Anemia

1. Anemia Mary Ann Hudson Danny Townsend The Ohio State University, College of Nursing July 26, 2010

2. Client Chief Complaint 48-year-old African-American Female with chief complaint of unexplained fatigue despite adequate sleep at night. Patient denies depression, insomnia, ETOH abuse, smoking, black or tarry stools, or prescription medications. Hospitalizations only for normal labor and delivery of her children. Hx of sinus complaint. Symptoms of perimenopause, namely irregular periods and occasional heavy periods. The Ohio State University, College of Nursing 2

3. Client Social History Client works long hours as a high school principal and is experiencing acute job stress. Client lives with her husband who also works in public school administration; their children are grown and live out of the home. Client reports that “life is good.” Client drinks wine at a level of 7-12 units/week. The Ohio State University, College of Nursing

4. Client Physical Exam Ht: 5’8” Wt: 127 lbs V/S: 155/80, 72, 14 All physical findings in head to toe exam are within normal limits except: Blood Pressure Palpation of a neck mass on upper right side of thyroid The Ohio State University, College of Nursing 4

5. Client Diagnostic Laboratory Results and Diagnosis CBC WDL except: RBC 3.7 M/uL Normal: 4.2-5.9 Hgb 10.1 g/dL Normal: 12-16 Hct: 30.6 % Normal: 37-48% Serum Ferritin: 10 Fe Deficiency significant at 0-12 Monocytes Electronic: 8.1% Normal: 3-7% Diagnosis is Iron Deficiency Anemia The Ohio State University, College of Nursing 5

6. Diagnosis Criteria for Fe Deficiency Anemia Manifestation of hypochromic, microcytic anemia as indicated by low RBC volume and low hemoglobin concentration. Common in infants, children and adolescents during rapid growth, pregnant and lactating women, patients with kidney disease, patients with gastrectomy or small bowel diseases, GI blood loss, and in menstrating women, especially pre and perimenopausal women who may already have low iron stores. The Ohio State University, College of Nursing

7. Anemia and Index of Suspicion With anemia diagnosis, it is important to discover underlying cause, especially in light of other significant clinical findings. Evaluating kidney function, investigating potential areas of blood loss (GI tract, for example), and ruling out cancer and infection are vital. Consider a chemistry panel, occult blood tests, and imaging studies for masses. This client, due to an increased blood pressure, increased monocytes, and palpable neck mass, should be evaluated for cancer, infection, and kidney function. Her neck mass should be imaged/biopsied, and chemistry panels drawn to evaluate BUN and creatinine. She can be treated for her Fe deficiency anemia while undergoing continued studies. In the event she is cleared of high index concerns, she should receive follow-up for BP. The Ohio State University, College of Nursing

8. Iron Deficiency Anemia develops due to an absence of adequate iron in the nucleus of the iron-porphyrin heme ring, which together with globin chains forms hemeglobin. Hemeglobin reversibly binds oxygen so that it can be delivered from the lungs to systemic tissues. In the absence of enough iron, small RBCs with insufficient hemoglobin are formed--microcytic hypochromic anemia. Clinically, this leads to fatigue, pallor, dizziness, exercise intolerance, and cardiovascular compensation like tachycardia and vasodilation. Pathophysiological Review The Ohio State University, College of Nursing 8

9. Treatment and Therapeutic Objectives Patient should achieve RBC, Hbg, Hct, and serum ferritin values within normal limits with resolution of clinical symptoms and minimal GI or systemic disturbance. Underlying causes of iron deficiency anemia should be addressed and resolved. Treatment for iron deficiency anemia should continue 3-6 months after the correction of the cause of iron loss. Patient should have blood draws every 2-3 weeks for the first 2 months of treatment, and periodically thereafter. If patient is unable to tolerate one formulation of Fe replacement therapy, others should be attempted. The Ohio State University, College of Nursing 9

10. Pharmacological Therapy Options for Iron Deficiency Anemia Oral Iron Therapy: A wide variety of oral preparations for iron deficiency anemia are available, all are iron salts and include ferrous sulfate hydrated, ferrous sulfate desiccated, ferrous gluconate, and ferrous fumarate. Patient can be consulted regarding preferences for drops, tablets, elixir, etc. based on compliance and tolerance. Parenteral Iron Therapy: This therapy is reserved for patients who cannot tolerate oral iron therapy, have chronic anemia that cannot be reversed with oral therapy alone, and includes patients with significant underlying causes for their anemia; for example, malabsorption syndromes. The Ohio State University, College of Nursing 10

11. Drug Classes Used to Treat Fe Deficiency Anemia

12. The Ohio State University, College of Nursing

13. 13 The Ohio State University, College of Nursing

14. 14 The Ohio State University, College of Nursing

15. 15 The Ohio State University, College of Nursing

16. 16 The Ohio State University, College of Nursing

17. 17 The Ohio State University, College of Nursing

18. Drug Selected • Ferrous Sulfate Slow Fe 90 Tabs: $34.97 Fer-In-Sol 100 mL: $27.97 Ferrous Sulfate 220 EXLIX: $19.47 Ferrous Sulfate 325: 100 tabs $30.00 The Ohio State University, College of Nursing

20. P-Drug Selection The Ohio State University, College of Nursing

21. P-Drug: Ferrous Sulfate • Pharmacodynamics: Forms the nucleus of the iron-porphyrinheme ring which together with globin forms hemoglobin. Hemoglobin reversibly binds oxygen and provides oxygen delivery from the lungs to tissues. • Pharmacokinetics: Absorption: Absorption is increased when iron stores are depleted or red blood cell production is increased. Conversely, high iron blood concentrations decrease absorption. The Ohio State University, College of Nursing

22. P-Drug: Ferrous Sulfate • Metabolism:Cytochrome P450 family(CYP450) • Excretion: No physiological system of elimination exists for iron, and it can accumulate in the body to toxic amounts; however, small amounts are lost daily in the shedding of skin, hair, and nails; and in feces, perspiration, breast milk (1.1 to 1.4 mg per day), menstrual blood, and urine.1 to 1.4 mg per day), menstrual blood, and urine The Ohio State University, College of Nursing

23. P-Drug: Ferrous Sulfate • Common Side Effects: Constipation; darkened or green stools; diarrhea; nausea; stomach upset. Severe allergic reactions (rash; hives; itching; difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue); black, tarry stools; blood or streaks of blood in the stool; fever; vomiting with continuing sharp stomach painContraindications: An allergy to any iron supplementAcute hepatitisHemosiderosis or hemochromatosis (conditions involving excess iron in body)Hemolytic anemiaHad repeated blood transfusions The Ohio State University, College of Nursing

24. Patient Provider Interaction • Review foods high in iron such as liver, seafood, nuts, beans, green leafy vegetables, whole grains, and fortified foods. • Review foods that block absorption of iron such as coffee, tea, egg whites. Avoid these while eating foods high in iron. • Review appropriate administration and use of medications The Ohio State University, College of Nursing 24

25. Patient Provider Interaction • Review causes and symptoms of anemia. • Vitamin C can help the body absorb iron better. • Tests used assess iron status: Serum ferritin, transferrin saturation, CBC, total iron binding capacity and MCV. • Increase fiber if constipation occurs. • Consult for mass on thyroid gland and BP. *If patient later presents with thyroid deficiency levothyroxine is not absorbed with Fe therapy. The Ohio State University, College of Nursing

26. Patient Provider Interaction • Don’t take iron with other vitamins and minerals. Take it with a full glass of water. Take it the same time every day. • Extended release iron is not recommended due to absorption issues. • Follow-up appointments will be needed. • If symptoms continue, seek medical help. • Use stool softeners, if needed The Ohio State University, College of Nursing 26

27. Board of Nursing Formulary • Nutrients and Nutritional agents may be found in the formulary on page 5. • CTP holders may prescribe PO vitamins and minerals such as magnesium sulfate and other trace elements to include iron. The Ohio State University, College of Nursing 27

28. Written Prescription • Nurse Practitioners of Columbus • 1111 Speedway Lane • Columbus, Ohio • (614)293-1111 • Name: Thomas James DOB: 07/07/1952 • Address: 1212 Nobodyknows • Columbus, Ohio 43215 • RX Ferrous Sulfate 325mg tablets Take one tablet three times each day Dispense 90(ninety) tablets • Refills:1 Best Nurse Practitioner 08/06/2010 The Ohio State University, College of Nursing 28

29. Clinical Studies • Study: Between March 1997 and April 1998, 3075 community-dwelling adults were recruited to participate in the Health, Aging, and Body Composition(Health ABC) Study. • Objective: Comparison study to determine whether the hemoglobin cutoff value below which adverse events occur is lower in blacks than in whites. This examined whether longitudinal effects of anemia vary by race in a cohort of well-functioning older adults. • Results: The baseline prevalence of WHO-defined anemia was significantly higher in older blacks compared to older whites. 21% of black women and 26% of black men were anemic at baseline, whereas 7% and 14% of white women and men. • Conclusion: Further outcome-based research is required to determine hemoglobin thresholds for defining anemia in racial/ethnic subpopulations and to evaluate treatment. (Patel et al, 2007) The Ohio State University, College of Nursing 29

30. Clinical Studies • Study: Randomized, double-blind, placebo-controlled study examined side-effects of 3 iron salt formulations using equal dosages of elemental iron. • Objective: To investigate the tolerability and side effects of 3 iron salt formulations used in the treatment of iron-deficiency anemia. • 1496 patients with comparable degree of anemia. • Results: All 3 iron salt formulations had comparable side-effects rates. • Conclusion: Ferrous Sulfate remains the standard first-line treatment for iron-deficiency anemia given its low cost, effectiveness, tolerability, and low cost. (Mcdairmidet al, 2002) The Ohio State University, College of Nursing 30

31. Clinical Studies • Study: 412 female blood donors were recruited. There was an initial visit and three subsequent a follow-up visits at four month intervals. Each was given 21 tablets of 150 mg ferrous sulfate tablets or a placebo to be taken three times daily for one week after blood donation. Their Hgb, Hct, serum ferritin, TIBC, and percent saturation of TIBC were tested throughout the course of study. • Objective: Compare blood studies between groups to determine effectiveness of iron sulfate in preventing anemia. • Result: The group taking ferrous sulfate showed no significant difference between the mean initial and the mean final result however there was significant decline in mean hb, hct, serum iron , serum ferritin, and percent saturation in the group taking the placebo. • Conclusion: Iron supplementation therapy can be considered as one of the strategies to promote safe blood transfusions in women. The Ohio State University, College of Nursing

32. References Johnson, D.E., & Mcdiarmid, T. (2007). Are any oral formulations better tolerated than ferrous sulfate. The Journal of Family Practice. 3(2),125-35. Dharmarajan, L.& Dharmajan, T.(2007) Anemia in older adults: an indication requiring evaluation. Family Practice Recertification. 29(6), 6-25. Chen, A.C. & Visscher, H.C. (1995). Detection and treatment of iron deficiency anemia in women of childbearing age. Preventive Care Update. 2(4), 135-138. 32 The Ohio State University, College of Nursing

33. References Epocrates Rx (2010). [database for PDA, Version 8.10]. San Mateo, CA: Epocrates, Inc. Retrieved from http://www.epocrates.com Alleyene, M. & Mcdonald, E.K. (2008). Individualized treatment for iron-deficiency anemia in adults. The American Journal of Medicine. 121(11), 943-948. Patel et al.(2007). Racial variation in the relationship of anemia with mortality and mobility disability among alder adults. Clinical Trails and Observations. 108(11), 4663-4670. 33 The Ohio State University, College of Nursing

34. (PDA) uCentral from Unbound Medicine http://www.nlm.nih.gov/medlineplus/druginfo/natural/patient-iron.html Basic & Clinical Pharmacology, by Bertram G. Katzung: The McGraw-Hill Companies, Inc., 11th edition, 2009. References The Ohio State University, College of Nursing

35. Questions? ? ? ? The Ohio State University, College of Nursing 35