Anemia

● Decrease in hemoglobin(hgb) and hematocrit(hct)

○ Pathophys:
■ Hgb carries o2 to tissues for consumptions and powering
■ RBC in bone marrow also uses the O2 of hgb to grow to immature RBC (reticulocytes)
● Then the reticulocytes will mature into erythrocytes with a life span of 120 days
■ In cases of untreated chronic anemia, the heart can start to compensate by pumping faster and stronger
which can in time cause hypertrophy
● Causes: impaired RBC production, increased RBC destruction, blood loss, nutritional deficiencies (low iron, folate,vitamin B12)
● Symptoms: fatigue, weakness, shortness of breath, exercise intolerance, headache, dizziness, anorexia, pallor
○ Glossitis(inflamed sore tongue), koilonychias (thin, concave spoon-shaped nails) or Pica(craving or eating non food
like clay or chalks) = these symptoms can be seen with iron deficiency
○ Vitamin B12 can cause neuro symptoms such as peripheral neuropathies
● Types: microcytic (smaller RBCs) vs macrocytic (Larger RBCs)
● Diagnosing: MCV levels(look at the size of a RBC and volume)
○ < 80 fL = microcytic → iron studies due to iron deficiency
○ >100fL = macrocytic → Vitamin B12 and folate levels low/deficient
 Notes:
o High reticulocytes when blood loss occur due to bone marrow trying to replace what it have lost.
o Low reticulocytes means that low levels of folic acid, vit-b12 and bone suppression as there is not enough needed
material for the body to make the RBC
 Lab test for anemia
o RBC component: hgb, hct, RBC, reticulocytes
o RBC indices: MCV, MCHC, RDW
o Iron studies: serum iron, serum ferritin, total iron binding capacity. TSAT
o Other test: serum folate, serum vit-B12, methylmalonic acid, homocysteine.
Iron deficiency anemia
● most common
● causes if iron deficiency:
○ low intake due to vegan or vegetarian
○ blood loss: hemorrhage, chronic condition like donation or heavy flow
○ decrease absorption: high gastric pH, GI disease (IBS, celiac disease)
○ increase iron demand: preggo, lactation, infants.
● Dietary iron 2 forms: Heme(meat and seafood) and Non-heme (nuts, beans, veggies, and fortified grains)
● Treatment: 100-200 mg elemental iron daily on an empty stomach=> 2023 text book
○ 1 tablet once qd or q other day on empty stomach( 1 hour before or 2 hours after meal) => 2024 text book
■ higher dosage of elemental iron does not equal to more being absorbed so just 1 tab qd or q other day is
fine
○ Avoid H2Ras and PPI and avoid antacid in general as iron can interact with the H2RA/PPI/Antacid
■ The stomach pH are increased by the H2RA/PPI/antacid which would then lower absorption of iron
■ Take iron 2 hours before or 4 hours after antacid
■ PPI and H2RA raise pH for up to 24 hours so avoid taking the two together in general
○ Enteric coated and extended release have less GI but poor GI absorption so not recommended
● IV iron used for dialysis, unless unable to tolerate PO then will give IV iron
○ Usage of IV iron is limited to these pt
■ CKD on HD that may or may not be receiving ESA
■ Unable to tolerate PO due to Gi issues ( celiac disease, GI bypass procedures, IBD, etc….)
■ Severe anemia ( hgb < 7 ) or rapid blood loss faster then PO iron can replace
■ When blood transfusion is not an options (typically due to religious belief)
Oral Iron

Ferrous Sulfate(ferosul) 325 mg PO daily -Q Boxed Warnings: keep away from children can cause
20% elemental iron other D fatal overdoses, call poison control if OD occur

Ferrous sulfate, dried (slow-Fe, slow 160 mg PO daily- Q Contraindications: hemochromatosis (deadly iron
iron) ER tablets other D overload), hemolytic anemia(destroyed RBC release
30% elemental iron iron that are being reused), hemosiderosis

Ferrous fumarate( ferretts, ferrimin) 324 mg PO daily- Q Side Effects: constipation, dark, tarry stools, nausea,
33% elemental iron other D stomach upset
 Anemia

Ferrous gluconate (ferate) 324 mg PO daily- Q

12% elemental iron other D Monitoring: Hgb, iron studies, RBC indices,
reticulocytes
Carbonyl iron 90 mg PO daily- 1 t QD
100% elemental iron Peds pt can tk with food if gi upset occurs but avoid
milk product
Polysaccharide iron complex 150 mg PO Daily - Q
100% elemental iron other D Notes: docusate is recommended for constipation
Antidote for overdose = deferoxamine (Desferal)
Ferric Maltol 30 mg PO BID
100% elemental iron DDI: iron is a polyvalent cation that lower absorption
of other drugs but binding to them and forming a
nonabsorbable complex.
 Quinolones and tetracycline Abc: take iron
2hr b/4 or 4-8 hr after taking abx
 Bisphosphonate : take iron 60 minutes after
po ibandronate or 30 minutes after
alendronate/risedronate
 Levothyroxine: separate iron by 2-4 hours
 INSTI: iron will bind onto INSTI and lower
absorption of INSTI
 Vitamin C: increase iron absorption as vit-c
can create an acid environment that help iron
absorption.

Intravenous Iron

Iron Sucrose (Venofer) Boxed Warnings(Iron dextran-infed and Ferumoxytol-faraheme): test dose
→ anaphylaxis (all parenteral/IV iron carry risk of anaphylaxis)
Ferumoxytol (Feraheme)
Side Effects: muscle aches, flushing, hypotension, hypertension, tachycardia,
Iron dextran complex (INFeD) chest pain, peripheral edema.
Iv iron s/x is more “systemic” based
Sodium Ferric gluconate (Ferrlecit)

Ferric carboxymaltose (Injectafer) Monitoring: Hgb, iron studies, reticulocytes, vital signs

Ferric derisomaltose (Monoferric) Notes: slow infusion to reduce risk of hypotension, stable in Ns for all form with
feraheme also stable in NS or D5W
Ferric pyrophosphate citrate (Triferic)
-specifically indicate for pt of CKD
dependent hemodialysis. This
should get added to the bicarbonate
concentrate for pt that is receiving HD.

Macrocytic Anemia
● Pernicious anemia→ B12 deficiency due to lack of intrinsic factor → life long parenteral vitamin B12
replacement
● Other causes: alcoholism, poor nutrition, GI disorders, and pregnancy
● B12 specific : long term useage of metformin and H2RA/PPI can decrease absorption of b12  neuro conditions such as
cognitive impairment and peripheral neuropathy  symptoms becomes irreversible if not treated for 3 months
● Folic acid specific: causes more of tongue and oral mucosa ulcers
 Anemia
● Methylmalonic acid and homocysteine can accumulate whenever B12 deficiency occurs as B12 is needed for enzymatic
reaction involving Methylmalonic acid and homocysteine.
● Macrocytic anemia treatment: B12 injections
Vitamin B12 and Folic Acid products

Cyanocobalamin, Vitamin IM/deep SC: 100-1,000mcg Contraindications: allergy to cobalt or vitamin B12
B12(nascobal, but PCP use daily/weekly/monthly Warnings: may contain aluminum (accumulate and cause cns/bone
generic mainly) Oral: 1,000-2,000 mcg tox if renal impaired) or benzyl alcohol (can cause gasping syndrome in
daily neonate)
Nascobol: 500 mcg in one Side Effects: rash, polycythemia vera, pulmonary edema (ALL rare)
nostril once weekly Monitoring: Hgb, Hct, vitamin B12, reticulocytes

Folic Acid, folate, Vitamin 0.4-1 mg daily Warnings: as above

B9(FA-8) Side Effects: bronchospasm, flushing, rash, pruritus, malaise (all rare)
Monitoring: Hgb, Hct, folate, reticulocytes
DDI:
 raltitrexed(chemo agent ) efficacy lowers when using in
combo with folic acid.
 Fosphenytoin, phenytoin, primidone and phenobarbital
concentration levels can lower in present of folic acid

Normocytic Anemia
● Anemia of CKD: deficiency in erythropoietin
○ IV iron first line then erythropoiesis-stimulating agents(ESAs) in HD pt, non-HD pt can be treated with PO iron.
■ KDIGO recommend iron therapy if TSAT </=30% and ferritin levels are </= 500 %
○ ESAs require normal iron levels to work
Erythropoiesis-Stimulating Agents

Epoetin alfa (Epogen, Procrit) HD: 50-100units/kg iv or SC Boxed Warning: increase risk fo death, MI, stroke, VTE,
3xweekly thrombosis. In ckd pt, hgb > 11 can increase risk of death
Initiate if Hgb <10 monitor. Not indicated when the anticipated outcome is cure.
Contraindication: uncontrolled HTN, pure red cell aplasia,
Chemo: 150 units/kg sc 3x wkor epogen multidose vial contain benzo alcohol that’s
40k units qwk also start with hgb contraindicated in neonate which can cause gasping syndrome
<10 Warnings: HTN, seizures, SJS/TEN, epogen may contain
infectious parts that can spread to pt
Darbepoetin (aranesp) 0.45 mcg/kg IV or SC weekly Side Effects: arthralgia, fever, headache, rash, N/V, cough,
dyspnea,
0.75 mcg/kg iv sc q 2 wk Monitoring: Hgb, Hct, TSAT, serrum ferritin, BP
Notes: Store in fridge and do not shake
Darpepoetin has longer half-life
Use lowest effective dose to reduce need for blood transfusion
IV recommended on HD pt

Aplastic Anemia:
● Bone marrow fails to make RBCs, WBCs, and platelets
● Tx: immunosuppressants, blood transfusion, or stem cell transplant
● Eltrombopag (Promacta): increase platelet counts
Hemolytic Anemia
● RBCs are destroyed and removed before the end of their normal lifespan
● Dx: Coombs test( immune mediated hemolysis = positive combs test), drug induced hemolytic anemia caused by g6dp
deficiency = negative combs test
● Glucose-6-phosphate dehydrogenase (G6PD) deficiency: X-linked inherited disorder that causes a loss in protection of RBCs
○ RBCs break apart in 24-72 hours
○ AVOID: dapsone, methylene blue, nitrofurantoin, pegloticase, quinidine, quinine, primaquine, rasburicase,
sulfonamides