I. Definitions. V. Evaluation A. History B. Physical Exam C. Laboratory evaluation D. Bone marrow examination E. Specialty referrals

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2 I. Definitions II. III. Red blood cell life cycle Iron metabolism IV. Causes of anemia A. Kinetic approach 1. decreased production 2. increased destruction 3. blood loss B. Morphologic approach 1. normocytic 2. microcytic 3. macrocytic V. Evaluation A. History B. Physical Exam C. Laboratory evaluation D. Bone marrow examination E. Specialty referrals VI. Treatment 1. Iron 2. Blood transfusion 3. Other therapies

3 6 Habits of Ineffective Anemia Evaluation & Treatment

4 Recognize ineffective habits in the evaluation & treatment of anemia. Replace with effective ones.

5 6 Habits of Ineffective Anemia Evaluation & Treatment 1. Giving iron to all anemics 2. Refilling iron to infinity 3. Transfusing to hemoglobin = Referring all anemics to GI 5. Referring all anemics to Hematology 6. Ignoring high MCV

6 What defines anemia? Hemoglobin Hematocrit RBC count

7 Hemoglobin g/dl

8 Hematocrit %

9 RBC count millions 0f cells per microl whole blood Accurate Reliable

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11 Mean Corpuscular Volume (MCV) average volume (size) of RBCs microcytic fl normocytic macrocytic

12 Red Cell Distribution Width (RDW) variation in RBC size 11.6 to 14.6 homogenous anisocytosis

13 Who needs iron? poor intake malabsorption 1 high requirements

14 Who needs iron? Nosebleeds Vomiting blood Rectal bleeding Heavy menstrual periods Bleeding gums Hematuria Bleeding from trauma or surgery

15 History diet bleeding living conditions

16 fatigue dizziness headache chest pain dyspnea joint pain feeling cold TISSUE HYPOXIA

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18 Glossy tongue (Atrophic glossitis) Spooning of nails (Koilonychia)

19 Low MCV (microcytosis) High RDW (anisocytosis) High platelet count

20 What test to order? FERRITIN

21 Ferritin reference range Men: ng/ml Women: ng/ml < 15 DEFINITE iron deficiency 16 to 50 likely iron deficiency 51 to 100 unlikely deficiency > 100 NO deficiency

22 Measures iron stores in SERUM Acute phase reactant Elevated in liver disease

23 FROM THE QUEST MENU Is ferritin included in an iron profile? Ferritin is a separate order. Iron profile has serum iron, unbound iron & total iron binding capacity (TIBC)

24 IRON PROFILES Unsaturated transferrin Iron bound to transferrin NORMAL IRON DEFICIENCY LATE PREGNANCY INFLAMMATION IRON OVERLOAD

25 Other helpful tests in iron deficiency Iron Profile Low serum iron Low iron saturation High unbound iron High TIBC RBC morphology (peripheral blood smear) Hypochromic Microcytic Anisocytosis Poikilocytosis

26 Genius order Reticulocyte panel severe iron deficiency Reticulocyte count bleeding Reticulocyte hemoglobin Immature retic fraction

27 Empty stomach Vitamin C? Dairy products, cereals, fiber, tea, coffee, eggs Antacids, H2 blockers, PPIs, calcium supplements

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29 Hemoglobin 8.5 GFR = 40 FEV1 = 35 % EF = 30%

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34 Hemoglobin 9.5 HYPOADRENALIN

35 Anemia of chronic disease Chronic inflammation Chronic infection FERRITIN Iron Binding Capacity

36 IRON AVAILABILITY

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38 Lab clues to anemia of chronic disease Normal MCV (normocytic) Low-normal RDW (homogenous) Reticulocyte count low to normal

39 Burr cells (echinocytes) Spur cells (acanthocytes) Target cells Target cells, Teardrop cells

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41 Ferritin Rheumatoid arthritis COPD Chronic liver disease Anemia of chronic disease + NSAID gastritis + malnutrition + bleeding varices Iron deficiency anemia Reticulocyte henoglobin

42 Treatment goals: Build up iron stores Resolve blood loss 2 Ferritin = Hb can lag behind, check in 2-3 mos Stop iron 3-6 mos. after normal hemoglobin

43 Transfusing when Hb < 10 = 3

44 BLOOD TRANSFUSION < 6 gm/dl : Definite 6 to 7 : Most likely, esp. in acute loss 7 to 8 : With symptoms, cardiovascular or pulmonary disease 8 to 10 : Selected cases severe smptoms, ongoing bleeding, coronary ischemia > 10 : Don t even think about it

45 IRON INFUSION GI Intolerance to oral iron Replete stores in few visits Ongoing blood loss exceeds capacity of oral iron Absorption issues Reduce need for transfusion

46 4 Dysphagia Reflux Vomiting blood Dark stools Belly pain Chest pain Aspirin NSAIDs Alcohol

47 Rectal bleed Hemorrhoids Belly pain Rectal pain Constipation Diarrhea Weight loss Family hx

48 CONFIRM Iron Deficiency FERRITIN Peripheral blood smear Reticulocyte panel HIGH retic count with bleeding LOW retic Hb

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50 Important: Ferritin More important: Fecal Immunochemical Test (FIT)

51 Refer to Hematology 5 Anemia of decreased production Bone marrow disorders Anemia of increased destruction Hemolytic anemias

52 Bone marrow disorder: Aplastic anemia Low RBCs Low WBCs Low Platelets

53 Bone marrow function: Reticulocyte count Peripheral blood smear

54 Bone marrow disorder: Myelodysplasia Risk of leukemia Insidious onset, elderly Splenomegaly High MCV High vitamin B12

55 Myelodysplasia: Peripheral blood smear Hypochromic Tear drop cell Red cell fragments

56 Hemolytic anemia Splenomegaly Jaundice

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58 Hemolytic anemia High LDH Low Haptoglobin High indirect bilirubin High reticulocyte count Smear: schistocytes, spherocytes

59 Macrocytosis 6 MCV > 100 Reticulocyte count > 2% Response to blood loss Response to hemolysis Normal or low reticulocyte count < 0.5% Abnomal DNA metabolism Bone marrow disorders Lipid abnormalities Unknown

60 MACROCYTOSIS, low-normal reticulocyte count Abnormal DNA metabolism Vitamin B12 deficiency Folate deficiency Drugs (MTX, 6MP, chemotx, anti-hiv) Bone marrow disorders Myelodysplastic syndromes Lipid abnormalities Liver disease Hypothyroid

61 MACROCYTOSIS, low-normal reticulocyte count Other or unknown mechanism Alcohol abuse Multiple myeloma Smoking, chronic lung disease Severe hyperglycemia Leukocytosis Post spelenectomy

62 Vitamin B12 deficiency

63 Vitamin B12 deficiency Autoimmune disease Type 1 diabetes Hypothyroid Grave s disease

64 Vitamin B12 deficiency on metformin on alcohol

65 Vitamin B12 deficiency

66 Vitamin B12 (cobalamin) deficiency Low or normal reticulocyte count Pancytopenia Low RBC Low WBC Low Platelets Macroovalocytes, Nuclear hypersegmentation of neutrophils

67 Vitamin B12 (cobalamin) levels pg/ml < 200 definitely deficient probably deficient Methylmalonic acid HIGH in B12 deficiency > 300 not deficient

68 Folate ng/ml < 2 definitely deficient 2-4 probably deficient Homocysteine HIGH in folate deficiency > 4 not deficient

69 1. Before prescribing iron confirm iron deficiency by history, exam, FERRITIN 2. STOP refilling iron prescription when hemoglobin or ferritin goal is reached

70 3. Restrict transfusion to lower hemoglobin levels (6-7). Consider symptoms & clinical scenario. 4. Before referring to GI confirm iron-deficiency, obtain FIT test

71 5. Hematology gets anemias of decreased production & increased destruction 6. High MCV has many causes. Treat low vitamin B12 & folate.

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