Anemia

Mary Ann HudsonDanny Townsend

Anemia

The Ohio State University, College of NursingJuly 26, 2010

Client Chief Complaint

The Ohio State University, College of Nursing 2

48-year-old African-American Female with chief complaint of unexplained fatigue despite adequate sleep at night.

Patient denies depression, insomnia, ETOH abuse, smoking, black or tarry stools, or prescription medications. Hospitalizations only for normal labor and delivery of her children. Hx of sinus complaint. Symptoms of perimenopause, namely irregular periods and occasional heavy periods.

Client Social History


Client works long hours as a high school principal and is experiencing acute job stress. Client lives with her husband who also works in public school administration; their children are grown and live out of the home. Client reports that “life is good.”

Client drinks wine at a level of 7-12 units/week.

Client Physical Exam


Ht: 5’8” Wt: 127 lbsV/S: 155/80, 72, 14

All physical findings in head to toe exam are within normal limits except:

Blood Pressure Palpation of a neck mass on upper right

side of thyroid

Client Diagnostic Laboratory Results and Diagnosis


CBC WDL except:

RBC 3.7 M/uL Normal: 4.2-5.9

Hgb 10.1 g/dL Normal: 12-16

Hct: 30.6 % Normal: 37-48%

Serum Ferritin: 10 Fe Deficiency significant at 0-12

Monocytes

Electronic: 8.1% Normal: 3-7%

Diagnosis is Iron Deficiency Anemia

Diagnosis Criteria for Fe Deficiency Anemia


Manifestation of hypochromic, microcytic anemia as indicated by low RBC volume and low hemoglobin concentration.

Common in infants, children and adolescents during rapid growth, pregnant and lactating women, patients with kidney disease, patients with gastrectomy or small bowel diseases, GI blood loss, and in menstrating women, especially pre and perimenopausal women who may already have low iron stores.

Anemia and Index of Suspicion


With anemia diagnosis, it is important to discover underlying cause, especially in light of other significant clinical findings. Evaluating kidney function, investigating potential areas of blood loss (GI tract, for example), and ruling out cancer and infection are vital. Consider a chemistry panel, occult blood tests, and imaging studies for masses.

This client, due to an increased blood pressure, increased monocytes, and palpable neck mass, should be evaluated for cancer, infection, and kidney function. Her neck mass should be imaged/biopsied, and chemistry panels drawn to evaluate BUN and creatinine. She can be treated for her Fe deficiency anemia while undergoing continued studies. In the event she is cleared of high index concerns, she should receive follow-up for BP.

Pathophysiological Review


Iron Deficiency Anemia develops due to an absence of adequate iron in the nucleus of the iron-porphyrin heme ring, which together with globin chains forms hemeglobin.

Hemeglobin reversibly binds oxygen so that it can be delivered from the lungs to systemic tissues. In the absence of enough iron, small RBCs with insufficient hemoglobin are formed--microcytic hypochromic anemia.

Clinically, this leads to fatigue, pallor, dizziness, exercise intolerance, and cardiovascular compensation like tachycardia and vasodilation.

Treatment and Therapeutic Objectives


Patient should achieve RBC, Hbg, Hct, and serum ferritin values within normal limits with resolution of clinical symptoms and minimal GI or systemic disturbance.

Underlying causes of iron deficiency anemia should be addressed and resolved.

Treatment for iron deficiency anemia should continue 3-6 months after the correction of the cause of iron loss.

Patient should have blood draws every 2-3 weeks for the first 2 months of treatment, and periodically thereafter.

If patient is unable to tolerate one formulation of Fe replacement therapy, others should be attempted.

Pharmacological Therapy Options for Iron Deficiency

Anemia


Oral Iron Therapy: A wide variety of oral preparations for iron deficiency anemia are available, all are iron salts and include ferrous sulfate hydrated, ferrous sulfate desiccated, ferrous gluconate, and ferrous fumarate. Patient can be consulted regarding preferences for drops, tablets, elixir, etc. based on compliance and tolerance.

Parenteral Iron Therapy: This therapy is reserved for patients who cannot tolerate oral iron therapy, have chronic anemia that cannot be reversed with oral therapy alone, and includes patients with significant underlying causes for their anemia; for example, malabsorption syndromes.

Oral Iron Salts Replacement

Indications are for iron replacement in patients who can tolerate and absorb iron salts PO. CDC recommends three months of Fe PO.

PharmacokineticsHematologic response begins in 3-10 days as Fe is absorbed in dudenum and upper jejunum. Food and an alkaline environment impair absorption (antacids). Excreted from sweat, urine, intestinal mucosa, menses, feces, nails.

Pharmacodynamics

Replaces Fe in nucleus of heme ring of hemoglobin.

Side EffectsGI--nausea, vomiting, diarrhea, constipation, anorexia. Mitigated by dose and preparation of Fe salt. Special cautions in regards to overdose toxicity and children should be observed: greater than 3 grams may be fatal to a child. Overdose requires cheleation.

InteractionsFe Salts decreases the absorption of many common drugs including quinolones, tetracyclines, levothyroxine, levodopa, and biphosphonates. Patients taking drugs in these classes may often present with anemia and careful prescriber planning is necessary.

Contraindicated

PO absorption disability;GI bleeding.Hemochromotic.

IV Fe Replacement

Indications are for iron replacement when PO is not tolerated or absorbed and for dialysis patients.

PharmacokineticsAbsorption with IV administration is complete and remains in the body for many months. Greater than 90% protein bound. Excreted in the same manner as PO.

Pharmacodynamics

Replaces Fe in nucleus of heme ring of hemoglobin.

Side EffectsNausea, vomiting, diarrhea, anaphalyxis, rash, hypersensitivity, hypotension, itching, IV and IM site reactions.

InteractionsFe Salts decreases the absorption of many common drugs including quinolones, tetracyclines, levothyroxine, levodopa, and biphosphonates.

Contraindicated

Cardioascular disease, hepatic impairment, allergy, hemochromitosis.

Drug Classes Used to Treat Fe Deficiency Anemia

The Ohio State University, College of Nursing

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Drug Name Efficacy Safety Suitability

Ferrous Sulfate

Adults:

2-3mg/kg/day in 2-4 divided doses. Or 60-100 mg BID (for deficiency)

Children:

Severe: 4-6mg/kg/day in 3 doses

Mild/Moderate: 3mg/kg/day in 1-2 doses

Pharmacodynamics: Enters bloodstream and is transported to the organs of the reticuloendothelial system (liver, spleen, bone marrow) where it becomes part of iron stores.

Pharmacokinetics:

5-10% absorbed (up to 30% in deficiency states). PO Fe absorbed via active and passive transport. Remains in body for months. Greater than 90% protein bound

Side Effects:

Nausea, constipation, dark stools, epigastric pain, GI bleeding, vomiting, headache. Liquid preparations may stain teeth.

Pregnancy category

B

The only clinical indication for the use of iron preparations is the treatment or prevention of iron deficiency anemia.

Hbg and Hct should be monitored every 3 weeks the first 2 months of therapy.

Dosing with ascorbic acid greater than 200mg may increase absorption.

Decreases the absorption of common drugs and should not be administered with ltertacyclines, levothyroxine, penicillamines, levodopa, methyldopa. Drugs that alter gastric secretions may decrease Fe absorption.

Use cautiously in diseases of the GI tract, alcoholism, liver impairment, and renal impairment.

Monitor for toxicity.


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Ferrous Gluconate

Adults:


Children:




Pharmacokinetics:

5-10% absorbed (up to 30% in deficiency states). PO Fe absorbed via active and passive transport. Remains in body for months. Greater than 90% protein bound.

Side Effects:


Pregnancy category

B








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Ferrous Fumarate

Adults:


Children:




Pharmacokinetics:

5-10% absorbed (up to 30% in deficiency states). PO Fe absorbed via active and passive transport. Remains in body for months. Greater than 90% protein bound.

Side Effects:


Pregnancy category

B








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Iron Dextran

Adults and Children:

Test dose of .5mL given 1 hr prior to therapy

.0476x(14.8-acutal Hbg)xlean body weight+1mL/5kg (to 14 mL) not to exceed 100 mg/day


Pharmacokinetics:

5-10% absorbed (up to 30% in deficiency states). IV Fe absorbed via active and passive transport and is complete. Remains in body for months. Greater than 90% protein bound.

Side Effects:

Seizure, headache, hypotension, tachycardia, abdominal pain, nausea, vomiting, taste disorder, flushing, pain at injection site, anaphylaxis

Pregnancy category

C






Monitor for carefully for toxicity.


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Sodium Ferric Gluconate Complex

Adults:

10mL (125 mg) repeated during 8 sequential dialysis treatments to a total cumlative dose of 1 g.


Pharmacokinetics:

5-10% absorbed (up to 30% in deficiency states). IV Fe absorbed via active and passive transport. Remains in body for months. Greater than 90% protein bound.

Side Effects:

Seizure, headache, hypotension, tachycardia, abdominal pain, nausea, vomiting, taste disorder, flushing, pain at injection site, anaphylaxis

Pregnancy category

B

The only clinical indication for the use of iron preparations is the treatment or prevention of iron deficiency anemia. In paitents undergoing hemodialysis or receving erythropoitin.







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Iron Sucrose

Adults:

100mg repeated during 10 sequential dialysis treatments to a total cumlative dose of 1 g.

200mg over 5 different days for non-dialysis patients

Total 1000mg dose divided in 3 doses 14 days apart for peritoneal dialysis.


Pharmacokinetics:

5-10% absorbed (up to 30% in deficiency states). IV Fe absorbed via active and passive transport. Remains in body for months. Greater than 90% protein bound.

Side Effects:

Headache, cough, dypsnea, hypotension, chest pain, CHF, diarrhea, nausea, vomiting, increased liver enzymes, taste alteration, pruritus, hypervolemia, anaphylaxis, fever, pain.

Pregnancy category

B

The only clinical indication for the use of iron preparations is the treatment or prevention of iron deficiency anemia. In paitents with chronic renal failure, receiving hemo or perioneal dialysis or receving erythropoitin.






Ferrous Sulfate

Slow Fe 90 Tabs: $34.97

Fer-In-Sol 100 mL: $27.97

Ferrous Sulfate 220 EXLIX: $19.47

Ferrous Sulfate 325: 100 tabs $30.00


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Drug Selected

Drug Name Efficacy Safety Suitability Cost

Ferrous Sulfate

Adults:


Children:




Pharmacokinetics:

5-10% absorbed (up to 30% in deficiency states). PO Fe absorbed via active and passive transport. Remains in body for months. Greater than 90% protein bound

Side Effects:


Pregnancy category

B







Slow Fe 90 Tabs: $34.97

Fer-In-Sol 100 mL: $27.97

Ferrous Sulfate 220 EXLIX: $19.47

Ferrous Sulfate 325: 100 tabs $30.00

Group: Efficacy Safety Suitability Cost

Ferrous Sulfate

+ + + +

Ferrous Gluconate

+ + + +/-

Ferrous Fumarate

+ + + +/-


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P-Drug Selection

Pharmacodynamics:Forms the nucleus of the iron-porphyrin heme ring which

together with globin forms hemoglobin. Hemoglobin reversibly binds oxygen and provides oxygen delivery from the lungs to tissues.

Pharmacokinetics:

Absorption: Absorption is increased when iron stores are depleted or red blood cell production is increased. Conversely, high iron blood concentrations decrease absorption.


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P-Drug: Ferrous Sulfate

Metabolism:Cytochrome P450 family(CYP450)

Excretion: No physiological system of elimination exists for iron, and it can accumulate in the body to toxic amounts; however, small amounts are lost daily in the shedding of skin, hair, and nails; and in feces, perspiration, breast milk (1.1 to 1.4 mg per day), menstrual blood, and urine.1 to 1.4 mg per day), menstrual blood, and urine

The Ohio State University, College of Nursing22


Common Side Effects: Constipation; darkened or green stools; diarrhea; nausea; stomach upset. Severe allergic reactions (rash; hives; itching; difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue); black, tarry stools; blood or streaks of blood in the stool; fever; vomiting with continuing sharp stomach pain

Contraindications: An allergy to any iron supplementAcute hepatitisHemosiderosis or hemochromatosis (conditions involving excess iron in body)Hemolytic anemiaHad repeated blood transfusions



Patient Provider Interaction


Review foods high in iron such as liver, seafood, nuts, beans, green leafy vegetables, whole grains, and fortified foods.

Review foods that block absorption of iron such as coffee, tea, egg whites. Avoid these while eating foods high in iron.

Review appropriate administration and use of medications

Review causes and symptoms of anemia. Vitamin C can help the body absorb iron better.Tests used assess iron status: Serum ferritin,

transferrin saturation, CBC, total iron binding capacity and MCV.

Increase fiber if constipation occurs.Consult for mass on thyroid gland and BP. *If

patient later presents with thyroid deficiency levothyroxine is not absorbed with Fe therapy.


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Don’t take iron with other vitamins and minerals. Take it with a full glass of water. Take it the same time every day.

Extended release iron is not recommended due to absorption issues.

Follow-up appointments will be needed.If symptoms continue, seek medical help.Use stool softeners, if needed

Board of Nursing Formulary


Nutrients and Nutritional agents may be found in the formulary on page 5.

CTP holders may prescribe PO vitamins and minerals such as magnesium sulfate and other trace elements to include iron.

Written Prescription


Nurse Practitioners of Columbus

1111 Speedway Lane

Columbus, Ohio

(614)293-1111

Name: Thomas James DOB: 07/07/1952

Address: 1212 Nobodyknows

Columbus, Ohio 43215

RX Ferrous Sulfate 325mg tablets

Take one tablet three times each day

Dispense 90(ninety) tablets

Refills:1 Best Nurse Practitioner 08/06/2010

Clinical Studies


Study: Between March 1997 and April 1998, 3075 community-dwelling adults were recruited to participate in the Health, Aging, and Body Composition(Health ABC) Study.

Objective: Comparison study to determine whether the hemoglobin cutoff value below which adverse events occur is lower in blacks than in whites. This examined whether longitudinal effects of anemia vary by race in a cohort of well-functioning older adults.

Results: The baseline prevalence of WHO-defined anemia was significantly higher in older blacks compared to older whites. 21% of black women and 26% of black men were anemic at baseline, whereas 7% and 14% of white women and men.

Conclusion: Further outcome-based research is required to determine hemoglobin thresholds for defining anemia in racial/ethnic subpopulations and to evaluate treatment.

(Patel et al, 2007)

Clinical Studies


Study: Randomized, double-blind, placebo-controlled study examined side-effects of 3 iron salt formulations using equal dosages of elemental iron.

Objective: To investigate the tolerability and side effects of 3 iron salt formulations used in the treatment of iron-deficiency anemia.

1496 patients with comparable degree of anemia. Results: All 3 iron salt formulations had comparable side-effects

rates. Conclusion: Ferrous Sulfate remains the standard first-line

treatment for iron-deficiency anemia given its low cost, effectiveness, tolerability, and low cost.

(Mcdairmid et al, 2002)

Study: 412 female blood donors were recruited. There was an initial visit and three subsequent a follow-up visits at four month intervals. Each was given 21 tablets of 150 mg ferrous sulfate tablets or a placebo to be taken three times daily for one week after blood donation. Their Hgb, Hct, serum ferritin, TIBC, and percent saturation of TIBC were tested throughout the course of study.

Objective: Compare blood studies between groups to determine effectiveness of iron sulfate in preventing anemia.

Result: The group taking ferrous sulfate showed no significant difference between the mean initial and the mean final result however there was significant decline in mean hb, hct, serum iron , serum ferritin, and percent saturation in the group taking the placebo.

Conclusion: Iron supplementation therapy can be considered as one of the strategies to promote safe blood transfusions in women.


Clinical Studies

References


Johnson, D.E., & Mcdiarmid, T. (2007). Are any oral formulations better tolerated than ferrous sulfate. The Journal of Family Practice. 3(2),125-35.

Dharmarajan, L.& Dharmajan, T.(2007) Anemia in older adults: an indication requiring evaluation. Family Practice Recertification. 29(6), 6-25.

Chen, A.C. & Visscher, H.C. (1995). Detection and treatment of iron deficiency anemia in women of childbearing age. Preventive Care Update. 2(4), 135-138.

References


Epocrates Rx (2010). [database for PDA, Version 8.10]. San Mateo, CA: Epocrates, Inc. Retrieved from http://www.epocrates.com

Alleyene, M. & Mcdonald, E.K. (2008). Individualized treatment for iron-deficiency anemia in adults. The American Journal of Medicine. 121(11), 943-948.

Patel et al.(2007). Racial variation in the relationship of anemia with mortality and mobility disability among alder adults. Clinical Trails and Observations. 108(11), 4663-4670.


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References

(PDA) uCentral from Unbound Medicine

http://www.nlm.nih.gov/medlineplus/druginfo/natural/patient-iron.html

Basic & Clinical Pharmacology, by Bertram G. Katzung: The McGraw-Hill

Companies, Inc., 11th edition, 2009.

Questions?


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