Anemia in Clinical Practice

7/30/2019 Anemia in Clinical Practice

1/24

Evaluation and Management of

Anemia in Family Practice

Anemia In Family Practice

Dr Marie AndradesAssistant Professor

Department of Family Medicine

The Aga Khan University


2/24

Hemoglobin below the normalreference level for the age and

sex of the individual


Reference range:

1-3 days:14.5 - 22.5g/dl 6 months to 2 years:10.5 - 13.5g/dl

Adult Men:13-18 g/dl

Adult Women:11.5-15.5g/dl


3/24

Prevalence:


South East Asia70%

National Health Survey Pakistanchildren < 5 years 60%

Adolescent 47%

Adult women 43%Adult men 19%

In Elderly, commonest anemia are

iron deficiency & chronic disease


4/24

Clinical Features(symptoms):


Infants

Irritability, restlessness

Anorexia, sleepiness

Behavioral changes

School going children


5/24

Clinical Features(symptoms):


Common

Fatigue/Muscle weakness

Headache/Lack of concentration

Faintness/dizziness

Exertional dyspnoea/palpitation

Angina/intermittent claudication


6/24

Clinical Features(signs):


Non-specific

pallor pucat, tacycardia, flow

mummer

Specific

koilonychia, angular stomatitis,

glossitis

neuropathy gangguan saraf, dementia

pusing, paraplegia


7/24

History:


Physiologicalanimia yang

bukan penyakit

mis pada wanitahamil

Inadequate intake

kurang asupan

Comorbids

Drug history

Family

historyherediter mis talasemia,

G6PD


8/24

Consequences of iron deficiency:akibat2 yang ditimbulakan oleh

kekurangan besi


Children with Hb < 10g/dl havereduced pengurangan cognitive

kecerdasan & psychomotor

keterampilan function despite a returnto normal hematological status

Reduced immunity and growth failure

Deficiency in dopamine receptors


9/24


Recommendations for Screeningin children:

US preventive service task force &

American academy of family physicians

high risk between 6-12 months of age American academy of pediatrics

all infants between 6-12 months of age


10/24


Classification of Anemia(Mean Corpuscular volume):

Microcyctic MCV < 80 fL

Macrocytic MCV > 100 fL

Normocytic MCV 80100 fL


11/24


Microcytic Anemia

Iron deficiency

Hemoglobinopathy penyakit

yang menyerang Hb seperti

talasemia

Sideroblastic

Lead poisoning


12/24


If no obvious cause

Serum Ferritin: < 15ug/l : Iron deficiency

Normal or: Serum Iron /Increased Total Iron binding capacity(TIBC)

Apabila ditemukan mikrositik pada hapusan

darah maka dilakukan pemeriksaan serum


13/24


Evaluation continued..Serum Iron TIBC Peripheral

smear

Irondeficiency

Decreased Increased Hypochromic

Target cellsBasophilic

stippling

Normal

Increased

Increased karena hematopoesis

inefektif sehingga meningkatkan

absorsi besi di saluran cernaThallasemi

a

DiamorphicNormalIncreased karena kerusakannya pada

molekul porfirin bukan pada besinyaSideroblast

Hypo/normo

chromic

DecreasedDecreased akibat makrofag

menimbun dan menahan besi

sehingga eritrosit kekurangan

besi. Alasan makrofag menahan

besi adalah untuk menghambatpertumbuhan bakteri sebab

bakteri dapat tumbuh subur jika

Chronic

disease


14/24


Thallesemia

Mentzer index: MCV/RBC count.


15/24


Rx of iron deficiency:Children

Elemental iron 3-6mg/kg/day, contd.. 4-6 months

Check Hb at 4 weeksAdults

Ferrous sulphate/gluconate/fumarate

Iron polymaltose complex

Elemental iron 200mg/day

Parental Iron

Normal Hb/PatientHbXwt(kg)X2.2


16/24


Diet for Iron Deficiency:In adults, limit milk intake - 500 mL/dayAvoid excess caffeine

Eat iron-rich foods

Protein foods Vegetables

Meats Greens Fish & Shelfish Dried peas & beans Eggs

Fruits Grains

Dried fruit Iron-fortified breads Juices Dry cereals

Most fresh fruits

Oatmeal cereal


17/24


Macrocytic anemia(evaluation):

Peripheral film & Reticulocyte count

Macrocytes absent

Normal reticulocyte

artifactual (hyperglycemia/natremia, cold

agglutinin, and extreme leucocytosis)

High reticulocyte

hemolysis, bleeding or nutritional response

to folate/B12/iron


18/24


Evaluation continued...Macrocytes present

With megaloblast MCV>120

B12 deficiency, Folic acid deficiency

Drugs (cytotoxic, anticonvulsant, antibiotic)

Without megaloblast MCV 100-120

Liver disease, Alcoholism

Hypothyroidism, Myelodysplastic disorders


19/24


Vitamin B12 deficiency(causes)

Nutritional

Malabsorption statesfood bound (prolonged use of gastric acid

blockers)

lack of intrinsic factor/parietal cells

(pernicious anemia,atrophic gastritis,

gastrectomy)

Ileal disease (crohns, bacterial overgrowth,

tape worm)


20/24


Vitamin B12 deficiency (Rx)

Oral: 1000-2000 mcg/day for 2

weeks1000 mcg/day for life

Intramuscular:1000 mcg alternate days to a

total of 3-5 mg1000 mcg every 3 months

Intranasal: Nascobal


21/24


Folic acid deficiency(causes & Rx)

Malnutrition

Anticonvulsants

Old age

Rx:

Oral folate I mg/day

reduces artherosclerosis if associated withelevated homocysteine levels


22/24


Normocytic anemia(causes):Increased RBC loss/destruction

acute blood loss, hypersplenism, hemolytic diseaseDecreased RBC production

primary cause i.e bone marrow disorders

secondary cause i.e CRF, liver disease, chronicdisease

Over-expansion of plasma volume

pregnancy, overhydration


23/24


Normocytic anemia(evaluation):CBC, Peripheral smear & Retic count

Normal retic and mild anemia >9gm/dl

chronic disease

Normal or decreased retic withleucopenia/thrombocytopenia/blast cell

bone marrow exam

Elevated retic count

Direct Coombs test: +ve autoimmune HA

-ve mechanical or other HA


24/24


Conclusion:

Evaluation based on MCV

Microcytosisis due to iron deficiencyunless proven otherwise

Megaloblast help in differentiating cause

of macrosytosis

CBC and reticulocyte count essential for

normocytic anemia

Documents

Anemia in Clinical Practice