What are the 3 principal causes of iron deficiency (secondary to increased iron demand)

1.  Pregnancy - blood expansion

2. Blood volume expansion during infancy and early childhood

3.  Chronic blood loss - GI or uterine origin

What is the major consequence of iron deficiency?

Microcytic, hypochromic anemia

What is the drug of choice for iron deficiency?

Ferrous Sulfate

How do you treat patients who can't tolerate po iron formulations?

IV Iron Dextran.

What is the major adverse effects of ferrous sulfate?

GI disturbance

Best treated by decreasing dosage rather than giving with food with significantly reduces absorption.

What is the risk of using Iron Dextran IV?

Fatal anaphylactic reactions.

Risk much lower with other IV iron products like iron sucrose.

What is the principal cause of Vitamin B12 deficiency?

Impaired absorption secondary to lack of intrinsic factor.

What is the principal consequence of Vitamin B12 deficiency?

Megaloblastic (macrocytic) anemia and neurologic injury.

How is vitamin B12 deficiency treated?

Lifelong with Cyanocobalamin.  IM monthly, po daily, intranasal weekly.

Initial Therapy for Vit B12 Deficiency, what is given along with the cyanocobalamin?

Folic Acid

What do you risk when adding Folic Acid to B12?

Masked continued B12 deficiency because folic acid can improve heamtologic picture while allowing the neurologic consequences to progress.

What is the primary causes of folic acid deficiency?

Poor diet (as in alcoholics) and malabsorption secondary to intestinal disease.

What is the principal consequence of Folic Acid deficiency?

megaloblastic anemia and neural tube defects in developing fetus.

who is at highest risk for anemia?

Women

African Americans

Hospitalized individuals

Elderly

What is anemia?

Deficiency of oxygen carrying RBC's; decrease in number, hgb content or a change in size of erythrocyte.

what is hematopoiesis? 

What does it require?

the formation of blood or of blood cells in the living body

Iron, B12, folate and several growth hormoes, particularly erythropoietin

what is the most common cause of anemia?

Iron, folic acid, and vit B12 deficiencies

Anemia - Hbg level for

menstruating women?

men and menopausal women?

pregnant women?

menstruating women - < 12g/dL

men and menopausal women - < 14g/dL

pregnant women - <10-15

What are some common causes of anemia? 

chronic blood loss - hemolysis

bone marrow dysfunction

deficiency in essential cofactors

infection, maligancy, endocrine deficiencies,

other disease states

pregnancy

inherited causes

What other factors affect Hgb levels?

Age

Race

socioeconomic status

exposure to tobacco smoke

What causes anemia in pregnancy?

Increased plasma volume

How is a rapid acute onset of anemia likely to present? (symptoms)

Cardio-respiratory

Tachycardia, hypotension, palpitations, lightheadness, breathlessness, orthostasis

What are the common symptoms of chronic anemia?

Fatigue, dizziness, exertional dyspnea, loss of libido, mood disturbance, sleep disturbances, tinnitus, and weakness.

What are the common symptoms of anemia in infants?

Irritabiity, poor feeding, and tachycardia

How is anemia classified?

According to the SIZE of the circulating erythrocytes.

Iron Deficiency - Microcytic anemia

B12 Deficiency/Folic Acid Deficiency - Macrocytic aka Megablastic anemia, aka pernicious

Who has the highest dietary requirements for iron?

infants and pregnant women

What causes Iron Deficiency Anemia?

what is the morphology?

Blood Loss

Rapid Growth

Pregnancy

Lactation

Menses

Morphology - microcytic / hypochromic erythrocytes

What are some food sources of iron?

meats, vegetables, & grains, ferrous compounds

How do you treat iron deficiency anemia?

replace depleted iron stores

raise iron in Hgb

Sources:

meats, veggies, grains

ferrous compounds

What is the choice agent for iron deficiency anemia?

Ferrous Sulfate

What is the most common SE of ferrous sulfate?

GI Disturbance - nausea - take with meals

Absorbs best in acidic environment

Does enteric coated or sustained release work as well as regular ferrous sulfate?

No, dissolving beyong the duodenum has little chance for absorption

How long does it take for a pt to respond to iron therapy?

2 days - increased energy and appetite

1 week - increase in reticulocyte count

6 months - restore storage sites

what are common side effects at therapeutic dose of ferrous sulfate?

Epigastric pain, n/v, diarrhrea, constipation and black stools.

What is the most SERIOUS side effect?

Potentially lethal toxicity

What drugs decrease absorption of iron?

food, antacids, PPI's, H2 antagonists, bile-acid binding drugs

What drugs effectiveness is decreased by iron?

tetracycline, levothyroxine, Vit E

How long does it take and at what does to reverse iron deficiency anemia?

4-6 months of oral iron at bid or tid dosage.

What is a common side effect in children?

Acute diarrhea - can be serious!

What are 5 rules of thumb for taking/giving iron?

1.  Ferrous compounds best

2.  take po ac or pc, liquid with straw to avoid staining teeth

3.  Instruct on foods high in iron

4.  consider giving anticonstipation agent

5.  Monitor CBC every 4-6 mos (ife of erythrocyte is 120 days)

What do you give when can't to po is ineffective/intolerable?

IV or IM (Z-track) Iron Dextran

What has Iron Dextran been associated with?

Fatal anaphylactic reactions

What are some of the complications of IM Iron Dextran?

pain, inflammation, sterile abscesses, and brown discoloration of skin (usually due to poor technique)

What are symptoms of accidental poisoning with Iron Dextran?

lethargy

n/v, abdominal pain, diarrhea, convulsions, pallor, cyanosis

What is a lethal dose of Iron for children?

2-10 Gm elemental iron

S&S can occur within mins to hours of swallowing tablets

What are the s&s of overdose in children?

n/v, diarrhea, and gi bleeding which can lead to shock, coma, and death.

How do you treat overdose?

1.  Induce vomiting with ipecac or lavage sodium bicarb

2.  antidote - deferexamine - avoid if in renal failure

3.  may use exchange transfusion

What causes megaloblastic (aka pernicious) Anemia?

B12 deficiency indicating defect in vit b12 absorption and transport chain

or folic acid deficiency

what are the symptoms of B12 (pernicious anemia) deficiency?

Same as iron deficiency anemia

GI, wt loss, fatigue, glossitis, lightheadedness, jaundice, neurological symptoms, neuropsychiatric symptoms, yellow blue color blindness

what is b12 deficiency usually associated with?

lack of intrinsic factor

malnutrition or strict vegetarian

total gastrectomy, distal ileium

enteritis

celiac disease

How do you give B12 supplements?

Usually IM because don't have intrinsic factor to absorb in gut.

Can give po but no intrinsic factor, nasal spray,

What are the major indications for folic acid?

1. prophylaxis in pregnancy

2. folate deficiency

3.  initial treatment of severe B12 deficiency

4.  poor nutritioin

5.  malabsorption syndrome

6.  drugs

7.  alcohol abuse

8.  anorexia

What is one risk of folic acid treatment?

May mask B12 deficiency - folate can correct pernicious anemia but leave neurologic damage untreated

What drugs impede the absorption of folic acid?

Methotrexate, BCP's, and anticonvulsants.

What drugs can be given to stimulate RBC production?

Epoetin Alpha (Epogen, Procrit, Aranesp)

What is the risk of increasingHgb levels above 12 gm/dL?

Increase risk of hypertension, stroke, MI, HF, and death