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Oncology Exam 2
Frei Anemia (C)
| Question | Answer |
|---|---|
| ***What is the definition of Anemia? *Remember its a 3:1 ratio | If female: Hgb < 12 g/dL or Hct < 36 % OR If male: Hgb < 13.5 g/dL or Hct < 41 % |
| Anemia, based on what Dr. Frei said, is? | tiredness and low red cells, but it doesn’t have anything to do with bleeding; whereas thrombocytopenia relates to the platelets and they have problems with bleeding |
| Table 104-3: What normal lab values will we have to remember for the exam? | Hgb (Male: 13.5-17.5 g/dL; Female: 12-16 g/dL); Hct (Male: 41-53%; Female: 36-46); MCV (80-100 fL); Platelets (150,000 to 450,000); WBC (4,500 and 11,000 cells/mm^3) |
| ***Initial Assessment of Treatment for Anemia—> | 1. Pt is identified as having anemia 2. Determine if packed red blood cell transfusion (PRBC) is needed *there is only 1 treatment for anemia that will result in rapid increase in hemoglobin |
| ***What are the benefits of Packaged red blood cell transfusion (PRBC)? | -Rapid increase in hemoglobin and hematocrit levels; -Possible survival benefit |
| ***1 unit of PRBCs usually raises the Hgb by ___g/dL or hematocrit by __% | 1; 3 |
| ***What are the risks of PRBC transfusion? | -Transfusion-related rxns -CHF -Bacterial contamination -Viral infections -Iron Overload |
| So who gets a Red blood cell transfusion? | Pts that have acute hemorrhage with evidence of hemodynamic instability (any Hgb level); Hgb < 7g/dL; Symptomatic < 8 g/dL; Hgb < 10 g/dL, Asymptomatic and Comorbidities (CHF, Coronary heart disease; Chronic pulmonary disease; cerebral vascular disease) |
| We give RBC transfusion to pts that have <7 because we are worried about? | oxygenation of the blood and end organ damage to the brain, the heart, and other organs *takes awhile to transfuse someone unless there bleeding; we don’t transfuse every pt |
| For pts that are symptomatic < 8 g/dL, what symptoms are we looking for to give a transfusion | Sustained tachycardia, Tachypnea, chest pain, Dyspnea on exertion; Lightheadedness; Syncope; Severe fatigue preventing work and usual activity |
| We will transfuse Hgb <10 g/dL, Asymptomatic and comorbidities but only in a high risk group for pts that already have organ damage seen in what comorbidities? | CHF; Coronary heart disease; chronic pulmonary disease; Cerebral vascular disease |
| There are several ways to determine the cause of anemia. The most objective way is to use the _____ | MCV (means corpuscle volume) *means the volume of the RBC or how big are my RBC |
| There are 3 major breakdowns of causes of anemia: | 1. Decreased production (maturation defect in cells, bone marrow does not produce enough cells) 2. Hemolysis or breaking down RBCs too much. Seen in intrinsic (sickle cell) or Extrinsic (mechanical cardiac valve-> can damage cells as their being pushed through); or both; 3. Blood loss Frei: *Use your MCV to help you figure out what the cause is (breaking cells down, loss through bleeding, or your not making enough) |
| ***Types of Anemia: Microcytic: MCV level? Cause? | MCV < 80; Iron deficiency Anemia |
| ***Types of Anemia: Normocytic: MCV level? Cause? | MCV 80-100; Anemia of Chronic Disease; Anemia of CKD |
| ***Types of Anemia: Macrocytic: MCV level? Cause? | MCV > 100; B-12 deficiency Anemia; Folic Acid Deficiency |
| ***“Absolute Iron deficiency” is? | Serum Ferritin < 30 mg/mL AND Transferrin Sat (Tsat) < 20%—> Tsat is solved by: dividing serum iron / total iron binding capacity |
| *** Serum ferritin is an acute phase reactant; if _____ and have chronic inflammation then can diagnose based off ________ Sat ONLY | HIGH; Transferrin *acute phase reactant—> means that when your body has inflammation from chronic diseases, some lab values will “sky-rocket” and look abnormal (falsely high and can’t use to interpret what is occurring. (So falsely high for chronic cancer or lupus means we can’t use serum ferritin as a value |
| What are causes of Iron deficiency? | -Increased iron requirements—> blood loss (GIT, Genitourinary tract, blood donation); Pregnancy and lactation -Inadequate iron supply—> (insufficient dietary iron, impaired iron absorption (Gastric surgery, intenstinal malabsorption, celiac disease) |
| ***Ferrous sulfate 325 mg tablets has how much elemental iron % and mg? | 20%; 65 mg |
| ***Ferrous Sulfate (Slow Fe) 160 mg tablets has how much elemental iron % and mg? | 30%; 50 mg |
| ***Ferrous Gluconate 325 mg tablets has how much elemental iron % and mg? | 12%; 39 mg |
| ***Ferrous Fumarate 300 mg tablets has how much elemental iron % and mg? | 33%; 99 mg |
| ***Polysaccharide Iron Complex 50 mg tab (Niferex) has how much elemental iron % and mg? 150 mg tab (Hytrinic)? | Niferex: 100%; 50 mg Hytinic: 100%; 150 mg |
| ***Ferric citrate (Auryxia) has how much elemental iron % and mg? | 100%; 210 mg |
| ***Heme Iron Polypeptide has how much elemental iron % and mg? | 100%; 11 mg |
| Exam Question on Oral Iron Product Comparison: “Sally is taking an iron product Ferrous sulfate 325 mg tablets once a day, how much elemental iron (mg)? | 65 mg |
| Most oral Iron products are similar in effectiveness and tolerance, They recommend in the guidelines that ______ _______ is the preferred one because it seems to be the least expensive | Ferrous sulfate |
| ***What is the Advantage of Oral Iron Therapy? | -Convenient dosage form -Avoid anaphylaxis risk with IV iron -Avoid risk of iron overload but with IV iron can get overload |
| ***What are the disadvantages of Oral Iron Therapy? | -GI adverse effects > 50% pts at 200 mg/day (Nausea, constipation) -BA related to GI acidity -Adherence may be difficult with multiple doses -Efficacy significantly reduced as GFR declines -Drug-drug interactions are common |
| ***Oral Iron Drug interactions with what medications? | -Levothyroxine (Iron could decrease absorption of levothyroxine) -H2 blockers, PPI, and antacids reduce absorption of iron products; -FQ and TCN abx (decreased absorption of these abx with oral iron) -Calcium can chelate with iron (limited absorption) -Coffee and tea decrease iron absorption -Vit. C increases iron absorption |
| ***Main point of “Parenteral Iron product slide”—> the risk of anaphylaxis with IV Iron is greatest with the low molecular weight _______ ________ (Infed) | ⭐️ Iron Dextran ⭐️ *risk of anaphylaxis decreases with the newer products available such as Ferric Na Gluconate (Ferrlecit) and Iron Sucrose (Venofer) which is lowest |
| What type of anemia is most common? (in the US) | Iron deficiency anemia |
| Which of the following meets the definition of anemia? -in females, Hgb < 13 mg/dL -in females, Hgb < 13.5 mg/dL -in males, Hgb < 13.5 mg/dL -it is same for both genders, Hgb < 14 mg/dL | in males, Hgb < 13.5 mg/dL |
| Which of the following is a factor effecting anemia in cancer pts? -type of treatment -liver dysfunction -brain metastasis -worse in infants compared to adults | Type of treatment |
| What produces erythropoietin? | Kidney |
| MJ is a 42 yo female who reports fatigue for the last months. She has been trying a variety of new diets to try to lose weight. What is the most likely type of anemia? Labs: WBC 5.6; Hgb: 11.2 g/dL; Hct 33.6%; plts 300; MCV 105; B12 300 pg/mL; folate 0.9 ng/mL; Iron 50 mcg/dL; TIBC 230 mcg/dL? | Folic acid derivative anemia |
| There is a required TEST DOSE with Low molecular weight _____ ______ because it has the highest risk of anaphylaxis of any of the iron products | Iron Dextran |
| What are the advantages of Parenteral Iron therapy? | -Significantly more effective than oral Iron -Avoid GI side effects with oral iron -Avoid drug-drug interactions with oral iron -Adherence can be documented |
| What are the disadvantages of Parenteral Iron therapy? | -Inconvenient dosage form -Increased risk of infusion rxns -increased risk of iron overload |
| AGA Clinical practice update on management of Iron deficiency Anemia: Expert review—> Oral Iron? | -Oral Iron formulations are similar in effectiveness and tolerance -Oral iron therapy once a day or every other day -Add Vitamin C to oral iron supplementation to improve absorption |
| AGA Clinical practice update on management of Iron deficiency Anemia: Expert review—> IV iron? | -IV iron for patient who do not tolerate oral iron or if pt has condition in which oral iron is not likely to be absorbed -Gastric bypass surgery -Inflammatory bowel disease -IV iron formulations that can replace deficits in 1-2 infusions are preferred to those requiring more |
| What is the definition of Iron Overload? | -Serum ferritin > 1000 ng/mL -Tsat exceeds 50% |
| Pts with Iron overload would see iron deposit where in their bodies? | Mostly in the liver resulting in cirrhosis |
| What do we do when we get iron overload—> 1st line therapy? | 1st line is reduction therapy—> therapeutic phlebotomy (draw blood out); If Hgb will not tolerate phlebotomy(i.e. Hgb too low), iron chelation therapy can be used |
| What is iron chelation therapy? | -small molecules that bind very tightly to metal ions and render the metal ion chemically inert -used for iron overload |
| What are the options for Iron chelation therapy? *be aware of generic names | -Deferoxamine (Desferal)- IV -Desferasirox (Exjade and Jadenu)- PO -Deferiprone (Ferriprox)- PO |
| Remember the types of anemias and causes: 1. Microcytic anemia? 2. Normocytic anemia? 3. Macrocytic Anemia? | 1. Iron deficiency Anemia 2. Anemia of Chronic disease; Anemia of CKD 3. B-12 deficiency (Pernicious Anemia); Folic Acid deficiency |
| ***What are drug therapies that can cause Aplastic Anemia? *aplastic anemia is where you have an anemia that affects all 3 cell lines (bone marrow does not make any cell lines) | -NSAIDS (phenylbutazone) -Sulfonamides -Acyclovir -Gancyclovir -Chloramphenicol -Anti-Epileptics (Phenytoin, carbamazepine, valproic acid) -Nifedipine *treatment is to remove offending agent; EXAM question “which agent can cause aplastic anemia?” |
| Anemia of Chronic Disease (ACD) is one of the most common forms of anemia ______. Usually a diagnosis of exclusion. Can coexist with IDA and anemia of CKD. Includes Anemia of cancer | clinically *diagnosis of exclusion—> means that we can’t find any other cause |
| In Anemia of Chronic Disease, your MCV is normal. What you have going on is the iron homeostasis for iron is not appropriate so you iron present but not able to use it because of? | inflammation (limits the utilization of iron for erythropoiesis); -decreased erythropoietin (inflammation affects formation and biological activity of erythropoietin; -Cytokines interfere with differentiation and proliferation of erythroid progenitor cells |
| What are diseases causing Anemia of Chronic Disease (ACD)? | -Chronic infections (endocarditis, Tuberculosis, HIV); -Chronic inflammation (RA, Gout, SLE) -Malignancies |
| Main thing to understand for Anemia for Chronic Disease from a lab value prospective is that the MCV is from ___-___ and there’s no other things like B12, folate or iron going on in deficiencies | 80-100 *remember its a diagnosis of exclusion; Lab findings for ACD are: normocytic/normochromic; ⬇️ serum iron; Serum ferritin is normal or increased; TIBC ⬇️; relative EPO deficiency |
| Anemia of cancer can lead to Tumor cells affecting RBC _______ (shortened) And less making of red cells | Survival |
| Therapies for Anemia of Chronic Disease (ACD) is to? | correction of underlying disease— ideal choice -other options are iron supplementation; RBC transfusions; ESAs (Epoetin Alfa, Epoetin Alfa-epbx, darbepoetin alfa) |
| Anemia during Chemotherapy: Can you get chemotherapy if Hgb/Hct low? | Any Hgb/Hct level—> give chemo *we don’t care, red cells have a short 1/2 life and arrange for RBC transfusion if appropriate |
| ESA therapy in cancer pts? remember ESA raise Hgb levels, stimulate red cells; why not? Feel better? Thought it would improve their QoL | Increase risk of mortality—> theory is that cancer cells have receptors for the EPO products, so potentially, we were stimulating cancer growth by giving these as well as stimulating red cells production |
| ***What are the benefits of giving ESA? | Prevent transfusions; Gradual improvement in fatigue |
| ***What are the risks of ESA? | -Increased mortality and tumor progression -Risk of thromboembolism -Risk of hypertension -Risk of pure cell aplasia (rare) |
| ESA dosing in cancer pts can be ______ and even __ or __ weeks. Admin of EPO doses: Darbepoetin 2.25 mcg/kg given? 200 mcg? 300 mcg? Erythropoietin Alfa 40,000 U given? 150 U/kg given? | weekly; 2-3; -q weekly; q 2 week; q 3 week; -q week; q TIW *all are given as SQ |
| ***How do we use ESAs in cancer pts? For pts with cancer & CKD, what is the treatment? | Consider ESA with kidney dosing |
| ***How do we use ESAs in cancer pts? For pts with myelosuppressive chemotherapy & INCURABLE & Hgb below 10 g/dL & iron, B-12, folate levels normal (ALL MUST BE PRESENT). What is the treatment? | ESAs recommended *not going to give ESAs to pt with curable cancer, not trying to make it worse |
| When placing a EPO products on a pt, what do we monitor? | -monitor baseline iron levels (ACD) and periodically -At time of each injection (usually weekly)—> Hgb (10 or higher, skip dose), Hct, BP, Clinical assessment for fatigue, s/sx of PE and DVT |
| When monitoring EPO effects in pts, you should assess response in ACD—> will see? | increase in reticulocyte count (remember these are the immature red cells) in a couple of days |
| When Assessing response in ACD (Anemia of Chronic Disease), what is the goal? | -Normal Hgb levels -If pt receiving EPO, Hgb—> 10 g/dL and d/c EPO if Hgb > 10 g/dL, can restart if Hgb < 10g/dL; If no response in 8 weeks (2 months) and no change in Hgb levels and you verified that B-12, folate, iron levels sufficient, d/c drug |
| When your MCV > 100, your anemia is considered ______. Two most common causes of this anemia? | macrocytic; B-12 and folate deficiencies *order both labs because symptoms are similar and both cause elevated MCV |
| B-12 anemia is an annual incidence that is more common in women. Prevalence increases in older adults: 40%. What is the etiology of Vit B-12 deficiency anemia? | -inadequate intake/utilization -malabsorption syndromes (lack of intrinsic factor-pernicious anemia) -METFORMIN |
| Pathophysiology of Pernicious B-12 anemia is? | Lack of Intrinsic factor due to autoimmune disorder; diagnostic test is Schilling test (antibody test for Intrinsic Factor) or a parietal cell biopsy *pts overtime stop making intrinsic factor so it can be due to an autoimmune disorder *Pernicious anemia is Lack of intrinsic factor) |
| What are symptoms of B-12 deficiency anemia? | Early stage—> asymptomatic; Later stage—> Beefy tongue (unique symptom), fatigue; Neurological manifestations (paresthesia, numbness, memory loss, psychosis *neurological manifestations can become permanent |
| Goals of Treatment of B-12 deficiency anemia includes? | -Reversal of hematologic manifestations -Replacement of body stores (pernicious anemia—> must replace with IM or IV B-12) ⭐️ -Prevention or reversal of neurologic manifestations (early tx is key to preventing neurologic manifestations from being PERMANENT) *oral replacement won’t work due to mechanism of pernicious anemia (missing the Intrinsic factor that helps you absorb it in your stomach, so oral will not get absorbed); has to be IM or IV (special) |
| Dietary sources of B-12 can come from? | Beefy liver; Breakfast cereal; Milk, Yogurt; Fish (tuna, haddock, salmon, trout) |
| B-12 replacement therapies for Pernicious Anemia- Severe Malabsorption, give? *indicated in pts exhibiting neurological symptoms | Cyanocobalamin IM (replace with IM) |
| B-12 replacement therapies for Pernicious Anemia- Mild malabsorption, give? | Still give IM due to Pernicious anemia |
| B-12 replacement therapies for Dietary deficiency, give? | supplements or foods fortified with B-12 or Cyanocobalamin PO until normalize |
| What are the ADR’s of Cyanocobalamin? (RARE) | -Hyperuricemia -Hypokalemia -Sodium retention -Rebound thrombocytosis (precipitate thromboembolic events) |
| Folic Acid Deficiency Anemia is? | • One of the most common vitamin deficiencies in the US • Occurs in alcoholics and pregnant women • Medications that interfere with folate utilization – Sulfasalazine, TMP-SMX, methotrexate |
| What is the etiology of Folic Acid deficiency Anemia? | – Increased need for folate is not matched by an increased intake – Dietary folate intake does not meet recommended needs – Folate excretion increases |
| Why is preventing Folic Acid deficiency Anemia important? | • Periconceptual period is IMPORTANT (*right around the time of conception)* • Deficiency has been associated with neural tube defects ⭐️ – Malformations of the spine (spina bifida) ⭐️ – Skull – Brain (anencephaly) |
| How do we prevent Folic Acid Deficiency Anemia? dose? | • 400 mcg of folic acid per day recommended for women planning to become pregnant or who are pregnant |
| Symptoms of Folic Acid Deficiency Anemia includes? | • Breathlessness • Tiredness • Dizziness • Rapid, weak pulse rate • Palpitations • Headaches • Paleness (of skin and inside eyelids) • Children – slow growth |
| What is the Treatment of Folic Acid Deficiency Anemia? | • Folic acid 1 mg daily is sufficient for replacement • Malabsorption syndromes – 5 mg • Therapy should continue for 4 months • If Chronic condition caused deficiency, pt may need long term folic acid administration *doses just remember the one for pregnancy (400 mcg or 0.4 mg per day) |
| Banana bags are used for alcoholics to replace nutritional deficits. What goes into a banana bag? | Thiamine (100 mg) + Folic Acid (1 mg) + Multivitamin injection (MVI) (1 ampule) added into 1 L of dextrose 5% and Normal Saline *one to two grams of Mg sulfate may also be added to the mixture |
| Summary Big points for anemia: | -Check Hgb/Hct (female—> Hgb <12 or Hct <36); Male Hgb <13.5 or Hct < 41 -If yes, Pt has ANEMIA! -If no, they are fine -check the MCV to determine the cause of the anemia and if pt can get the RBC transfusion |
| Summary: If other cell lines are ok, what is the MCV and RBC transfusion—> If MCV < 80, then it’s a _______ anemia. Check serum iron, ferritin, TIBC—> | microcytic; -If iron-deficiency anemia, look for sources of chronic bleeding – heavy menstrual bleeding, consider colonoscopy |
| Summary: If other cell lines are ok, what is the MCV and RBC transfusion—> If MCV 80-100, then it’s a _______ anemia. —> | normocytic; -Any inflammatory conditions that could result in anemia of chronic disease -Diagnosis of exclusion *fix the underline disorder and try to help the pt (difficult to treat) |
| Summary: If other cell lines are ok, what is the MCV and RBC transfusion—> If MCV > 100, then it’s a _______ anemia. —> | Macrocytic; -Check Vit. B 12, folate -Consider liver disease, alcoholism, myelodysplastic syndrome -Check medications: hydoxyurea, AZT, methotrexate *People can be deficient in both, and answer is to treat both at same time |
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