Evaluation and Management of Anemia in Family Practice

Anemia In Family Practice

Dr Marie AndradesAssistant Professor

Department of Family MedicineThe Aga Khan University

Hemoglobin below the normal reference level for the age and

sex of the individual

Anemia In Family Practice

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

Prevalence:

Anemia In Family Practice

South East Asia 70%

National Health Survey Pakistanchildren < 5 years 60%Adolescent 47%Adult women 43%Adult men 19%

In Elderly, commonest anemia are iron deficiency & chronic disease

Clinical Features (symptoms):

Anemia In Family Practice

Infants• Irritability, restlessness• Anorexia, sleepiness• Behavioral changes

School going children

Clinical Features (symptoms):

Anemia In Family Practice

Common• Fatigue/Muscle weakness• Headache/Lack of concentration• Faintness/dizziness

Exertional dyspnoea/palpitation

Angina/intermittent claudication

Clinical Features (signs):

Anemia In Family Practice

Non-specific• pallor, tacycardia, flow mummer

Specific• koilonychia, angular stomatitis, glossitis• neuropathy, dementia, paraplegia• jaundice, bone deformities, leg ulcer

History:

Anemia In Family Practice

Physiological Inadequate intake Blood loss Malabsorption

Comorbids Drug history Family history

Consequences of iron deficiency:

Anemia In Family Practice

Children with Hb < 10g/dl have reduced cognitive & psychomotor function despite a return to normal hematological status

Reduced immunity and growth failureDeficiency in dopamine receptors

Anemia In Family Practice

Recommendations for Screening in 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

Anemia In Family Practice

Classification of Anemia (Mean Corpuscular volume):

Microcyctic – MCV < 80 fL

Macrocytic – MCV > 100 fL

Normocytic – MCV 80 – 100 fL

Anemia In Family Practice

Microcytic Anemia

Iron deficiency

Hemoglobinopathy

Sideroblastic Lead poisoning Occasionally chronic disease

Anemia In Family Practice

• If no obvious cause

• Serum Ferritin:• < 15ug/l : Iron deficiency

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

Anemia In Family Practice

Evaluation continued..Serum Iron TIBC Peripheral

smear

Iron deficiency

Decreased Increased Hypochromic

Target cells Basophilic stippling

Normal Increased

IncreasedThallasemia

DiamorphicNormalIncreasedSideroblast

Hypo/normo chromic

DecreasedDecreasedChronic disease

Anemia In Family Practice

Thallesemia Mentzer index: MCV/RBC count. <13 Hb Electrophoresis

Sideroblastic anemia Bone marrow exam

Iron deficiency anemia in men/post menopausal women Gastro-intestinal endoscopy Barium studies

Evaluation continued..

Anemia In Family Practice

Rx of iron deficiency:Children

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

Check Hb at 4 weeks

AdultsFerrous sulphate/gluconate/fumarate

Iron polymaltose complex

Elemental iron 200mg/day

Parental IronNormal Hb/PatientHbXwt(kg)X2.2

Anemia In Family Practice

Diet for Iron Deficiency:In adults, limit milk intake - 500 mL/day

Avoid excess caffeineEat 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

Anemia In Family Practice

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

Anemia In Family Practice

Evaluation continued... Macrocytes present

With megaloblast MCV>120B12 deficiency, Folic acid deficiency

Drugs (cytotoxic, anticonvulsant, antibiotic)

Without megaloblast MCV 100-120Liver disease, Alcoholism

Hypothyroidism, Myelodysplastic disorders

Anemia In Family Practice

Vitamin B12 deficiency (causes)Nutritional

Malabsorption states food bound (prolonged use of gastric acid

blockers)

lack of intrinsic factor/parietal cells (pernicious anemia,atrophic gastritis, gastrectomy)

Ileal disease (crohn’s, bacterial overgrowth, tape worm)

Anemia In Family Practice

Vitamin B12 deficiency (Rx)

Oral: 1000-2000 mcg/day for 2 weeks

1000 mcg/day for life

Intramuscular:1000 mcg alternate days to a total of 3-5 mg

1000 mcg every 3 months

Intranasal: Nascobal

Anemia In Family Practice

Folic acid deficiency (causes & Rx)

Malnutrition Anticonvulsants Old age

Rx:

Oral folate I mg/dayreduces artherosclerosis if associated with elevated homocysteine levels

Anemia In Family Practice

Normocytic anemia (causes):

Increased RBC loss/destructionacute blood loss, hypersplenism, hemolytic disease

Decreased RBC productionprimary cause i.e bone marrow disorders

secondary cause i.e CRF, liver disease, chronic disease

Over-expansion of plasma volumepregnancy, overhydration

Anemia In Family Practice

Normocytic anemia (evaluation):

CBC, Peripheral smear & Retic count

Normal retic and mild anemia >9gm/dl chronic disease

Normal or decreased retic with leucopenia/thrombocytopenia/blast cell

bone marrow exam

Elevated retic count Direct Coombs test: +ve autoimmune HA

-ve mechanical or other HA

Anemia In Family Practice

Conclusion:

• Evaluation based on MCV

• Microcytosis is due to iron deficiency unless proven otherwise

• Megaloblast help in differentiating cause of macrosytosis

• CBC and reticulocyte count essential for normocytic anemia