Types of Anaemias and their Management S. Moncrieffe, Pharm.D., - - PowerPoint PPT Presentation

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Types of Anaemias and their Management S. Moncrieffe, Pharm.D., - - PowerPoint PPT Presentation

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Types of Anaemias and their Management S. Moncrieffe, Pharm.D., MPH, Dip.Ed., RPh. PSJ CE Mandeville Hotel April 27, 2014 Objectives At the end of the presentations participants should be able to: 1. Define the term Haematopoiesis 2.

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  • S. Moncrieffe, Pharm.D., MPH, Dip.Ed., RPh.

PSJ CE – Mandeville Hotel April 27, 2014

Types of Anaemias and their Management

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Objectives

At the end of the presentations participants should be able to:

  • 1. Define the term Haematopoiesis
  • 2. Understand the diagnostic and laboratory

parameters for evaluating Haematopoetics cells

  • 3. Differentiate the types of Anaemias
  • 4. Recommend and evaluate the treatment for the

different types of Anaemias

  • 5. The pharmacist role in the management of

Anaemia.

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Haematopoiesis

The formation and maturation of blood cells and their derivatives.

More than 6 billion cells produced per kilogram of body weight every 24 hours

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Haematopoiesis

  • Important to a wide array of physiologic

functions

–Haemostasis –Immunity –Oxygen delivery.

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HEMATOPOIETIC SYSTEM

  • Consists of three primary cell components:

–Platelets –Erythrocytes – red blood cells –Leukocytes – white blood cells

  • neutrophils, eosinophils, basophils,

monocytes/macrophages, lymphocytes, and plasma cells.

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  • Average human being has about 1.7L of

bone marrow.

  • Immature hematopoietic cells are found

mainly in the bone marrow.

Bone Marrow

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Average (Normal Range) Adult Blood Cell Concentration

White cell count (cells/mm3)

7,800 (4,400–11,300)

Red cell count (× 106/mm3)

Male 5.21 (4.52–5.90) Female 4.60 (4.10–5.10)

Haemoglobin (g/dL)

Male 15.7 (14.0–17.5) Female 13.8 (12.3–15.3)

Haematocrit

Male 0.46 (0.42–0.50) Female 0.40 (0.36–0.45)

Mean corpuscular volume

(fl/red cell) 88.0 (80.0–96.1)

Platelet count (cells/mm3)

311,000 (172,000–450,000)

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Anaemia

  • Definition:

–a condition in which the number of red blood cells or their oxygen-carrying capacity is insufficient to meet physiologic needs.

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Three approaches are commonly used to classify or describe Anaemias:

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Morphologic Classification of Anaemias:

RBC MORPHOLOGY NORMOCYTIC Macrocytic (MEGALOBLASTIC) MICROCYTIC

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Etiologic Classification of Anaemias:

ETIOLOGY DEFICIENCY CENTRAL PERIPHERAL

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Classification of Anaemias

PATHOPHYSIOLOGY EXCESSIVE LOSS EXCESSIVE DESTRUCTION INTRA-RBC FACTORS DECREASED PRODUCTION

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EXCESSIVE BLOOD LOSS ACUTE LOSS TRAUMA GI Bleed CHRONIC LOSS GI Bleeding NSAIDS Malignancy Menorrhagia

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Treatment of Acute Blood Loss

  • Whole Blood
  • Fresh-Frozen Plasma (FFP)
  • Packed Red Blood Cells(PRBCs)
  • Crystalloid Volume Expansion

–(NaCl 0.9%)

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Classification of Anaemias

PATHOPHYSIOLOGY EXCESSIVE LOSS EXCESSIVE DESTRUCTION

Haemolysis

INTRA-RBC FACTORS DECREASED PRODUCTION

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EXCESSIVE RBC DESTRUCTION RBC ANTIBODIES Haemolytic transfusion reaction DRUGS Drug-induced Haemolysis PHYSICAL TRAUMA Artificial heart valve EXCESSIVE RBC REMOVAL Hypersplenism

Cephalosporins* Levofloxacin Methyldopa NSAID, Penicillin

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Terminologies

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  • Haematocrit - proportion of total blood volume

that is composed of red blood cells. Indicates whether there is too few or too many red blood cells

  • Reticulcocytosis - where there is an increase in

reticulocytes (immature red blood cell). It is commonly seen in anaemia. They are seen on blood films

  • Schistocytes – fragments of red blood cells
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  • Bilirubin - a waste product of the normal

breakdown of red blood cells. Higher level may indicate increase rate of RBC destruction.

  • Haemoglobinuria – haemoglobin is found in

abnormally high concentrations in the urine.

  • Haptoglobin – bind & transport free hemoglobin to

blood-forming organs. Binding with free hemoglobin causes serum (free) haptoglobin to decrease

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Terminologies

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Excessive RBC Destruction

  • some consequences
  • Increased free haemoglobin
  • Decreased hematocrit
  • Reticulcocytosis (if chronic)
  • Schistocytes on peripheral smear
  • Increased indirect bilirubin
  • Haemoglobinuria
  • Decreased haptoglobin
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  • Remove offending causes (drugs)
  • Supportive care – transfuse PRN Hb < 8 Gm/dl
  • Pain management
  • Iron supplementation PRN if not transfused

and if iron studies suggests deficiency

  • Splenectomy if indicated, which warrants

vaccination

Excessive RBC Destruction

Treatment

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Classification of Anemias

PATHOPHYSIOLOGY EXCESSIVE LOSS EXCESSIVE DESTRUCTION INTRA-RBC FACTORS DECREASED PRODUCTION

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INTRA-RBC FACTORS DISORDERS OF Hgb SYNTHESIS SICKLE CELL THALASSEMIAS PORPHYRIAS G6PD DIFICIENCY Caution: NSAID, Tylenol, Sulfa drugs, Quinolones etc.

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Sickled RBC

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Thalassemia

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Treatment of Disorders of Haemoglobin synthesis

  • Supportive care
  • Hydration (SSD)
  • Analgesia (SSD)
  • Transfusion
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Classification of Anemias

PATHOPHYSIOLOGY EXCESSIVE LOSS EXCESSIVE DESTRUCTION INTRA-RBC FACTORS DECREASED PRODUCTION

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Common Deficiencies that cause Anaemia

  • Iron
  • Vitamin B12
  • Folate

Must differentiate to know how to treat properly.

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Terminologies

Mean Corpuscular Volume (MCV) – Focuses on the size of the cell itself – Describes mean size of a single RBC – Normal is 80 – 100fl

** fl - femtoliter

Erythropoietin (EPO) – The hormone that stimulates stem cells in the bone marrow to make more red blood cells. EPO is made by cells in the kidney. These cells release more EPO when blood oxygen levels are low.

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Iron Deficiency Anaemia

  • Decreased Hgb and haematocrit
  • Decrease mean corpuscle volume (MCV) -

microcytic

  • Patients may or may not be symptomatic:

– Koilonchia – Angular stomatis – Glossitis – Pica

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Normal RBC Microcytic RBC

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Iron Deficiency Anaemia

  • Further investigate

– Ferritin = stored iron (low) – Serum iron = free in plasma (low) – Transferrin saturation = % of carrier protein saturated with iron (low) – TIBC = ability of transferrin to bind in vitro (high)

Several anaemias resemble iron deficiency anaemias. If ALL lab criteria are not met, the patient does NOT have iron deficiency anaemia.

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Iron Deficiency Anaemia

Treatment

  • Replace iron orally or parenterally (IV,IM)

– Oral replacement

  • Consider salt form
  • Divided doses
  • Beware of decreased iron absorption

– food ↓es absorption and F by 50%

  • Beware of drug-drug interactions

– Quinolones – Thyroid hormones » Space 3 -4 hours from iron

  • Iron needs acid to be absorbed.
  • Goal is 200mg elemental iron per day
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Iron Deficiency Anaemia Response to treatment

  • HGB should increase by 1% to 2 % weekly
  • Reticulocytosis occurs within 3 – 4 days
  • A haematocrit increase of <2% after 3

weeks is not acceptable

  • Treatment to continue for 3 to 6 months

(if losses cease)

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Cobalamin (Vitamin B12)

  • Essential vitamin that is required for the

development of red blood cells.

  • Used to make the protective coating

surrounding nerves (mylein sheath).

  • Found mainly in animal based foods such as

meat, poultry, milk products, eggs and fish.

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Cobalamin (B12) Deficiency

  • Decrease hemoglobin and haematocrit
  • Increase MCV (>100fl) – macrocytic
  • Body stores of cobalamin are very high

compared to daily dietary intake

  • Deficiency develops over years
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Normal RBC Macrocytic RBC

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Cobalamin (B12) Deficiency Who is at risk?

  • Elderly with poor dentition
  • Achlorhydric patients
  • Strict vegetarians (vegans)
  • Partial gastrectomy
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Cobalamin (B12) Deficiency

  • Further investigate

–Decrease serum B12 (cobalamin) –Mild leukopenia and thrombopenia maybe present –Decrease reticulocyte count –Neurologic or psychiatric abnormalities –Pernicious Anaemia (lack intrinsic factor)

  • Schilling test
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Cobalamin (B12) Deficiency-

TREATMENT

  • If able to absorb B12, 250mcg PO daily until

normalization of haematologic parameters

  • If pernicious Anaemia, 1000mcg IM daily 2-3

weeks, then 1000mcg IM weekly until normalization of hematologic parameters. Give 1000mcg IM monthly for life.

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Cobalamin (B12) Deficiency-

TREATMENT

  • It is a medical myth that patients with

pernicious anaemia can not be treated with

  • ral B12. Dose of 1-2mg po daily x 1 to 2

weeks then 1mg po daily. Can result in adequate absorption. (d/t passive absorption

which can occur if dose is high enough)

  • Because of serious neurologic consequences of

deficiency, both compliance and adequate response must be assessed and assured.

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Caution!!

  • Administration of FOLIC ACID in a B12 deficient

patient will reverse the macrocytosis but will NOT slow progression of neurologic damage.

  • Always conform diagnosis with serum B12 levels.
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Folate Deficiency

  • Decrease Hgb and haematocrit
  • Increase MCV (>100fl) - macrocytic
  • Looks like B12 deficiency (need to

differentiate)

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Folate Deficiency

  • Persons at risk are:

–Elderly (poor dentition) –Alcoholic patients –Pregnant/lactating mothers w/o supplementation

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Folate Deficiency

  • Dietary insufficiency (lack of vegetables)
  • Haemodialysis
  • Drugs

– Phenytoin – Rifampin – Barbiturates – Ethanol – Sulfasalazine or other chronic sulfonamide

  • e.g. Cotrimoxazole
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Folate Deficiency

  • Body stores of folate are not high

compare to daily intake

  • Deficiency can develop over weeks to

months

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Folate Deficiency

  • Further investigate:

– Low serum folate (perhaps) – Folate can be released from lysed cells into serum: serum conc. Will appear normal – Low RBC folate

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Folate Deficiency –

Treatment

  • RULE OUT B12 DEFICIENCY
  • Administer 1 – 5mg folic po daily
  • Assess

– Recticulocytosis in 2 -4 days – Hbg should rise within 2 weeks – Hgb should be normal within two months – MCV will normalize over 2 months

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Anaemia of Chronic Disease

  • Associated with chronic illness of >2 months

duration (may be less)

  • Most strongly associated with inflammatory

conditions or infections or malignancies

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Pathophysiology of Anaemia of Chronic Disease

  • Iron release from marrow is blocked
  • Erythropoietin production (e.g. Anaemia of

Chronic Renal Disease)

  • RBC lifespan is shortened
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Pharmacist role in the Management of Anaemia.

  • Understand the different types of Anaemia
  • How to differentiate types of Anaemia
  • Know the different treatment regimens
  • Be familiar with the different iron salts and

their properties

  • Make the correct treatment recommendation

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THANK YOU

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