Anemia-Case Study

Case 1

Chief Complaint• “I feel weak and tired and think I have low

blood.”

HPI

Walter Adams is a 71-year-old man who presents to the hospital complaining of being fatigued, particularly over the past week. Five days ago, he noted dark and black stool that has continued. He went to a local health clinic and was told that he was very anemic and needed to go to a hospital for a blood transfusion. He states that he takes ibuprofen, 600-mg tablets 3 or 4 times a day, for “old-age” arthritis, which is especially bad in his knees. He denies hematemesis but has been nauseated, dizzy, and lightheaded. He was evaluated 7 years ago for GI bleeding but has no recollection of a diagnosis being made.

PMH

• Gastrointestinal bleeding 7 years ago• CAD with 98% blockage of right coronary artery;

angioplasty done 3 years ago• von Recklinghausen disease (neurofibromatosis)• Chronic headaches

• PSHInguinal hernia repair last year

• FHMother died in childbirth in 1937; father died of cancer at age 93

SH• No smoking; quit in 1982. No alcohol; quit in

1990. He is married.

ROSNo fever or chills; (+) burning pain in stomach after meals; denies heartburn or melena; good appetite, has one daily BM; no significant weight changes over past 5 years; (+) fatigue, tires easily; (–) paralysis, fainting, numbness, paresthesia, or tremor; headache only occasionally; has myopic vision; (–) tinnitus or vertigo; has hay fever in spring;(–) cough, sputum production, or wheezing; denies chest pain, edema, dyspnea, or orthopnea; denies nocturia, hematuria, dysuria, or Hx of stones; (+) unilateral joint pain in right knee for over 5 years

• MedsIbuprofen 600 mg 3 or 4 times a day for knee painAntacids PRN for stomach pain

• AllCodeine (upset stomach)Aspirin (upset stomach)

Physical Examination

• VSBP 168/71, P 79, RR 22, T 36.2°C, pulse oximetry 99% on room air;Wt 61 kg, Ht 5'11''SkinMultiple neurofibromatosis-related nodules over entire face and body

• HEENTPERRL; EOMI; conjunctivae are pale; upper and lower dentures inplace; membranes moist; normal funduscopic examination with noretinopathy noted; deviated nasal septum; no sinus tenderness;oropharynx clear

• Neck/Lymph NodesNeck supple without masses; trachea midline; no thyromegaly, (–) JVD

• Thorax Lungs clear to A & P; breath sounds equal bilaterally

• CVRegular rhythm with a soft systolic murmur;

• AbdSoft, tender to palpation; no masses or organomegaly; normalPeristalsis

• Genit/RectNormal external male genitalia; rectal examination (+) stool guaiac

• MS/ExtSlight joint enlargement, with pain and tenderness noted, and limited ROM of right knee; crepitation noted on dorsiflexion of joint; changes consistent with OA; strong pedal pulses bilaterally; no peripheral edema; spooning of fingernails

• NeuroA & O × 3; DTR 2+; normal gait

• OtherPeripheral blood smear: hypochromic, microcytic red blood cells

Labs

What should be immediate plan?

• Infuse 4 units PRBCs• Ferrous sulfate 325 mg TID• Begin esomeprazole (Nexium) 40 mg IV daily• Refer to gastroenterologist

CLINICAL COURSE The next day, the patient was seen by a gastroenterologist and underwent

both EGD and colonoscopy.

Findings included severe gastritis, with multiple small bleeds noted with small hiatal hernia and normal duodenum.

Colonoscopy results were normal.

Final assessment: chronic, severe IDA secondary to unspecified GI blood loss.

Gastroenterology consult concluded that the bleeding was likely related to either NSAID-induced gastritis and/or small bowel arteriovenous malformations (AVMs) perhaps associated with neurofibromatosis.

Problem Identification

1.a. What potential drug therapy problems does this patient have?

1.b. What signs, symptoms, and laboratory findings are consistent with the finding of iron deficiency anemia secondary to blood loss?

• Desired Outcome2. What are the goals of pharmacotherapy for this patient’s anemia?

• Therapeutic Alternatives3.a. What nondrug therapy may be effective for managing this anemia?3.b. What pharmacotherapeutic alternatives could be used to treat this patient’s anemia?

• Optimal Plan4. Outline an optimal pharmacotherapy plan for this patient.

• Outcome Evaluation5. What clinical and laboratory parameters are necessary to evaluate the therapy for achievement of the desired therapeutic outcome and to detect and prevent adverse effects?

• Patient Education6. What information should be provided to the patient to enhance compliance, ensure successful therapy, and minimize adverse effects?

CLINICAL COURSE Mr. Adams’ hemoglobin and hematocrit slowly increased as a result of the PRBCs to 12.6 g/dL and 40.8% by the fourth day of

hospitalization. At that time, he was discharged and referred for outpatient management of his chronic iron deficiency anemia. In addition to the recommended anemia therapy, Walter is given a prescription for omeprazole 20 mg po once daily.

On his return to the clinic 1 month later for evaluation, he has no complaints of adverse effects from his medications. He indicates that he is fairly compliant with his iron therapy and is not experiencing any dose-limiting side effects.

At that time, he is instructed to return in 3 months. Laboratory values continue to improve and his next follow-up visit is in 6 months. Laboratory values at 1, 3, and 6 months into therapy are shown in Table 105-2.

SELF-STUDY ASSIGNMENTS

• 1. Assume that on the patient’s initial presentation the physician wanted to correct the anemia using parenteral iron dextran. Calculate the correct total dose iron dextran for this patient, and write a comprehensive order for its administration.

2. Make a list of oral medications that should not be taken close to the time of iron administration; note the medications for which ferrous salts may interfere with their absorption.

3. Perform a literature search to determine the evidence supporting use of various sustained-release iron preparations, and determine the incremental cost of such products.

4. What monitoring steps should be incorporated into your pharmaceuticalcare plan to: a. Check for recurrence of signs/symptoms of iron deficiency due to his chronic GI bleed?b. Educate the patient concerning his risk of GI bleed associated with NSAID therapy and how he can minimize this risk?c. Monitor for recurrence of signs and symptoms of gastropathy?d. Monitor for efficacy of new treatments (such as acetaminophen or glucosamine) for his osteoarthritis?

Case history- 2A 65-year-old woman presents to the medical out-patient department with a history of fatigue. She has in the last few months been undergoing adjuvant cytotoxic chemotherapy for a node-positive resected breast cancer. The patient is pale, but no other abnormalities are noted. Her full blood count shows a haemoglobin level of 9.8 g/dL with a mean corpuscular volume of 86 fL; other haematological indices and serum transferrin are normal. Her faecal occult blood is negative.

She is started on oral iron sulphate and given weekly injections of erythropoietin 40,000 U subcutaneously. Three months later, her haemoglobin level has risen to 13.5 g/dL, but she presents to the Accident and Emergency Department with acute-onset dysphasia and weakness of her right arm. Her supine blood pressure is 198/122mmHg. Her neurological deficit resolves over 24 hours and her blood pressure settles to 170/96 mmHg. She has no evidence of cardiac dyshythmias or of carotid disease on ultrasonic duplex angiography, and her serum cholesterol concentration was 4.2 mmol/L.

• QuestionWhat led to this patient’s acute neurological episode? Does she require further therapy?

AnswerHer mild normochromic-normocytic anaemia was most likely related to her cytotoxic cancer therapy. Treatment with iron and erythropoietin was indicated. She was not iron deficient, and using iron and erythropoietin in combination for a haemoglobin 10 g/dL is well justified. The most common dose-limiting side effects of erythropoietic drug administration are hypertension and thrombosis, which are implicated in the left middle cerebral transient ischaemic attack (TIA) she has suffered.

Treatment with erythropoietin and iron should be stopped, and her blood pressure monitored over 8–12 weeks. If hypertension is solely related to the erythropoietin therapy, her blood pressure should normalize and no further treatment will be required. In retrospect it may have been prudent to have more closely monitored her erythropoietic therapy and once her Hb 12 g/dL stopped it as this may have avoided her neurological event.