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138 Cards in this Set
- Front
- Back
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What term describes the reduction of red cell mass?
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anemia
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What term describes a decrease in the Hgb concentration in blood to a level below normal physiologic requirement necessary fro adequate tissue reoxygenation
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anemia
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Who has a higher normal hemoglobin, men or women?
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men
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Anemia is a disease state, T or F?
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F. Anemia is a symptom. Need to investigate the cause of the anemia
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Where is 90% of EPO made?
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Kidneys
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Where is 10% of EPO made?
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liver
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What stimulates EPO production and release into the plasma?
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A decrease in tissue oxygen concentration
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What are the three categories of classification of anemia by pathophysiologic characteristics?
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Increased red cell loss, decreased red blood cell production, excessive red blood cell destruction
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What can cause anemia characterized by increased red cell loss?
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acute or chronic bleeding
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What can cause anemia characterized by decreased red blood cell production?
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disturbances in stem-cell proliferation or differentiation
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What can cause anemia characterized by excessive red blood cell destruction?
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autoimmune reactions, abnormal Hgb synthesis
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What are the morphologic characteristics for anemia classification?
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macrocytic, normochromic normocytic, microcytic hypochromic
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What is macrocytic anemia normally associated with?
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B12 or folate deficiency
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What is microcytic hypochromic anemia normally associated with?
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iron-deficiency anemia
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What are the acute symptoms of anemia?
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more cardiorespiratory; slight exertional dyspnea, tachycardia, lightheadness, increased angina, palpitations
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What are the chronic symptoms of anemia?
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fatigue, weakness, HA, vertigo, faintness, pallor
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What is normal hemoglobin for women?
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12-16g/dl
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What is normal hemoglobin for men?
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13-18g/dl
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What is normal hemocrit for women?
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35-45%
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What is normal hemocrit for men?
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40-50%
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What can be used as a rough estimate of the oxygen-carrying capacity of the blood?
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hemoglobin
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What is the actual volume of RBC in a unit vol of whole blood?
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hematocrit
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What lab value looked at in CBC is typically 3x the Hgb value?
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hematocrit
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What is mean corpuscular volume?
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Hct/RBC; average volume (size) of RBCs
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What does a low MCV in anemia indicate?
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microcytic anemia
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What does a high MCV in anemia indicate?
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macrocytic anemia
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What does a normal MCV in anemia indicate?
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normocytic anemia or mixed anemia
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What is more useful, mean corpuscular hemoglobin (MCH) or mean corpuscular hemoglobin concentration (MCHC)?
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MCHC as MCH can be decreased in both microcytosis and hypochromia
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What does a low MCHC indicate?
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hypochromia
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What does a high MCHC indicate?
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normochromia
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What does red cell distribution width indicate?
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variability of RBC size
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What does a high red cell distribution width indicate?
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early IDA (iron deficiency anemia) or mixed anemia
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What does a high reticulocyte lab value indicate in anemia?
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acute blood loss or hemolysis
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What does a low reticulocyte lab value indicate?
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nutritional anemia
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When is the best time to drawl serum ferritin?
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inn the AM (has diurinal variation)
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What does total iron binding capacity help to distinguish?
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iron deficiency anemia and anemia of chronic disease
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What is serum iron level a measure of?
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the concentration of iron bound to transferrin
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What is an indirect measurement of the iron-binding capacity of serum transferrin?
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Total iron binding capacity aka transferrin saturation
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What is serum ferritin measure of?
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proportional to total iron stores; a low value would indicate iron deficiency anemia
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What can a high level of serum homocysteine indicate?
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folate deficiency or b12 deficiency anemia
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What does a high level of serum methylmalonic acid indicate?
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B12 deficiency anemia; occurs early in B12 deficiency anemia prior to serum B12 level decrease
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How much iron is lost daily by men and nonmenstruating women?
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1mg/d
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How much iron is lost daily by menstruating women?
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2-3mg/d
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What are common sources of iron loss?
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urine, sweat, sloughing of intestinal mucosal cells containing ferritin, mensturation, pregnancy, lactation
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How much iron does the avg american diet provide per day?
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12-15mg
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What form is more readily absorbed, ferrous or ferric?
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ferrous
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How is ferric changed to ferrous?
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the acidic in the stomach changes it
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Where is iron absorbed?
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duodenum and upper jejunum (via active transport)
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What are the two dietary iron forms?
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heme iron and nonheme iron
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Which form of dietary iron is better absorbed, plant or animal source?
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animal (heme iron) is 3x more absorbed than nonheme iron
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What are possible etiologies of IDA?
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blood loss, decreased absorption, increased requirements
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What is the most common cause of IDA?
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blood loss. 1ml whole blood=0.5mg iron. Blood loss can occur with menstruation, GI (PUD, hemorrhoids), trauma
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What can decrease the absorption of iron?
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medications such as antacids, PPI, H2RA, tetracycline or other chelating Abxs; gastrectomy (less ferric -> ferrous), regional enteritis
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When in life is there an increased requirement for iron?
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infancy, early childhood, adolescence, pregnancy, lactation
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During pregnancy, what are the iron requirements per day?
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3-4mg/d
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When is the greatest demand for iron in pregnancy?
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2nd and 3rd trimesters
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What are the specific signs of iron deficiency anemia?
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decreased serum ferritin, increased RDW in early IDA, decreased serum Fe, increased TIBC, decreased % sat, decreased MCV, decreased MCHC, decreased reticulocyte, smear: microcytic, hypochromic
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What are the specific symptoms of IDA?
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brittle or spoon shaped nails, angular stomatitis, pica, glossitis
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What is the dosing of iron in IDA of 9-12 months yo?
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3mg/kg of elemental iron qd or bid x2-3 months after anemia is corrected
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What is the dosing of iron in IDA of "older children" months yo?
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6mg/kg/d elemental iron into 2 to 3 divided daily doses
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What is the dosing of iron in IDA of adults?
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30-40mg of elemental iron
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What is the bio-availability of oral iron?
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10-20%, therefore need to take total of 200-400mg elemental iron/d to absorb 30-40mg elemental iron
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What % of elemental iron is ferrous sulfate (feosol)?
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20%
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What % of elemental iron is ferrous gluconate (fergon)?
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11%
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What % of elemental iron is ferrous fumurate (feostat)?
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33%
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What % of elemental iron is carbonyl?
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100%
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What % of elemental iron is Polysaccharide-iron complex (niferex)?
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100%
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coffee increases or decreases absorption of iron?
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decreases
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tea increases or decreases absorption of iron?
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decreases
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milk products increases or decreases absorption of iron?
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decreases
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eggs increases or decreases absorption of iron?
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decreases
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whole-grain breads increases or decreases absorption of iron?
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decreased
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bicarbonates increases or decreases absorption of iron?
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decreases
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carbonates increases or decreases absorption of iron?
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decreases
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oxalates increases or decreases absorption of iron?
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decreases
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phosphates increases or decreases absorption of iron?
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decreases
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antacids increases or decreases absorption of iron?
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decrease
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H2RA increases or decreases absorption of iron?
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decreases
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PPI increases or decreases absorption of iron?
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decreases
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citric acid increases or decreases absorption of iron?
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increases
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lactic acid increases or decreases absorption of iron?
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increase
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ascorbic acid increases or decreases absorption of iron?
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increase
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What are the side effects associated with iron supplementation?
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epigastric distress, abdominal cramping, nausea, diarrhea or constipation, dark stools
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What are the patient education points for iron supplementation?
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Best to take on an empty stomach, if gi upset can minimize by taking with food or taking small amount more freq, may need to start stool softener, adequate intake of liquids, do not take with milk or antacids (2h before or 2h after), keep out of reach of children
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What are the indications for parental iron therapy?
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severe iron malabsorption, noncompliance with oral therapy, sever intolerance to oral therapy, chronic uncorrectable bleeding, diminished erythropoesis such as pts on renal dialysis
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Which IV iron product requires a test dose?
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Iron dextran
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What are the SE associated with Iron Dextran?
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Fever, malaise, flushing, myalgias (higher prevalence with total dose infusion), anaphylaxis
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What are the SE associated with IV ferric gluconate?
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Cramps, N/V, flushing, hypotension, rash, pruritis, hypersensitivity (rare)
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What are the SE associated with IV iron sucrose (venofer)?
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Cramps,
hypotension, nausea, vomiting, diarrhea, headache |
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What is a potential problem with iron supplementation with Ferumoxytol (Feraheme)?
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May alter MRI imaging
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When are blood transfusions indicated in anemia?
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if pt is symptomatic, hgb <8g/dl (or <10g/dL if cardia or pulm pt)
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What does 1 unit of pRBC raise Hgb by?
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1g/dl
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How should therapy be monitored in iron replacement in IDA?
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reticulocyte count in 1 week, reevaluate after 3-4 wks of oral therapy
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How long does it take for IDA to correct?
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around 6 weeks, however need to continue therapy 3-6 months after Hgb normalized to replete iron stores
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What is are the classifications of megaloblastic anemias?
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vit b12 deficiency or folic acid deficiency
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What is the primary source of b12?
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animal protein
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How much b12 is taken in a typical diet?
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5-15 mcg/d
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How much b12 is typically lost per day?
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1 mcg
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What are the total body store of b12?
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2000-5000mcg (large body stores, so will take 3-4 years before sx develop)
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What is the purpose of intrinsic factor in relation to b12?
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aids in absorption
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Can a person absorb b12 without intrinsic factor?
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yes, evidence supports existence of alternative system for absorption of B12 that is independent of intrinsic factor
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What are the functions of b12?
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essential for hematopoesis, maintenance of myelin throughout the entire nervous system, production of epithelial cells
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What is the function of transcobalamin II?
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resposible for transporting b12 through cell membranes and delivering it to the liver and other organs
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What are the etiologies of b12 deficiency anemia?
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inadequate intake (rare), malabsorption syndromes, lack of intrinsic factor (pernicious anemia), long term use of acid suppression therapy, other gi causes (crohn's disease)
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What are the specific signs of B12 deficiency anemia?
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decreased serum b12, increased serum methylmalonic acid (MMA) and homocysteine levels, increased MCV, mild leukopenia, thromnocytopenia, decreased reticulocyte, possible elevated LDH and bilirubin
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What are the specific symptoms of B12 deficiency anemia?
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neurologic: depressed, deep tendon reflexes, ataxia, loss of vibration and position sense; glossitis, muscle weakness, dysphasia, anorexia, psychiatric (irritability, personality change, impaired memory, depression), CV (possible increase risk of MI and stroke)
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What is the oral dosing tx for b12 deficiency anemia?
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1000-2000mcg/d x 1-2 wks then 1000mcg/d x life
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What is the parental dosing tx for b12 deficiency anemai?
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1000 mcg IM or deep SC injection daily for 1 week, weekly for 1 month, then monthly for life
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When is parental b12 preferred over oral?
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Preferred over oral in pts w/ neurologic sx until resolution of sx and hematologic indices
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What is the place in therapy for intranasal b12?
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only for maintenance therapy
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Should oral b12 be used for initial tx of b12 deficiency anemia?
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no
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What are the monitoring parameters in b12 deficiency anemia?
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1. reticulocytes in 5-7 days 2.
LDH and bilirubin—should normalize in 1-3 weeks 3. S/sx (CNS sx reversible if <6 mo duration) 4. CBC and serum B 12 level within 1-2 mo after initiation and then q 3-6 months (Hematologic picture normalizes within 2 mo) 5. MMA and homocysteine repeated 2-3 mo after initiation of replacement therapy |
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What are common folic acid food sources?
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fresh green vegetables, fruits, yeast, animal protein
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What is the min daily adult requirement for folic acid?
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50-100mcg/d (400mcg in nonpregnant females)
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What is the min daily of folic acid requirement for pregnant women?
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600mcg (500mcg for lactating)
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How large are folic acid stores?
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small: 5-10mg
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How long does anemia take to occur in decreased folic acid intake?
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3-4 months
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What are possible etiologies for folic acid deficiency anemia?
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inadequate intake, alcoholism, pregnancy, conditions of rapid cell turn over (hemolytic anemias, leukemias, lymphomas), chronic hemodialysis, disease that imprair absorption from the small intestine, extensive jejunal resection, drugs that alter folate metabolism (oral contraceptives, TMP, sulfasalazine, methotrexate)
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What are the symptoms of folic acid deficiency anemia?
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same as b12 but no neurologic sc
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What are the labs of folic acid deficiency anemia?
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increased MCV, decreased serum folate conc, increased homocysteine level, mild leukopenia thrombocytopenia, decreased reticulocyte, LDH and bilirubin may be increased
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What is the tx for for folic acid deficiency anemia?
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1mg po qd x 4 months
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What are possible drug interactions of folic acid?
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decreases effect of phenytoin; phenytoin, primidone, para-aminosalicylic acid and sulfasalazine may decrease serum folate levels
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What is the recommended dosing of folic acid in pregnancy and prior to conception to prevent neural tube defects?
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800-1000mcg
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In folic acid deficiency anemia tx, what is the monitoring note on reticulocyte count?
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count—start to increase by day 2-3 days and peak with day 5-8
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In folic acid deficiency anemia tx, what is the monitoring note on HgB/Hct?
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Hgb/Hct should rise within 2 weeks and should normalize within 1-2 months
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In folic acid deficiency anemia tx, what is the monitoring note on LDH and bilirubin?
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LDH and bilirubin—should normalize in 1-3 weeks
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What are the etiologies of anemia of chronic disease (anemia of inflammation)?
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Chronic infections (ie. endocarditis, osteomyelitis, HIV)
Chronic inflammatory conditions (ie. rheumatoid arthritis) Malignancies Hepatic dysfunction Renal dysfunction—often Anemia of Renal Disease is discussed separately Includes acute diseases as well—diseases lasting less than 10 days |
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What are the signs specific for anemia of chronic disease?
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serum fe decreased, tibc normal or increased, ferritin normal or increased
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What is the tx for anemia of chronic disease?
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Treat underlying cause
Concurrent IDA may exist Erythropoetin stimulating factors often used in HIV and cancer pts (non-myeloid malignancies) -Epoetin alfa -Darbepoetin alfa |
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What is the dosing for Epogen/Epoetin Alfa?
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50-100 u/kg 3 x/week; maintenance at around ½ induction dose can be given 1-3 x/week
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What is the time to response for Epogen?
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2-8 wks
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What are the dose adjustments for epogen?
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reduce dose by 25% if increased more than 1 g/dL in 2-week period
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What are the SEs related to epogen?
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HTN, HA, arthralgias
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What is the black box warning on epogen about?
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increased risk of death and serious and life-threatening CV events seen in pts who had target Hgb>12
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What is the dosing for Aranesp/Darbepoetin Alfa?
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0.45 mcg/kg once weekly, titrated to limit increases in Hgb to <1 g/dL over any 2-week interval
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What are the dose adjustments for Aransep/Darbepoetin Alfa?
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If Hgb increased is < 1g/dl over 4 weeks, increase dose by 25%
decrease dose by 25% if Hgb increases > 1g/dL in any 2 week period or exceeds 12 g/dL Increases should not be made more frequently than once a month |
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What are the SEs for Aranesp/Darbepoetin Alfa?
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diarrhea, HA, HTN, hypotension, infection, myalgia
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What is the black boxed warning on Aranesp?
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increased risk of death and serious and life-threatening CV events seen in pts who had target Hgb>12
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