ANEMIA AND IRON DEFICIENCY ANEMIA

List microcytic, normcytic, macrocytic

* Mean cell volume (MCV) < 70 fl is due to iron deficiency or thalassemia **MCV > 125fl is megaloblastic anemia or myelodysplasia ***Also note: NEWBORNS usually have a high hemoglobin at birth and then drop because of rapid growth/ blood volume, and the RBC life span in 90 days, and erythropoietin is low

How is iron dextran (3) given and what are the ADRs (3)?

- Im or IV (preferred IV) - Test dose if first time receiving - ADRs • Flushing • Diaphoresis • Nausea/vomiting/diarrhea

Why is a test dose required for many IV iron products? (2)

- This is to see if PT can tolerate the iron products without strong adverse effects - Also to make sure patient does not overload on iron

How is Ferumoxytol (Feraheme)) given (5)and what are the ADRs (4)?

- Tx for pts with chronic kidney Dz - Iron replacement therapy via rapid IV infusion - 2 doses requires for usual iron replacement requirements - No test dose needed - ADRs • Hypotension • Headache • N/V/D • Potential anaphylaxis

How is Iron sucrose (Venofer) or Ferric Gluconate (Ferrlecit) given (4)and what are the ADRs (4)?

- Tx for pts with kidney disease who are on an ESA (erythropoiesis-stimulating agents) - IVPB or slow IVP (IVPiggyback preferred because it goes through IV line) - No test dose needed but done anyway - ADRs • Hypotension • Headache • N/V/D • Potential anaphylaxis

What are some causes of anemia? (3)

1- Congenital Anemia 2- Poor diet 3- Bleeding (common cause in adults)

Remember, it is a good idea to treat the anemia, but you have to find out the cause and fix that too! Treatment Principle:

1- Correct the underlying problem 2- Administer iron 3- Document the response

What are some DDIs with oral iron? What is the mechanism of these DDIS? (3)

1- Decrease Fe absorption (inc pH or form complex): Food: milk, fiber, antacids, H2 blockers Meds: Levodopa, methyldopa, thyroid supplements, quinolones, tetracyclines 2- Increases Fe absorption: Vitamin C 3- Fe may cause false positive in FOBT

Stages of Anemia (4)

1- Depletion of storage pools 2- Decrease in serum iron 3- Microcytosis 4- Hypochromasia

Describe how oral iron is taken. This is important. (3)

1- Ferrous sulfate 3x a day; which provides 180mg of iron daily of which up to 10mg is absorbed 2- Introduce the medicine more slowly in a gradual escalating dose 3- Often lower doses are given to allow for compliance

What is the expected response? How long should therapy continue?

1- Hemocrit values should return halfway toward normal within 3 weeks and full after 2 months 2- Iron therapy should last 3-6 months

List the available IV iron preparations. (3)

1- Iron dextran ( Dexferrum) 2- Iron sucrose (Venofer) or Ferric Gluconate (Ferrlecit) 3- Ferumoxytol (Feraheme)

Other signs of Anemia: (10)

1- Jaundice 2- Cholelithiasis 3- Spleomegaly 4- Pregnancy 5- Paresthesias 6- Glossitis 7- Bone Pain 8- Malignancy 9- Syncope/ Orthostatic Hypotension

List 4 physical exam findings that may indicate hematologic disease.

1- Lymphadenopathy 2- Hepatospenomegaly 3- Bone tenderness 4- Mucosal changes; such as smooth tongue (suggest megaloblastic anemia)

Describe the blood smear on iron def anemia. (3)

1- Microcytic & hypochromic RBCs 2- Further progression: Anisocytosis and Poikilocytosis 3- Severe progression: target cells, pencil shaped cells, small amount of nucleated cells

1- What is the onset of action of oral iron therapy? 2- How long should it be continued in someone with IDA?

1- Onset of action: 3-10 days 2- Continue Therapy for 3-6 months for complete restoration of iron stores. May need up to 12 months

What are some important counseling points for someone on oral iron? (4)

1- Potential side effects 2- Potential for poisonings in children 3- Take in divided doses to improve absorption 4- Take on an empty stomach with water or juice (may take with food if not tolerated otherwise)

How are anemias classified? (2 ways)

1- Related to diminished production 2- According to red blood size

What are the risk factors for and the causes of Iron Deficiency Anemia? (7) A M P G G R S

A- Age: infants, adolescents, menopausal women, and old age M- Medications: ASA and NSAIDS P- Physiological: Pregnancy, breast feeding G- GI: Appetite or weight changes, changes in bowl habit, GI Bleed, gastric/bowel surgery G- Gender: women R- Renal: Renal failure, hematuria (rare) SH- Diet: especially vegetarians

What are an advantage and a disadvantage of slow-release formulations of oral iron?

Advantage: Claim to have better GI tolerance Disadvantage: Absorbed past the duodenum and jejunum; decreased absorption, decreased effect

List the signs and symptoms of iron def anemia.

As a general rule...Iron deficiency anemia are those of anemia itself Look above

Until proven otherwise, what is the assumed cause of iron def anemia in adults?

Bleeding

What is "the most important" cause of iron deficiency anemia?

Blood loss; especially gastrointestinal bleeding

With what other ingredients is iron often combined? What is the purpose of these combinations? (3)

Combo Products: 1- Vitamin C: used to increase absorption rate - 1g increases absorption by 10% lower doses not significant 2- Contain Vitamin C, folic acid, and B12: 3- Stool softeners: decrease constipation

Describe PICA. This is kind of cool - it is sometimes the first presenting symptom!

Craving for specific foods associated with iron deficiency: Ice chips Clay dirt Starch Salt

Where in the GI tract is iron absorbed?

Duodenum and upper jejunum

What are some factors that decrease absorption of iron? (10)

F- Ferric form of iron F- Food A- Alkaline GI A- Antacids G- Green Tea G- Good iron status C- Chronic Inflammation C- Chronic Diarrhea D- Dietary phosphates M- Malabsorption

List the various oral iron salts and their percent of elemental iron. (3)

F- Ferrous Fumarate; 30% F- Ferrous Sulfate; 20% F- Ferrous Gluconante; 10%

What are the indications for IV iron therapy? (3)

Failure to respond to oral therapy because of: 1- Noncompliance 2- Malabsorption 3- Continuing blood loss > rate of RBC production

What protein is responsible for its storage? Where is it stored?

Ferritin; Stored in liver and heart

Which patients should receive parenteral iron? What is the risk associated w/ parental iron?

Indications: 1- Intolerance to oral iron 2- Refractoriness to oral iron 3- Gastrointestinal disease 4- Blood loss that cannot be corrected Risks 1- Anaphylactic reactions

What is hemoglobinuria? Why would it lead to iron def anemia?

Iron in urine; Iron will be excreted in the urine

What treatments are available for iron overload?

Iron overload is when serum iron levels are >300mcg/ml Treatments are Iron Chelators 1- Deferoxamine (Desferal) IV 2- Deferasirox (Exjade) PO - Take on an empty stomach 30 minutes before meals

What are some factors that increase absorption of iron? (8) P-P-I-C-A-A-F-E

P- Pregnancy P- Pyridoxine deficiency I- Iron deficiency C- Chelates (sugars and low MW aa's) A- Acidic GI A- Ascorbic acid F- Ferrous form of iron E- Empty Stomach

What is the treatment dose of iron for IDA? What is the prevention dose? ***HELP

Prophylaxis: 60 mg of daily of elemental iron Treatment: 200 mg daily of elemental iron

Define Plummer-Vinson syndrome.

Results from dysphagia because of the formation of esophageal webs

Lab findings: is each of the following hi, lo, or normal in a pt with iron def anemia? Serum ferritin: Serum iron: Transferrin: MCV:

Serum ferritin: low Serum iron: low Transferrin: high MCV: low

What protein is responsible for the transport of iron?

Transferrin

About how much iron do we absorb and lose in a day?

We absorb 1 mg/day and loose 1 mg/day