Anemia

Question 1

What is anemia?

Answer 1

• Anemia is a decrease in hemoglobin (Hgb) and hematocrit (Hct) concentrations below normal range for age and gender

Question 2

What is Hgb and what does it do in the body?

Answer 2

• Hgb is an iron-rich protein found in RBCs
• Hgb’s main purpose is to carry oxygen from the lungs to the tissues

Question 3

RBCs are formed in the ______ where they take up ____ and ____ before being released into the circulation as ____ , known as ____.

Fill in the blanks

Answer 3

• Bone marrow
• Hgb
• Iron
• Immature RBCs
• Reticulocytes

Question 4

What can cause anemia?

Answer 4

• Nutritional deficiencies (e.g., iron, folate, vitamin B12)
• CKD
• Malignancy

Question 5

What are the symptoms of anemia?

Answer 5

• Fatigue
• Weakness
• SOB
• Exercise intolerance
• Headache
• Dizziness
• Anorexia and/or pallor

Question 6

What are symptoms of iron deficiency anemia?

Answer 6

• Glossitis (inflamed, sore tongue)
• Koilonychias (spoon-shaped nails)
• Pica (eating non-foods like clay/chalk)

Question 7

T/F: Vitamin B12 deficiency can present with neurologic symptoms, including peripheral neuropathies

Answer 7

TRUE

Question 8

What is used to determine the type of anemia and the possible underlying cause?

Answer 8

• The mean corpuscular volume (MCV); size or average volume of RBCs

Question 9

What does low MCV and high MCV mean?

Answer 9

• Low MCV: RBCs are smaller than normal (microcytic)
• High MCV: RBCs are larger than normal (macrocytic)

Question 10

What are microcytic, normocytic and macrocytic MCV values and their likely causes?

Answer 10

~~~
```Microcytic: MCV <80 fL
* Iron deficiency

Normocytic: MCV 80-100 fL
* Acute blood loss

• CKD
• Bone marrow failure (aplastic anemia)
• Hemolysis

Macrocytic: MCV >100 fL
* Vitamin B12

• Folate deficiency

Question 11

What laboratory tests are used to further evaluate microcytic and macrocytic anemia?

Answer 11

• Microcytic: Iron studies
• Macrocytic: Vitamin B12 and folate levels

Question 12

A reticulocyte count measures the production of RBCs and it is low in ____ due to iron, folate or B12 deficiency and with ______.

Fill in the blanks

Answer 12

• Untreated anemia
• Bone marrow suppression

Question 13

What are common laboratory tests in anemia?

Answer 13

Relevant CBC Components
* Hgb

• Hct
• RBC count
• Reticulocyte count

RBC Indices
* MCV

• MCH
• Mean Corpuscular Hemoglobin Concentration (MCHC)
• Red Blood Cell Distriburion Width (RDW)

Iron Studies
* Serum iron

• Serum ferritin
• Total Iron Binding Capacity (TIBC)
• Transferrin Saturation (TSAT)

Additional Tests
* Serum folate

• Serum vitamin B12
• Methylmalonic acid
• Homocysteine

Question 14

```

~~~

What are the causes of iron deficiency?

Answer 14

Inadequate Dietary Intake
* Iron poor diets (e.g., vegetarian, vegan)

• Malnutrition
• Disease-related (e..g., dementia, psychosis)

Blood Loss
* Acute (GI hemorrhage)

• Chronic (heavy menses, blood donations, PUD, IBD)
• Drug-induced (NSAIDs, steroids, antiplatelets, anticoagulants)

Decreased Iron Absorption
* High gastric PH (e.g., PPIs)

• GI diseases (celiac disease, IBD, gastrectomy, gastric bypass)

Increased iron Requirements
* Pregnancy

• Lactation

Question 15

What are the laboratory findings for iron deficiency anemia?

Answer 15

• ↓ Hgb, MCV <80 fL, ↓ RBC production (low reticulocyte count)
• ↓ Serum iron, ferritin and TSAT
• ↑ TIBC

Question 16

How do you treat iron deficiency?

Answer 16

• Iron therapy: 100-200 mg elemental iron/day *
• Take iron on an empty stomach **
• Avoid H2RAs and PPIs; seperate from antacids
• Sustained-release or enteric-coated formulations cause less GI irritation but are not recommended due to poor absorption

*One oral formulation is not better than the other if dosed appropriately based on elemental iron needs.

** 1hr before or 2 hrs after meals; can be taken with food if GI upset occurs

Question 17

1. Ferrous gluconate: %
2. Ferrous sulfate: %
3. Ferrous sulfate, dried: %
4. Ferrous fumarate: %
5. Carbonyl iron, polysaccharide iron complex, ferric maltol: %

Give % of elemental iron in each of the listed oral products

Answer 17

1. 12%
2. 20%
3. 30%
4. 33%
5. 100%

Question 18

What are the treatment goals in iron deficiency anemia?

Answer 18

• ↑ in serum Hgb by 1 g/dL every 2-3 weeks; continue treatment for 3-6 months after anemia has resolved until iron stores return to normal

Question 19

Most IDA is adequately treated with ___ supplements. Parenteral iron is primarily used in ___.

Fill in the blanks

Answer 19

• Oral iron
• Dialysis

Question 20

Ferrous sulfate/Ferrous sulfate, dried - dosing, BW, SEs

Answer 20

Ferrous sulfate: 325 mg (65 mg elemental iron) PO daily to TID.

Ferrous sulfate, dried: 160 mg (50 mg elemental iron) PO daily to TID.

Boxed Warning
* Accidental overdose of iron-containing products is a leading cause of fatal poisoning in children under 6; go to emergency department or call poison control center asap (even if asymptomatic)

Side Effects
* Constipation (dose-related)

• Dark and tarry stools

Question 20

T/F: A stool softener such as docusate is recommended to prevent iron-induced constipation

Answer 20

TRUE

Question 21

What is the antidote for iron overdose?

Answer 21

• Deferoxamine (Desferal)

Question 22

Oral iron - DDIs

Answer 22

Antacids, PPIs and H2RAs ↓ iron absorption by ↑ gastric PH
* Patients should take iron 2 hours before or 4 hours after taking antacids

Iron is a polyvalent cation that can ↓ the absorption of other drugs by binding with them GI tract. Seperate administration iron with:
* Quinolone and tetracycline antibiotics - take iron 2 hrs before or 4-8 hrs after
* Bisphosphonates - take iron 60 min after oral ibandronate or 30 min after alendronate/risedronate

• Levothyroxine - seperate from iron 2-4 hrs

Vitamin C ↑ the absorption of iron. Giving iron with ascorbic acid may enhance the absorption to a minimal extent

Question 23

Which patient population IV iron is restricted to? Why?

Answer 23

Due to the severe ADRs and the cost of therapy, IV iron is restricted to patients who are;

• CKD on hemodialysis (most common IV iron use)
• CKD receiving erythropoiesis-stimulating agent (ESAs)
• Unable to tolerate oral iron or failure of oral therapy (e.g., IBD, celiac disease, certain gastric bypass procedures, achlorhydria and H.pylori)
• Religious reasons

Question 24

IV iron - BWs, SEs, brand/generic names

Answer 24

Iron sucrose (Venofer) Ferumoxytol (Feraheme) Iron dextran complex (INFeD) **Boxed Warning** * Anaphylactic reactions with iron dextran and ferumoxytol - all patients receiving iron dextran should be given test dose prior to first full dose **Side Effects** * All parenteral iron products carry a risk for hypersensitivity reactions

Question 25

What is the only indication for IV ferric pyrophosphate citrate (Triferic)?

Answer 25

* Iron replacement in patients with hemodialysis-dependent CKD * It should be added to the bicarbonate concentrate of the hemodialysate for patients receiving hemodialysis

Question 26

Pernicious anemia, the most common cause of vitamin B12 deficiency, occurs due to a lack of ____. | Fill in the blank

Answer 26

* Intrinsic factor (IF)

Question 27

T/F: Pernicious anemia requires a lifelong parenteral vitamin B12 replacement

Answer 27

TRUE

Question 28

What are the other causes of macrocytic anemia?

Answer 28

* Alcoholism * Poor nutrition * GI disorders (e.g., chrons disease, celiac disease) * Pregnancy

Question 29

The long term use (>= __ years) of ___, ___ or ___ can decrease the the absorption of vitamin B12.

Answer 29

* 2 * Metformin * PPIs * H2RAs

Question 30

Vitamin B12 deficiency can result in serious neurologic dysfunction, including ___ neuropathies. If left undiagnosed, neurologic symptoms can become ___. | Fill in the blanks

Answer 30

* Peripheral * Irreversible

Question 31

Folic acid deficiency does not cause neurologic symptoms; it causes ___ of the tongue and oral mucosa and changes to skin, hair and fingernail pigmentation | Fill in the blank

Answer 31

* Ulcerations

Question 32

T/F: Macrocytic anemia = low Hgb, high MCV

Answer 32

TRUE

Question 33

How do you treat macrocytic anemia?

Answer 33

Cyanocobalamin, vitamin B12 * First-line * IM or deep SC: 100-1,000 mcg daily/weekly/monthly * Nascobal: 500 mcg in one nostril once weekly Folic acid, folate, vitamin B-9

Question 34

What is erythropoietin (EPO)?

Answer 34

* EPO is a hormone produced by kidneys that stimulates the bone marrow to produce RBCs

Question 35

What happens if EPO is deficient?

Answer 35

* Anemia of CKD

Question 36

How is anemia of CKD treated?

Answer 36

* Erythropoiesis-stimulating agents (ESAs) should be initiated

Question 37

How do ESAs work in the body?

Answer 37

* ESAs help maintain Hgb levels and reduce the need for blood transfusions * They are ineffective if iron stores are low

Question 38

Epoetin alfa, Darbepoetin - brand/generic names, dosing

Answer 38

**Epoetin alfa (Epogen, Procrit)** * **CKD:** 3x/week, initiate when Hgb <10 g/dL ↓ or interrupt dose when Hgb approaches or exceeds 11 g/dL (CKD on HD) * **Cancer (taking chemo):** initiate when Hgb <10 g/dL **Darbepoetin (Aranesp)** * **CKD:** IV or SC weekly * t1/2 is 3-fold longer than epoetin alfa (it can be given weekly)

Question 39

ESAs - BWs, SEs, warnings, monitoring, storage/use

Answer 39

**Boxed Warning** * ↑ risk of death, MI, stroke, VTE, thrombosis * Use the lowest effective dose to reduce the need for blood tranfusions * CKD: ↑risk of death when Hgb >11 g/dL * Cancer: not indicated when the anticipated outcome is cure **Side Effects** * Arthralgia **Warnings** * HTN **Monitoring** * Hgb, Hct, TSAT, serum ferritin, BP **Storage/use:** * Store in the refrigerator * Do not shake

Question 40

What is the cause of hemolytic anemia?

Answer 40

* Acquired (e.g., drug-induced) * Inherited (e.g., G6PD deficiency)

Question 41

T/F: The direct coombs test is used for hemolytic anemia

Answer 41

TRUE

Question 42

List drugs that can cause hemolytic anemia

Answer 42

* Cephalosporins * Dapsone - * Isoniazid * Levodopa * Methyldopa * Methylene blue - * Nitrofurantoin - * Pegloticase - * Penicillins * Primaquine - * Quinidine * Rasburicase - * Rifampin * Sulfonamides - | -Avoid in G6PD deficiency