Term
|
Definition
below normal concentration of Hb in body;
Men: Hb <13 mg/dL
Females: Hb <12 mg/dL
Results in reduction of O2 carrying capacity of blood --> decreased Hb or decreased # of RBCs |
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Term
| Consequences of Chronic Anemia |
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Definition
decreased quality of life;
decreased survival;
increased risk of cardiac complications |
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Term
| Vitamin B12 deficiency & folic acid deficiency anemias |
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Definition
| macrocytic megaloblastic anemias |
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Term
| iron-deficiency anemia, sickle cell anemia, thallassemia |
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Definition
| microcytic hypochromic anemias |
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Term
| recent blood loss, hemolysis, bone marrow failure, anemia of chronic dx, renal failure anemia |
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Definition
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Term
|
Definition
90% produced in kidneys;
initiates & stimulates production of RBCs;
MoA: prevents apoptosis of erythroid precursor cells to allow for proliferation & subsequent maturation;
Decrease in tissue O2 conc. --> increase in production of this & release into plasma |
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Term
|
Definition
| time it takes for entire process of formation of RBCs from erythroid precursor cells |
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Term
|
Definition
| normal survival time of RBCs |
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Term
| Patient Evaluation of Personal History for Diagnosis |
|
Definition
Evaluate pt hx, PhEx/clinical presentation, & Lab tests;
Duration of anemia, family hx, social hx, exposure to toxic chemicals, menstrual hx, bowel hx, renal & hepatic dx, diet, previous blood transfusions, peptic ulcers, GI tract malignancies |
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Term
| Clinical Presentation of Acute-Onset Anemias |
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Definition
tachycardia (decreased systemic vascular resistance w/ severe intravascular blood loss);
lightheadedness; palpitations;
angina; hypotension; dyspnea |
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Term
| Clinical Presentation of Chronic Anemia |
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Definition
Present after 1-2 months:
weakness; fatigue; HA; vertigo;
faintness; symptoms of HF;
sensitivity to cold; loss of skin tone & pallor;
May initially present as asymptomatic |
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Term
|
Definition
CBC w/ Hb, Hct, WBC count, & platelets;
RBC count & MCV; Peripheral smear;
Stool sample for occult blood; |
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Term
|
Definition
Males: 14-17.5 g/dL;
Females: 12.3-15.3 g/dL;
An estimate of O2 carrying capacity of blood. |
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Term
|
Definition
Males: 42-50%
Females: 36-45%;
Decreased Hct --> decrease in # of RBCs or an increase in plasma volume |
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Term
|
Definition
50 - 150 mcg/dL;
Concetration of iron bound to transferrin;
Decreased in IDA & anemia of chronic dx; |
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Term
| Total Iron Binding Capacity (TIBC) |
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Definition
250-410 mcg/dL;
measures capacity of transferrin to bind to iron;
Usually higher when Fe stores are low; |
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Term
| Transferrin Saturation (TSAT) |
|
Definition
30-50%;
= (serum Fe/TIBC) x 100;
Reflects extent to which Fe-binding sites are vacant on transferrin & indicates amount of Fe readily available for erythropoeisis; |
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Term
|
Definition
<10 - 20 mcg/L;
Indicates amount of Fe stored in liver, spleen, and bone marrow cells;
Best indicator of Fe deficiency or iron overload; |
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Term
|
Definition
Plasma: 3.1-12.4 ng/mL;
RBC: 125 - 600 ng/mL;
Decreased levels = Folate deficiency megaoloblastic anemia |
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Term
|
Definition
180 - 600 pg/mL;
Used to determine vitamin B12 deficiency;
May be falsely low in folate deficiency, pregnancy, & oral contraceptives use |
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Term
|
Definition
increase Hb level:
improve RBC O2 carrying capacity,
alleviate symptoms,
prevent anemia complications |
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Term
|
Definition
vital nutrient in development of functioning erythrocytes;
essential for formation of hemoglobin |
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Term
| Groups at high risk for Iron Deficiency Anemia |
|
Definition
children <2 yrs old;
adolescent girls;
pregnant females;
elderly >65 yrs old |
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Term
|
Definition
inadequate iron intake (dietary deficiency);
when demand > intake (blood donations, endurance sports, menstruation, pregnancy & lactation, infancy & adolescence [growth spurts]);
active bleeding/large blood loss;
inadequate absorption (drug or food interactions, gastrectomy, malabsorptive states);
impaired utilization; |
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Term
| Recommended Daily Allowances of of Iron |
|
Definition
Males: 8 mg;
Postmenopausal Females: 8 mg;
Menstruating Females: 18 mg;
Children & Pregnant Women require higher amounts: 30 mg/day for primary prevention of IDA; |
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Term
|
Definition
Best absorbed in Fe2+ (ferrous) form;
Fe3+ is ionized in stomach acid, then reduced to Fe2+ form --> 10-20% absorbed in duodenum & jejunem via intestinal mucosal cell uptake |
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Term
|
Definition
| amount of iron found in a normal western diet |
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Term
|
Definition
decreased serum Fe;
decreased serum ferritin;
decreased TSAT%;
INCREASED TIBC |
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Term
|
Definition
decreased Hb;
decreased Hct;
peripheral smear: microcytosis, hypochromia |
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Term
|
Definition
appear when Hb < 9 g/dL:
General symptoms - HA, cardiovascular, SOB;
glossitis (smooth, sore tongue);
reduced salivary flow;
pica (compulsive eating of nonfood items);
pagophagia (compulsive eating of ice);
koilonychia (spoon shape form to fingernails);
GI - nausea, anorexia, constipation |
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Term
|
Definition
Treat underlying causes - severity & cause determines approach;
Replenish Fe stores;
Initial Tx:
1) dietary supplementation w/ iron-rich foods;
2) administer oral Fe therapy - 200 mg elemental Fe daily;
3) Parenteral therapy if indicated |
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|
Term
| 200 mg elemental iron daily in 2-3 divided doses (maximize tolerability) |
|
Definition
recommended oral iron dose for pts with IDA;
depends on pt's ability to tolerate iron preparations;
tolerance improves w/ small initial dose & gradual escalation to full dose; |
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Term
| Recommendations for pts who cannot tolerate recommended oral iron dose (200 mg) |
|
Definition
smaller amounts are usually sufficient to replace stores but at a slower rate;
take at bedtime;
try a different formulation;
take with food --> decreases absorption by 50% but decreases GI side effects |
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Term
| sodium ferric gluconate (Ferrlecit) |
|
Definition
Ferrlicit;
NO Black Box Warning;
NO test dose required;
ADRs: cramps, nausea, vomiting, flushing, hypotension, rash, pruritus, upper gastric pain |
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|
Term
| iron dextran (InFeD, DexFerrum) |
|
Definition
InFeD, DexFerrum;
For pts w/ DOCUMENTED Fe DEFICIENCY;
Black Box Warning: anaphylactic-type rxns - Test dose required;
ADRs: pain & brown staining at injection site, flushing, hypotension, fever, chills, myalgia, anaphylaxis;
Equation used to determine amt needed:
Dose (mL) = 0.0442 (Desired Hb-Observed Hb) x IBW + (0.26xIBW) |
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Term
|
Definition
Venofer;
NO test dose required;
Black-Box Warning: anaphylactic-type rxns;
ADRs: leg cramps, hypotension |
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Term
|
Definition
Faraheme;
NO test dose required;
For pts with IDA AND CKD;
ADRs: hypotension, dizziness, constipation, nausea, peripheral edema |
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Term
| epoetin (Epogen, Procrit) |
|
Definition
1st line therapy for Anemia of CKD after ruling out other deficiencies;
Starting Dose:
SC - 80-120 units/kg/wk divided 2-3x/wk
IV - 120-180 units/kg/wk divided 2-3x/wk
Half-life = 27 hrs |
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Term
|
Definition
1st line therapy for Anemia of CKD after ruling out other deficiencies;
INCREASED duration of action;
ADV: less frequent dosing;
DISADV: longer time period to see effect;
Dosing:
Starting - 0.45 mcg/kg SC OR IV once weekly;
Half-life = 43 hrs --> less frequent dosing, weekly OR every other week;
Beneficial in pts in nondialysis CKD & pts who receive peritoneal dialysis; |
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Term
| Equation used to determine appropriate dose of parenteral iron (Iron Dextran) in pts w/ IDA or anemia 2ndary to blood loss |
|
Definition
Dose (mL) = 0.0442 (Desired Hb-Observed Hb) x IBW + (0.26xIBW)
Where Hb is 12 g/dL and dose is in mL, so must multiply by 50mg/mL of iron dextran to obtain mg dose.
Remember: iron dextran supplied as 50mg/mL |
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Term
|
Definition
| ferrous sulfate, ferrous gluconate, ferrous fumarate, polysaccharide iron complex, carbonyl iron |
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Term
|
Definition
20% elemental percentage;
elemental amount provided: 60-65 mg per 324-325 mg tablet;
formulation of choice for treatment of IDA b/c of tolerability, effectiveness, & low cost |
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Term
| Adverse Rxns to Oral Iron Products |
|
Definition
GI - dark discoloration of feces, CONSTIPATION, abdominal cramping, N/V;
-dose related; |
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Term
| Response to Oral & Parenteral Iron Therapy |
|
Definition
should be seen in 7-10 days;
Hb should rise 2-4 g/dL q3 weeks;
Reassess if Hb DOES NOT increase by 2 g/dL in 3 wks;
Administer 1 hr before or 2 hrs after meals;
Addition of ascorbic acid (vitamin C) 500-1000mg may INCREASE Fe absorption by 10% but if taken on empty stomach--> more GI side effects |
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Term
| Drugs that Decrease Oral Fe Absorption |
|
Definition
Al-, Mg2+, and Ca2+-containing antacids;
tetracycline, doxycycline;
H2-antagonists;
PPIs;
Cholestyramine;
caffeine |
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Term
| Drugs Affected by Oral Iron |
|
Definition
decreased L-dopa;
decreased methyldopa;
decreased levothyroxine;
decreased penicillamine;
decreased fluoroquinolones;
decreased tetracycline & doxycycline;
decreased mycophenolate |
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Term
| Counseling Pts for Oral Iron Therapy |
|
Definition
Keep out of reach of children;
Take on an empty stomach - at least 1 hr before meals;
Take 2 hrs before or after antacids, PPIs, and H2-antagonists, Ca supplements, fluoroquinolones, & tetracyclines;
Combine with stool softener or laxative to prevent constipation;
Liquid preparations --> teeth discoloration, can mix w/ fruit juice or milk, drink with straw; |
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Term
| Common causes of Tx Failure in pts taking Oral Fe Therapy |
|
Definition
poor pt adherence;
inability to absorb Fe;
incorrect diagnosis;
continued bleeding;
concurrent condition that impairs full reticulocyte response |
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Term
|
Definition
| amount of time oral treatment for IDA should be continued after anemia is resolved --> allows for repletion of Fe stores to prevent relapse |
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Term
| Indications for Parenteral Fe Therapy |
|
Definition
evidence of iron malabsorption;
intolerance to oral administration;
Long-term nonadherence suspected;
pts w/ significant blood loss who refuse transfusions; |
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Term
| NO, parenteral does not provide a quicker hematological response than oral Fe therapy |
|
Definition
| Does parenteral iron lead to a quicker hematological response than oral iron? |
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Term
| vitamin B12 deficiency anemia |
|
Definition
| before treating folic acid deficiency anemia, this anemia MUST be ruled out |
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Term
| Etiology of Vitamin B12 Deficiency Anemia |
|
Definition
inadequate intake (RARE) - diet is only source;
decreased absorption - pernicious anemia (lack of intrinsic factor 2ndary to immune destruction of gastric mucosa);
inadequate utilization - transcobalamin II deficiency, renal glomerular dx, liver dx;
HYPERutilization - hyperthyroidism, pregnancy; |
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Term
| Physical Findings of Vitamin B12 Deficiency Anemia |
|
Definition
glossitis;
dysphagia;
anorexia/weight loss;
beefy red tongues; |
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Term
| Neurologic Findings of Vitamin B12 Deficiency Anemia |
|
Definition
numbness;
paresthesias;
peripheral neuropathy;
ataxia;
diminished vibratory sense;
increased deep tendon reflexes;
decreased proprioception;
imbalance |
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Term
| Psychiatric Findings of Vitamin B12 Deficiency Anemia |
|
Definition
irritability;
personality changes;
memory impairment;
dementia;
depression;
psychosis (rare) |
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Term
| Lab Value Findings for Vitamin B12 Deficiency Anemia |
|
Definition
decreased Hct;
INCREASED MCV;
INCREASED MCH;
decreased reticulocyte count;
decreased Vit. B12 level;
INCREASED iron & TSAT% |
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Term
| Peripheral Blood Smear for Vitamin B12 Deficiency Anemia |
|
Definition
macrocytosis;
hypersegmented polymorphonuclear leukocytes;
oval macrocytes;
anisocytosis;
poikilocytosis; |
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Term
| Goals of Tx for Vit. B12 Def. Anemia |
|
Definition
reversal of hematologic manifestations;
replacement of body stores;
prevention or resolution of neurological manifestations; |
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|
Term
|
Definition
Take 1-2 mg PO daily x 1-2 wks then 1 mg daily;
As effective as IM therapy in achieving hematological & neurological response;
AVOID time-released preps;
OTC is available; |
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Term
| Parenteral cyanocobalamin (IM) |
|
Definition
Initial: 1000 mcg/day x 2 wks, then 1000 mcg/wk until Hb WNL;
Maintenance: 1000 mcg/month;
Preferred route for pts exhibiting neurological symptoms; |
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Term
| Intranasal gell cyanacobalamin |
|
Definition
Inhale 500 mcg/wk (1 spray/wk);
AVOID in pts receiving meds intranasally in same nostril;
AVOID administering 1 hr before or after ingestion of hot foods or beverages;
ADV: pts who are homebound, have cognitive impairment, or dysphagia;
DISADV: efficacy not well studied, ONLY USED FOR MAINTENANCE therapy; |
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|
Term
| Adverse Events from Cyanacobalamin (RARE) |
|
Definition
| RARE - hyperuricemia, hypokalemia, injection site pain, pruritus, rash, diarrhea; |
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Term
| Monitoring Parameters for Tx w/ cyanacobalamin for Vit. B12 Deficiency Anemia |
|
Definition
1) neurologic symptoms - improvement in 24 hrs, may not completely resolve;
2) CBC improvement - Hb & Hct normalize within 6-8 wks, reticulocyte count INCREASES within 3-4 days, Check CBC every 3-6 months |
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|
Term
| Etiology of Folic Acid Deficiency Anemia |
|
Definition
1) inadequate intake - poor eating habits (elderly, teenagers, alcoholics, food faddists, low socioeconomic class);
2) malabsorptive syndromes;
3) medication use (drugs that directly inhibit DNA synthesis [azathioprine, 6-mercaptopurine, 5-fluorouracil, hydroxyurea, zidovudine] & drugs that are folate antagonists - methotrexate, pentamidine, trimethoprim, primidone);
4) inadequate utilization;
5) hyperutilization - pregnancy, chronic inflammatory dxs, long-term dialysis, burn pts, growth spurts; |
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|
Term
| Lab Value Changes in Folic Acid Deficiency Anemia |
|
Definition
decreased Hct;
INCREASED MCV;
INCREASED MCH;
decreased reticulocyte count;
DECREASED folic acid level;
DECREASED erythrocyte folic acid level;
increased serum iron & TSAT%; |
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Term
| Goals for Treatment of Folic Acid Deficiency Anemia |
|
Definition
induce hematologic remission;
replace body stores;
resolve signs & symptoms;
treat underlying disorder;
increase dietary intake; |
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|
Term
| Replacement Dosing for Folic Acid Deficiency Anemia |
|
Definition
1 mg daily x 4 months;
may continue if risk factors for deficiency are still present; |
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Term
| Maintenance Dosing for Folic Acid Deficiency Anemia |
|
Definition
| 0.1-0.4 mg daily - up to 0.8 mg for pregnant/lactating women (initial prevention: 0.4 mg/day) |
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Term
| Adverse Effects of Folic Acid Supplementation |
|
Definition
bitter/bad taste;
GI upset - nausea, flatulence, anorexia;
nontoxic at high doses --> rapidly excreted in urine |
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Term
| Monitoring Parameters for Treatment of Folic Acid Deficiency Anemia |
|
Definition
| CBC - MCV initially increases because of increases in reticulocytes |
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Term
|
Definition
a common form found particularly in elderly; results from:
Chronic inflammation - TB, HIV, bacterial endocarditis, osteomyelitis, chronic UTIs;
Chronic Inflammation - RA, SLE, IBD, IOA, gout, etc.;
Malignancies - carcinoma, lymphoma, leukemia, multiple myeloma |
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Term
| Lab Values for Anemia w/ Chronic Dx |
|
Definition
decreased iron;
decreased or WNL transferrin;
decreased TSAT%;
INCREASED or WNL serum ferritin;
WNL soluble transferrin receptor;
DECREASED or WNL TIBC; |
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Term
| Treatment Goals for Anemia of Chronic Dx |
|
Definition
Aimed at underlying pathology;
RBC transfusions reserved for Hb <8-10 g/dL;
Use erythropoeitin and iron supplementation in proper pts; |
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|
Term
| Indications for Erythropoeitin Use in pts w/ Anemia of Chronic Dx |
|
Definition
cancer receiving chemotherapy;
chronic kidney dx;
HIV pts receiving myelosuppressive therapy |
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|
Term
| Indications for Iron Supplementation in pts w/ Anemia of Chronic Dx |
|
Definition
iron deficiency;
pts receiving erythropoietic agents |
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Term
| Anemia of Chronic Kidney Dx |
|
Definition
common form of anemia in these pts;
normocytic, normochromic anemia;
Factors responsible:
DECREASED ERYTHROPOIETIN PRODUCTION, shorter life span of RBCs, blood loss during dialysis, Fe deficiency, ACD, renal osteodystrophy |
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|
Term
| Initiate in pts w/ Stage III CKD or higher: GFR <60 ml/min, Hb conc. <11 g/dL |
|
Definition
| When should one start anemia evaluation & treatment for pts with chronic kidney disease? |
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|
Term
| Target Hb Level for Pts w/ Anemia of CKD |
|
Definition
Hb >11-12 g/dL - NOTHING HIGHER THAN 12 g/dL!!!;
Hb >12 --> INCREASED cardiovascular events |
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|
Term
| Adverse Events with Erythropoeitin agents |
|
Definition
HYPERTENSION (most common);
seizures, thrombotic events, allergic rxns |
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Term
| Monitoring of Outcomes for Erythropoiesis Stimulating Agents - epoietin, darbapoietin |
|
Definition
Hb monitored every 1-2 wk, then every 2-4 wks when stable;
DO NOT change dose upwards more than every 4 wks;
Make adjustments in 25% intervals based on Hb levels;
Target Hb levels: 11-12 g/dL;
Withhold therapy if Hb >12 g/dL;
Pts who do not respond to therapy after 8 wks of optimal dosage should D/C |
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|
Term
| Common Causes of Indequate Response to ESA Therapy |
|
Definition
| IRON DEFICIENCY (most common), infection/inflammation, chronic blood loss, osteitis fibrosa, aluminum toxicity, hemoglobinemias, folate or B12 deficiency, multiple myeloma, malnutrition, hemolysis, vit. C deficiency hypothyroidism |
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|
Term
| Provide Iron Supplementation in Pts w/ Anemia of CKD |
|
Definition
check baseline iron before & during ESA treatment;
Most pts REQUIRE supplemental therapy;
Maintain Stores at:
TSAT >20%, serum ferritin >100 ng/mL (pts NOT receiving hemodialysis), serum ferritin >200 ng/mL (hemodialysis pts);
if BELOW goal indices --> recommend supplementation |
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|
Term
| IV Iron therapy recommended |
|
Definition
| For pts with Anemia of CKD, use this form of iron therapy |
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|
Term
| Indications for Oral Iron Therapy |
|
Definition
Pts w/ Anemia of CKD who DO NOT have IV access:
Pts w/ Stage III & IV CKD,
receiving peritoneal dialysis,
switch to IV if unable to manage |
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|
Term
| Evaluation of Therapeutic Outcomes w/ Iron Therapy |
|
Definition
for pts receiving ESA therapy, monitor Fe stores:
monthly in pts NOT receiving iron supplements,
EVEY 3 MONTHS in pts WHO ARE receiving Fe supplements;
When goal Hb is met (11-12 g/dL), monitor stores EVERY 3 MONTHS |
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