can interfere with absorption

When should you administer oral iron?

AEs of oral iron

GI discomfort, dark discoloration of feces, diarrhea, constipation, nausea, and vomiting (dose related)

children

Iron toxicity from overdose is more common in ________

3-6 mo after anemia is resolved to allow for repletion of iron stores and to prevent relapse

What is the tx duration of oral iron in IDA?

20%

Ferrous sulfate is ____ elemental iron

30%

Ferrous sulfate (exsiccated) is _____ elemental iron

12%

Ferrous gluconate is _____ elemental iron

33%

Ferrous fumarate is ______ elemental iron

-poor adherence

-inability to absorb iron

-continued bleeding

Oral iron failures are typically due to:

drugs that decrease iron absorption

-Al-, Mg- and Ca2+ containing antacids

-Tetracycline and doxycycline

-Histamine2 antagonists

-Proton-pump inhibitors

-Cholestyramine

parenteral

If you are unable to correct IDA with oral iron, transition to ___________ iron

parenteral iron

• Increase Hgb faster than oral iron

• Reduces GI issues found with oral administration

common ADE of parenteral iron

Arthralgias, flushing, infusion related reactions, nausea/vomiting

Iron Dextran(INFeD)

• Requires test dose prior to full dose administration

• FDA recommends that resuscitation equipment and trained staff be available during administration of all iron dextran

preparations

• 2 doses separated by at least 7 days

severe allergic reactions

What is the BBW with iron dextran (INFeD)?

Sodium ferric gluconate (Ferrlecit)

• Short half-life (1 hr)

• Does not require iron to be transferred to transferrin

• Requires frequent dosing

Iron Sucrose (Venofer)

• Do not give at the same time as oral iron; will result in decrease absorption

• Requires multiple doses

Ferumoxytol (Feraheme)

2 doses separated by at least 7 days

severe allergic reactions (observe for at least 30 mins)

What is the BBW for Ferumoxytol (Feraheme)?

Ferric carboxymaltose (Injectafer)

• Causes hypophosphatemia

• 2 doses separated by at least 7 days

Megaloblastic Anemia

• Macrocytic anemias (↑MCV) caused by abnormal DNA metabolism

- Vitamin B12 deficiency

- Folate deficiency

• Impairing maturation process results in immature, large RBC

-Inadequate intake

-Malabsorption syndromes

-Inadequate utilization

What are the major causes of B12 deficiency anemia?

Metformin--reversible

Proton pump inhibitors

Histamine 2 antagonists

What are the drugs that can decrease B12 absorption?

neurologic symptoms

Pts with vitamin B12 deficiency anemia can present with _____________ (paresthesia/neuropathy inextremities, gait abnormalities).

Mean cell volume (MCV) in vitamin B12 deficiency anemia

-Average volume of RBC

-↑

serum vitamin B12 deficiency anemia

-Normal > 200 pg/mL

-↓

-dietary sources of vit B12

-vitamin B12 supplements (oral or parenteral)

What are the tx options for Vitamin B12 Deficiency Anemia?

2 mcg

What is the recommended daily allowance of dietary vitamin B12 in adults?

70 mcg

Beef liver has ____ of vitamin B12

6 mcg

Breakfast cereal has ____ of vitamin B12

2-5 mcg

Fish (salom, trout, tuna) has ______ of vitamin B12

1.2

Milk has _____ of vitamin B12

1.1

Yogurt has _____ of vitamin B12

ORAL vitamin B12

• As effective as IM

• Avoid time-released preparations

• PREFERRED if minimally low B12 levels

• 1000 mcg daily

Parenteral vitamin B12

• Given IM

• 1000 mcg daily x 1 week then once monthly

• PREFERRED if neurologic symptoms present

-no absorption issue

no bc it is water soluble

Can you OD on vitamin B12?

Major Causes of Folic Acid Deficiency

- Inadequate dietary intake

- Decreased absorption (heavy alcohol consumption)

- Increased requirements (pregnancy, hemolytic anemia, malignancy,

growth spurts)

- Drugs (folate antagonists like methotrexate)

mean cell volume in folic acid deficiency anemia

-Average volume of cells

-↑

decreased

folate in folic acid deficiency anemia

-dietary folic acid

-oral supplement

Tx in folic acid difiency anemia:

400 mcg

What is the recommended daily allowance of dietary folic acid in non-pregnant adults?

food sources of folic acid

- Lima, Kidney, and Garbanzo Beans

- Dark and Leafy vegetables

- Cereal

- Broccoli

- Avocado

- Citrus fruits

oral supplement of folic acid

• 1 mg daily

• Treat minimum 4 months

• Non-toxic (water soluble)

anemia of inflammation

-anemia of chronic disease (ACD)

-anemia of critical illness (ACI)

-dx of exclusion

-patho multifactorial

Anemia of Chronic Disease (ACD)

Develops over months and years due to chronic disease (HIV, autoimmune conditions, heart failure, alcoholism)

Anemia of Critical Illness (ACI)

Rapid onset, occurring most often in hospital setting (surgical blood lose, sepsis)

patho of anemia on inflammation

blunted EPO response, impaired proliferation of erythroid progenitor cellsand disturbance in iron homeostasis

lab findings in anemia of inflammation

• Usually normocytic, normochromic with mildly depressed Hgb

• May exist in conjunction with iron, B12 or folic acid deficiencies

decreased

Iron in AI is _________

decreased or normal

Transferrin in AI is _________

decreased

Transferrin saturation in AI is ____________

increased or normal

Ferritin in AI is ___________

normal

Soluble transferrin receptor in AI is _________

decreased

Iron in IDA is __________

increased

Transferrin in IDA is __________

decreased

Transferrin saturation in IDA is __________

decreased

Ferritin in IDA is __________

increased

Soluble transferrin receptor in IDA is ___________

Oral iron may not be as effective due to impaired absorption

Tx of AI with iron deficiency:

RBC transfusion

If a pt with AI has severe anemia (Hgb < 8) how do you treat them?

ESAs in AI

• May need higher doses to overcome hypo-responsiveness

• Need to ensure other deficiencies are corrected first

• Do not treat past Hgb of 12 g/dL or rise > 1 g/dL every 2 weeks

ESAs and look for other deficiencies

If a pt is anemia with CKD you use: