anemia
WHO criteria for definition of anemia in adults > age 18: - Answer HGB < 13 g/dL for
males
HGB < 12 g/dL for non pregnant females
HGB < 11 g/dL for pregnant females
distinguish 3 types of anemia - Answer Most common approach to classification is
based on Mean Corpuscular Volume (MCV) level:
Microcytic anemia: MCV < 80 fL
Normocytic anemia: MCV 80 - 99 fL
Macrocytic anemia: MCV > 100 fL
How to Evaluate/Compare Current Status of Anemia - Answer Always look at previous
CBC results to see if the anemia is new, old, or progressive.
In addition to looking at RBC indices, look for other clues in the CBC:
Anisocytosis (Size variation)
Pokilocytosis (Shape variation)
WBC abnormalities
Initial approach/ questions to ask about the anemia - Answer Is the patient bleeding now
or in the past
Is there evidence for increased RBC destruction?
Is the bone marrow suppressed?
Is the patient iron deficient? If yes, why?
Is the patient deficient in folic acid, or vitamin B12? If yes, why?
Differential Diagnosis of Anemia by MCV classifications - Answer Microcytic anemia
MCV <80:
iron deficiency
Thalassemia
Anemia of chronic dz/chronic inflammation
Sideroblastic anemia
lead poisoning
Normocytic anemia MCV 80-99:
Sickle cell
Aplastic anemia
hemolytic anemia
Anemia of chronic dz/chronic inflammation
Macrocytic anemia>100:
b12 deficiency
folate deficiency
Evaluation of Microcytic Anemia (Mayo clinic) - Answer
Lab Values in Microcytic Anemias - Answer
,anemia
Other Clues r/t RBC Morphology - Answer
Iron Deficiency Anemia - Answer Most common type of anemia in the world.
Earliest indicator is low ferritin level.
S/S:
Often asymptomatic but may c/o fatigue, decreased exercise tolerance, weakness,
palpitations, irritability, headaches.
Possible Causes:
inadequate intake, malabsorption, increased requirements, blood loss, malignancies.
Reticulocyte Count in Iron Deficiency Anemia - Answer When bone marrow is
stimulated, reticulocytes are released prematurely.
Reticulocyte count is the best test to distinguish RBC underproduction from hemolysis.
High reticulocyte counts occur when the bone marrow is responding normally to blood
loss, hemolysis, or replacement of iron.
Normal reticulocyte count is 0.5 - 1.5%
Reticulocyte count should increase in 7-10 days with iron therapy and MCV should
normalize.
Most Common Etiologies of Iron Deficiency Anemia in Adults - Answer
Possible clinical findings in Iron Deficiency Anemia - Answer Conjunctival Palor
Angular Cheilitis
Koilonychia
pallor of palms and hands
decreased tongue papillae
Oral Iron Therapy - Answer Should not be given with food because phosphates,
phyates, and tannates in food bind the iron and impair its absorption.
Other factors that can impair absorption of iron:
Antacids, H2 receptor blockers, proton pump inhibitors, calcium-containing foods and
beverages, calcium supplements, certain antibiotics (quinolones; tetracycline) and the
ingestion of iron along with cereals, dietary fiber, tea, coffee, eggs, or milk
Iron should be given 2 hours before or 4 hours after ingestion of antacids
Iron is best absorbed as the ferrous (Fe++) salt in a mildly acidic medium so add a 250
mg ascorbic acid tablet or a half-glass of orange juice at the time of iron administration
to enhance absorption.
The least expensive preparation is ferrous sulfate that contains 65 mg of elemental iron
in a 325 mg tablet.
The recommended oral daily dose for the treatment of iron deficiency in adults is in the
range of 150-200 mg/day of elemental iron. So a single 325 mg ferrous sulfate tablet
taken orally tid between meals provides 195 mg of elemental iron per day.
, anemia
Comparison of Elemental iron in different oral preparations - Answer
Oral Iron Therapy: Dosing in Older Adults - Answer Ferrous sulfate elixir contains 44mg
of elemental iron per 5ml.
One preparation is: 10 ml of ferrous sulfate elixir (88 mg of elemental iron) mixed in
1/5th glass of orange juice taken 30 minutes before breakfast. The dose can be reduced
to 5ml if 10ml causes irritation. Also, a 50 or 100mg ascorbic acid tablet can be
substituted for the orange juice.
Side Effects of Oral Iron Therapy - Answer 50% or more of those taking oral iron
complain of nausea, constipation, diarrhea, epigastric distress and/or vomiting
Management:
patient may take an iron preparation with a smaller dose of elemental iron (i.e. switch
from ferrous sulfate to ferrous gluconate) or switch from tablet to liquid preparation.
Patient may slowly increase the dose from 1 tablet per day to the recommended 3
tablets per day
Pt. may try taking it with meals but that will decrease absorption by about 40%
Expected Response to Oral Iron Therapy - Answer Immediate disappearance of pica or
RLS
Improved feeling of well being within first few days of treatment
In patients with moderate to severe anemia, a modest reticulocytosis will be seen in 7-
10 days. Those with mild anemia may have no reticulcytosis.
Hemoglobin will rise slowly after approximately 1-2 weeks and will rise 2g/dL over
approximately 3 weeks.
The hemoglobin deficit should be halved by approximately 1 month and the hemoglobin
level should return to normal by 6-8 weeks.
Duration of Oral Iron Therapy - Answer Some disagreement about how long to treat:
Some providers stop iron treatment when the hemoglobin level becomes normal so that
further blood loss will alert them to the return of the problem that causes the iron
deficiency.
Others treat for at least 6 months following normalization of the hemoglobin in order to
replenish iron stores.
Failure to Respond to Oral Iron Therapy - Answer Coexisting diseases interfering with
marrow response (infection, inflammatory disorder, malignancy, uncorrected
hypothyroidism, coexisting folic acid or vitamin B12 deficiency)
Diagnosis of IDA is incorrect (Look for Thalassemia, lead poisoning, Anemia of chronic
disease/chronic inflammation, copper deficiency (zinc toxicity), Myelodysplastic
syndrome/refractory sideroblastic anemia
Patient is not taking the medication
WHO criteria for definition of anemia in adults > age 18: - Answer HGB < 13 g/dL for
males
HGB < 12 g/dL for non pregnant females
HGB < 11 g/dL for pregnant females
distinguish 3 types of anemia - Answer Most common approach to classification is
based on Mean Corpuscular Volume (MCV) level:
Microcytic anemia: MCV < 80 fL
Normocytic anemia: MCV 80 - 99 fL
Macrocytic anemia: MCV > 100 fL
How to Evaluate/Compare Current Status of Anemia - Answer Always look at previous
CBC results to see if the anemia is new, old, or progressive.
In addition to looking at RBC indices, look for other clues in the CBC:
Anisocytosis (Size variation)
Pokilocytosis (Shape variation)
WBC abnormalities
Initial approach/ questions to ask about the anemia - Answer Is the patient bleeding now
or in the past
Is there evidence for increased RBC destruction?
Is the bone marrow suppressed?
Is the patient iron deficient? If yes, why?
Is the patient deficient in folic acid, or vitamin B12? If yes, why?
Differential Diagnosis of Anemia by MCV classifications - Answer Microcytic anemia
MCV <80:
iron deficiency
Thalassemia
Anemia of chronic dz/chronic inflammation
Sideroblastic anemia
lead poisoning
Normocytic anemia MCV 80-99:
Sickle cell
Aplastic anemia
hemolytic anemia
Anemia of chronic dz/chronic inflammation
Macrocytic anemia>100:
b12 deficiency
folate deficiency
Evaluation of Microcytic Anemia (Mayo clinic) - Answer
Lab Values in Microcytic Anemias - Answer
,anemia
Other Clues r/t RBC Morphology - Answer
Iron Deficiency Anemia - Answer Most common type of anemia in the world.
Earliest indicator is low ferritin level.
S/S:
Often asymptomatic but may c/o fatigue, decreased exercise tolerance, weakness,
palpitations, irritability, headaches.
Possible Causes:
inadequate intake, malabsorption, increased requirements, blood loss, malignancies.
Reticulocyte Count in Iron Deficiency Anemia - Answer When bone marrow is
stimulated, reticulocytes are released prematurely.
Reticulocyte count is the best test to distinguish RBC underproduction from hemolysis.
High reticulocyte counts occur when the bone marrow is responding normally to blood
loss, hemolysis, or replacement of iron.
Normal reticulocyte count is 0.5 - 1.5%
Reticulocyte count should increase in 7-10 days with iron therapy and MCV should
normalize.
Most Common Etiologies of Iron Deficiency Anemia in Adults - Answer
Possible clinical findings in Iron Deficiency Anemia - Answer Conjunctival Palor
Angular Cheilitis
Koilonychia
pallor of palms and hands
decreased tongue papillae
Oral Iron Therapy - Answer Should not be given with food because phosphates,
phyates, and tannates in food bind the iron and impair its absorption.
Other factors that can impair absorption of iron:
Antacids, H2 receptor blockers, proton pump inhibitors, calcium-containing foods and
beverages, calcium supplements, certain antibiotics (quinolones; tetracycline) and the
ingestion of iron along with cereals, dietary fiber, tea, coffee, eggs, or milk
Iron should be given 2 hours before or 4 hours after ingestion of antacids
Iron is best absorbed as the ferrous (Fe++) salt in a mildly acidic medium so add a 250
mg ascorbic acid tablet or a half-glass of orange juice at the time of iron administration
to enhance absorption.
The least expensive preparation is ferrous sulfate that contains 65 mg of elemental iron
in a 325 mg tablet.
The recommended oral daily dose for the treatment of iron deficiency in adults is in the
range of 150-200 mg/day of elemental iron. So a single 325 mg ferrous sulfate tablet
taken orally tid between meals provides 195 mg of elemental iron per day.
, anemia
Comparison of Elemental iron in different oral preparations - Answer
Oral Iron Therapy: Dosing in Older Adults - Answer Ferrous sulfate elixir contains 44mg
of elemental iron per 5ml.
One preparation is: 10 ml of ferrous sulfate elixir (88 mg of elemental iron) mixed in
1/5th glass of orange juice taken 30 minutes before breakfast. The dose can be reduced
to 5ml if 10ml causes irritation. Also, a 50 or 100mg ascorbic acid tablet can be
substituted for the orange juice.
Side Effects of Oral Iron Therapy - Answer 50% or more of those taking oral iron
complain of nausea, constipation, diarrhea, epigastric distress and/or vomiting
Management:
patient may take an iron preparation with a smaller dose of elemental iron (i.e. switch
from ferrous sulfate to ferrous gluconate) or switch from tablet to liquid preparation.
Patient may slowly increase the dose from 1 tablet per day to the recommended 3
tablets per day
Pt. may try taking it with meals but that will decrease absorption by about 40%
Expected Response to Oral Iron Therapy - Answer Immediate disappearance of pica or
RLS
Improved feeling of well being within first few days of treatment
In patients with moderate to severe anemia, a modest reticulocytosis will be seen in 7-
10 days. Those with mild anemia may have no reticulcytosis.
Hemoglobin will rise slowly after approximately 1-2 weeks and will rise 2g/dL over
approximately 3 weeks.
The hemoglobin deficit should be halved by approximately 1 month and the hemoglobin
level should return to normal by 6-8 weeks.
Duration of Oral Iron Therapy - Answer Some disagreement about how long to treat:
Some providers stop iron treatment when the hemoglobin level becomes normal so that
further blood loss will alert them to the return of the problem that causes the iron
deficiency.
Others treat for at least 6 months following normalization of the hemoglobin in order to
replenish iron stores.
Failure to Respond to Oral Iron Therapy - Answer Coexisting diseases interfering with
marrow response (infection, inflammatory disorder, malignancy, uncorrected
hypothyroidism, coexisting folic acid or vitamin B12 deficiency)
Diagnosis of IDA is incorrect (Look for Thalassemia, lead poisoning, Anemia of chronic
disease/chronic inflammation, copper deficiency (zinc toxicity), Myelodysplastic
syndrome/refractory sideroblastic anemia
Patient is not taking the medication
