Labs

Lab	Low	High	Unit
Hgb (M)	13.5	17.5	g/dL
Hgb (F)	12	16	g/dL
Hct (M)	41	53	%
Hct (F)	36	46	%
RBC (M)	4.5	5.9	M/mcL
RBC (F)	4.1	5.1	M/mcL
MCV	80	100	fL
RDW	11	15	%
Folate	1.8	16	ng/mL
B12	100	900	pg/mL

Considerations in Lab Evaluation

• Acute bleeding may not be reflected for 36-48hr after bleed
• Pregnancy will show anemia in 3rd trimester, but will actually by polycythemic, error due to increased volume
• Volume depletion may look like polycythemia, or normal in anemic pts
• Smoking increases Hct
• Living at high altitudes increased Hgb

SSx

Acute Anemia

• Tachycardia
• Tachypnea
• Orthostatic Hypotension
• Light-headedness
• Angina

Chronic Anemia

• Fatigue
• Weakness
• HA
• Dyspnea
• Dizziness
• Cold sensitivity
• Pallor
• CHF / Angina exacerbation

Risk Factors

• Age
  • Elderly
  • Teenager
• Female
• EtOH abuse
• GI Disease
• Poor diet

Common Causes

Microcytic

• Iron Deficiency
• Cu Deficiency
• Zn Deficiency
• Pb, Al, EtOH, and some drugs
• Thalassemias
• Iron Metabolic Defects

Normocytic

• Hemorrhage
• Mixed Anemias
• Anemia of Chronic Disease
• Epo Deficiency

Macrocytic

• B12 or Folate Deficiency
• Hemolysis / Reticulocytosis
• EtOH abuse
• Liver Disease
• Hypothyroidism
• Drugs
• Multiple Myeloma

Dx and Treatment

Transfusion for Severe Acute Anemia

• Criteria
  • Acutely Symptomatic
  • Hgb < 8 (some argue 7)
• Admin PRBCs
  • Type and cross before admin
  • 1 U &approx; 300 mL &approx; Δ 1 g/dL Hgb
  • Consider activation of massive transfusion protocol
  • Hemorrhaging / trauma pts may require infusions of FFP and Plt as well to sustain coagulation, strongly consider before using large volumes of crystalloid
  • Pts refusing transfusion can be given high dose iron, B12, and Epo, look up protocol
• Complications
  • Iron Overload
  • Infection (HIV etc, rare)
  • Hyperviscosity syndrome
  • Alloimmunization
  • Volume overload
  • Transfusion reactions

Iron Deficiency Anemia

SSx

• Pica
• Angular Stomatitis (rash at the edges of the mouth)
• Glossitis
• Koilonychia (dented fingernails)

Lab Evaluation

Lab	Low	High	Unit
Ferritin	10	20	mcg/L
Serum Iron	60	150	mcg/dL
Transferrin	20	50	%
TIBC	250	400	mcg/dL

$$\text{Serum Fe} / \text{TIBC} = \text{Tranferrin} \%$$

Treatment

• Peds
  • 9-12mo: 3 mg/kg elemental iron QD or BID x2-3mo until resolved
  • Older: 6 mg/kg elemental iron QD in 2-3 divided doses
• Adults
  • 200mg elemental iron QD

PO Iron

Product	Dosage Form	Elemental Iron	Dose	Note
Fe Sulfate	325mg tab	65mg	325mg TID
Fe Gluconate	300mg tab	12%	600mg TID	Best Tolerated PO
Fe Fumarate	300mg tab / liquid	99mg	300mg BID
Polysaccharide Fe	150mg tab / liquid	150mg	150-300mg QD	Worst tolerated
Carbonyl Fe	50mg	50mg	50mg TID

• SEs
  • Epigastric Distress
  • Cramping
  • N / D / C
  • Discolored feces
• Counseling Tips
  • Take on empty stomach
  • Many med interactions, check
  • Divide doses for less SEs

IV Iron

Product	Test Dose	Dose	SEs	Notes
Iron Dextran (INFeD)	25mg observe 1hr	100mg QD IV or IM See specific dosing below	Fever Malaise Flushing Myalgias Anaphylaxis	Admin over 2-6hr
Iron Sucrose (Venofer)	n/a	HD: 100 mg 1-3x weekly x10 doses Non-HD: 200mg IV x5doses	Cramps Hypotension N / V / D HA	IVP at 1 mL/min (over 20min)
Ferric Gluconate (Ferrlecit)	n/a	125 mg 1-3x weekly x8 doses (1000mg cumulative)	Cramps N / V Flushing Hypotension Rash Pruritis Hypersensitivity	Admin over 1hr
Ferraheme (Ferumoxytol)	n/a	510 mg repeated x1 in 3-8d	Hypersensitivity N / D / C Interfere w/ MRI	1 mL/sec
Ferric Carboxymaltose (Injectafer)	n/a	≥ 50kg: 750mg repeat q7d x1 dose < 50kg: 15 mg/kg repeat q7d x1 dose		Non-HD CKD Only
Ferric Pyrophosphate (Triferic)	n/a	1 27.2mg ampule in 2.5gal bicarb concentrate at each dialysis session		HD CKD Only

$$\text{Dose (mL)} = 0.0442 (\text{Goal Hgb} - \text{Hgb}) \times \text{IBW} + 0.26\times \text{IBW}\\ (\text{only if >15kg})\\ \text{Hemorrhagic Dose (mg)} = \text{Blood Loss (mL)} \times \text{Hct}$$

• Indications
  • Iron malabsorption
  • Noncompliance / Intolerance w/ PO
  • Chronic bleeding
  • Diminished erythropoiesis
• Monitoring
  • TSAT & Ferritin q3mo
  • Do not replet in CKD if TSAT > 30% or Ferrit > 500 ng/mL
  • Expect Δ 1 g/dL Hgb change q2-3wks
• SEs of Iron Overload
  • Metabolic Acidosis
  • Gastric Ulcers
  • Organ Damage

B12 Deficiency

Causes

• Dietary Deficiency
• Intrinsic Factor Deficiency (Pernicious Anemia)
• PPI / H2 Use
• Metformin

SSx

• Neuro
  • Parasthesias
  • Peripheral Neuropathy
  • Depressed Deep Tendon Reflexes
• Psych
  • Irritability
  • Mood Changes
  • Memory Impairment
  • Depression
  • Psychosis
• Dysphagia
• Glossitis
• Muscle Weakness
• Anorexia

Treatment

• PO B12
  • 1000-2000 mcg QD x1-2wks then 1000mcg QD for life
• Parenteral B12
  • 1000mcg IM or SubQ QD x1wk then weekly x1mo then monthly for life

Folate Deficiency

Causes

• EtOH abuse
• Inadequate intake in the elderly
• Jejunal resection
• Malabsorptive diseases
• Hyperutilization
  • Pregnancy
  • Malignancy
  • Chronic Inflammatory Diseases
  • Growth Spurts
  • Dialysis
• Drugs
  • Methotrexate
  • Trimethorpim
  • Phenytoin
  • Phenobarb
  • Azathiprine
  • 6-mercaptopurine
  • 5-fluorouracil

Treatment

• PO Folate
  • 1mg QD typical
  • 5mg QD for malabsorption pts
  • 500mcg QD for anticonvulsant interaction

Epo Deficiency / Anemia of Chronic Disease

Causes

• CKD
• Infection
• Malignancy
• Autoimmune

Treatment

• Epoetin Alfa (Epogen)
  • 50-100 U/kg 3 times weekly
  • Response in 2-8 wks
  • SEs include HA, HTN, and arthralgias
• Darbepoetin Alfa (Aranesp)
  • 0.45 mcg/kg weekly
  • SEs include diarrhea, HA, HTN, hypotension, and infection
• Do Not Exceed Hgb of 12 w/ Epo Agents: Risk of CV event

Sickle Cell Anemia

SSx

• Chronic Anemia
• Fever
• Pallor
• Arthralgia
• Scleral Icterus
• Abdominal Pain
• Weakness
• Anorexia
• Fatigue
• Hematuria
• Enlarged Heart, Spleen, and / or liver

Lab Evaluation

• Elevated:b
  • Bilirubin
  • Reticulocyte count
  • Plts
  • WBC
• Decreased
  • Hgb

Acute Chest Syndrome

• Presentation
  • New pulmonary infiltrate
  • Cough / Dyspnea / Hypoxia
  • Fever (sometimes)
• Treatment
  • Pain managment
  • Broad-Spectrum Abx including mycoplasma and chlamydia coverage
  • O₂
  • Steroids

Sickle Cell Crisis

• Vasoocclusive Pain Crisis
  • Hydrate: 3-4 L QD for adults or 1.5-2x maintenance for peds
  • Analgesia
• Acute Splenic Sequestration
  • Sudden spleen and liver enlargment
  • Transfusion for hypovolemia and anemia
  • Broad spectrum Abx
• Priapism
  • Analgesia
  • Aspiration
  • Vasoconstrictors: Phenylephrine or epinephrine
  • Vasodilators: Terbutaline or hydralazine
  • Surgical Shunt placement

Misc Treatment

• Immunize w/ Influenza and Pneumococcal
• Prophylactic Penicillin for those < 5yo
  • < 3: 125mg PO BID
  • ≥ 3 & < 5: 250mg PO BID
• Folate supplementation
• Consider Hydroxyurea to cause increased HgF production
  • 10-15 mg/kg QD (NTE 35 mg/kg QD)
  • Monitor Hgb, MCV, CVC q2wks until stable then q4-6wks (also ANC and Plts then)
  • SEs: Bone marrow suppression, skin ulcers, N / D / C

Aplastic Anemia

SSx

• Pallor
• Fatigue
• Weakness
• Fever
• Chills
• Sx of Infection
• Bruisability
• Petechiae
• Bleeding

Dx Criteria

2 of the Following

• WBC < 3.5 k/mcL
• Plt < 55
• Hgb < 10
• Reticulocytes < 30k

Common Drug Causes

• Carbamazepine
• Phenytoin
• Propylthiouracil
• Thiazides
• Sulfonamides
• Methimazole

Agranulocytosis

SSx

• Sore throat
• Fever
• Malaise
• Weakness
• Chills
• SSx of infection

Common Drug Causes

• Methimazole
• Propylthiouracil
• Clozapine
• TCAs
• Cocaine
• Heroin
• Sulfasalazine
• H2 Antagonists
• Dapsone
• Isotretinoin
• Sulfonamides
• Chloroquine
• Quinine
• Phenytoin
• Valproate
• Carbamazepine

Hemolytic Anemia

Non-Drug Causes

• Sickle Cell
• G6PD Deficiency and Other Metabolic Defects
• Thalassemias
• TTP
• HUS
• Malaria

Common Drug Causes

• Phenytoin
• Phenobarbital
• Quinidine
• Others

Treatment

• Generally avoid precipitating factors
• Warm-Ig Mediated Autoimmune Hemolytic Anemia
  • Dx w/ positive Coomb’s test
  • Steroids and splenectomy
• Cold-Ig Mediated Autoimmune Hemolytic Anemia
  • Does not respond to steroids

Megaloblastic Anemia

Common Drug Causes

• Methotrexate
• Cotrimoxazole
• Phenytoin
• Phenobarbital

Thrombocytopenia

Non-Drug Causes

• Hemorrhage
• Infection
• DIC
• TTP

Common Drug Causes

• Heparins
• Chemotherapies
• Quinine
• Quinidine
• Gold salts
• Sulfonamides
• Rifampin
• GPIs
• Procainamide

Methemoglobinemia

• Can be congenital or aquired

Common Drug Causes

• Dapsone
• Topical anesthetics
• NO

Treatment

• < 20% and Asymptomatic require no treatment
• 1-2 mg/kg Methylene Blue IV over 5min, repeat if necessary
• Methemoglobinemia Treatment: EMCrit