Anemias (Clinical Pharmacy II: hematology)

Objectives
To describe the components of the (Full Blood Examination) FBE and how to interpret the results To describe the laboratory data associated with different causes of anaemia To describe the treatment of common anaemias

Haematology lab data

Includes:
red cells white cells platelets

FBE (Full Blood Examination)

red blood cell count haemoglobin haematocrit red blood cell indices mean cell volume mean cell haemoglobin mean cell haemoglobin concentration
reticulocyte count white blood cell count platelet count & mean platelet volume

Red blood cell count

Normal range:
Males: 4.6-6.2 x1012 cells/L Females: 4.2-5.4 x1012 cells/L

Count of red blood cells in a given amount of blood Decrease=anaemia

Associated with a proportionate decrease in Hb

Red Blood cells

Haemoglobin
Normal range:
Males: 13.5-17.5gm/dl Females: 12-16gm/dl

Provides a direct indication of the oxygen carrying capacity of the blood Proportionately low in anaemia

Hemoglobin

Haematocrit (Packed cell volume)

Normal range:
Males: 42-52% Females: 37-47%

Percentage volume of blood composed of erythrocytes % usually ~ 3x Hb (in g/dl)

abnormal when cells abnormal size/shape

Low in anaemia

FBE (Full Blood Examination)

red blood cell count haemoglobin haematocrit red blood cell indices mean cell volume mean cell haemoglobin mean cell haemoglobin concentration
reticulocyte count white blood cell count platelet count & mean platelet volume

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Red blood cells indices

Assess size & Hb content of the red blood cells Calculated (not measured) from Hb, RBC count & Hct Consist of:
Mean corpuscular volume (MCV) Mean corpuscular hemoglobin (MCH) Mean corpuscular hemoglobin concentration (MCHC)

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Mean Cell Volume (MCV)

An estimate of the average volume of RBCs Hct/RBC count Macrocytic cells: abnormally large, increased MCV
Eg Vit B12 & folate deficiency

Microcytic cells: abnormally small, decreased MCV

Most common cause is iron deficiency and thalasemias Decreased MCV implies abnormality in Hb synthesis

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Mean Cell Haemoglobin (MCH)

Hb/RBC count Hypochromic
Low MCH, pale RBCs eg iron deficiency anaemia (insufficient iron to manufacture usual amount of Hb)

Hyperchromic
High MCH Eg B12/folate deficiency

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Mean Cell Haemoglobin Concentration (MCHC)

Hb/Hct Routinely decreased in iron deficiency anaemia

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FBE (Full Blood Examination)

red blood cell count haemoglobin haematocrit red blood cell indices mean cell volume mean cell haemoglobin mean cell haemoglobin concentration

reticulocyte count white blood cell count platelet count & mean platelet volume

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Reticulocyte count
Final cell form that precedes development of mature RBCs
Normally present in small numbers in circulating blood Persist in circulation for 1-2 days then mature into erythrocytes

Reticulocyte count is an indirect measure of recent RBC production

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Reticulocyte count
Normally 1% of circulating RBCs replaced daily
Retic count ~ 1%

Acute blood loss

Associated with increase in retic count reflects attempt by bone marrow to compensate for lack of circulating erythrocytes
> increased RBC production allows more reticulocytes to escape into the general circulation earlier than normal

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Reticulocyte count
Untreated anaemia 2o iron, folate or B12 deficiency
Retic count decreased unable to meet demand for increased RBC production Replacement of lacking factor (iron,folate,vit. B12) causes rapid increase in retic count (5-7 days)
> Can be used to monitor response to treatment

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FBE (Full Blood Examination)

red blood cell count haemoglobin haematocrit red blood cell indices mean cell volume mean cell haemoglobin mean cell haemoglobin concentration

reticulocyte count white blood cell count platelet count & mean platelet volume

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Laboratory assessment of anaemia

Definition: decrease in either RBC count or Hb concentration Causes:
Decreased production of erythrocytes
> Lack of nutrients (iron, folate, B12) > Bone marrow disorders (eg aplastic anaemia) > Bone marrow suppression (eg chemotherapy)

Increased destruction of erythrocytes

> Haemolytic anaemia (inherited or acquired)

Acute blood loss

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Laboratory assessment of anaemia

Signs & symptoms depend on severity & rapidity of development
Eg severe acute blood loss causes more dramatic symptoms than chronic iron deficiency anaemia Mild anaemia: often asymptomatic Moderate : pallor, weakness, fatigue, Severe: SOB, tachycardia, palpitations

Signs & symptoms relate to decreased O2 delivery to tissues +/- hypovolaemia (if anaemia due to acute blood loss)
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Laboratory assessment of anaemia

Patient with anaemia -low Hb/RBC

Macrocytic High MCV

Normocytic

Microcytic Low MCV

Possible causes: Vit B12 deficiency Folate deficiency Drug induced BM toxicity

Possible causes: Acute blood loss anaemia Haemolytic anaemia Anaemia of chronic disease Chronic renal failure

Possible causes: Iron deficiency Anaemia of chronic disease

Helpful lab tests: Vitamin levels Schillings test

Helpful lab tests: Retic count Antiglobulin test

Helpful lab tests: Red Blood cells Distribution Width RDW

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Macrocytic anaemia
Most commonly
Vit B12 deficiency Folate deficiency

Can be drug/alcohol related

Bone Marrow toxicity: antineoplastics Altered folate metabolism: anticonvulsants, methotrexate, alcohol, etc B12 malabsorption: colchicine
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Macrocytic anaemia
Untreated folate/B12 deficiency can lead to severe anaemia
In B12 deficiency can also cause neuropsychiatric disease eg peripheral neuropathy, spinal cord degeneration, cognitive deterioration The Schilling test is a medical investigation used for patients with vitamin B12 deficiency. The purpose of the test is to determine if the patient has pernicious anemia. (How ??)

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Vitamin B12 deficiency

Normally large body stores compared with daily requirements
Takes a long time to become deficient Several years for abnormalities

Normal intake is dietary (meat, eggs, dairy)

Deficiency possible in vegans Gastric acid & pepsin required to cleave B12 from proteins and release the free B12 > Elderly may be less likely able to complete this step Free B12 binds to intrinsic factor (IF) for absorption > Some patients may develop autoantibodies to IF (eg Pernicious anaemia)
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Vitamin B12 deficiency

Symptoms
GI: loss of appetite, smooth/sore tongue, diarrhoea or constipation CNS: paraesthesia, loss of co-ordination, tremor, irritability, somnolence, taste/smell abnormalities Haematopoietic: anaemia

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Vitamin B12 deficiency

Serum vitamin B12 levels
Sensitive for detection of B12 deficiency BUT
> Low concentration doesnt necessarily mean tissue deficiency
Could also be: pregnancy, folate deficiency, iron deficiency,, vegetarian diet, etc

> Shouldnt be ignored but should be considered in conjunction with clinical findings

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Vitamin B12 deficiency

Schilling test (radioactive B12) can be used to determine if deficiency due to
Inadequate intake Impaired absorption/deficiency of IF
> A normal result shows at least 5% of the radio-labeled vitamin B12 in the urine over the first 24 hours.

The test is not currently in general use; easier to check for antibodies to IF & parietal cells. Vit B12 Deficiency can be treated with IM replacement

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Folate deficiency
Body folate stores limited
Anaemia can arise from folate deficient diet in 4-5 months

Causes:
Inadequate dietary intake Alcohol (inhibits absorption) Pregnancy (requires increased intake) Malabsorption syndromes Medications eg methotrexate, cotrimoxazole, phenytoin

Clinical presentation: haematological changes same as for B12 deficiency BUT NO neurological changes

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Folate deficiency
One of the steps in folate metabolism also requires B12
Replacement should be after B12 replacement to avoid serious & irreversible neurological damage

Diagnosis:
Serum folate Red cell folate

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Serum folate (7-40nmol/L)

Usual first test for folate deficiency May become subnormal after only 3 weeks of inadequate intake Low level does not necessarily indicate body folate depletion (with subsequent haematological changes) but may precede it
Eg may be low with recent alcohol intake; doesnt mean body depletion May be falsely normal if patient given folate supplementation

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Red cell folate (360-1400nmol/L)

Direct measure of red cell folate stores Falls after 4/12 of negative folate balance Low level implies significant depletion of folate stores Subnormal levels may also occur in severe B12 deficiency & return to normal after B12 replacement alone

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Treatment of B12/folate deficiency

B12 replaced as hydroxocobalaminCyanocobalamin
Starting dose 1000mcg IM daily or alternate days for 1-2 weeks
> Saturates B12 stores in the body

Weekly until normalisation of FBE Monthly Should be associated with a rapid response otherwise questionable diagnosis
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Treatment of B12/folate deficiency

Folic acid replenished orally
Starting dose 1-5mg/d Replenishes body stores within 2-3 weeks Can be ceased after 4 months if underlying cause treated Chronic administration: 500mcg/d Treatment can also reverse some haematological changes from B12 deficiency but wont reverse neurological changes

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Laboratory assessment of anaemia

Patient with anaemia -low Hb/RBC Macrocytic High MCV Normocytic Microcytic Low MCV

Possible causes: Vit B12 deficiency Folate deficiency Drug induced BM toxicity

Possible causes: Acute blood loss anaemia Haemolytic anaemia Anaemia of chronic disease Chronic renal failure

Possible causes: Iron deficiency Anaemia of chronic disease

Helpful lab tests: Vitamin levels Schillings test

Helpful lab tests: Retic count Antiglobulin test

Helpful lab tests: Red Blood cells Distribution Width (RDW)

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Microcytic anaemia
Most commonly associated with iron deficiency (also hypochromic)
Decreased MCV is a late indicator of iron deficiency Can also be caused by thalassaemia (hereditary haemolytic anaemia), & Anaemia of Chronic Disease (ACD)

Iron required for Hb synthesis

Most obtained by recycling Only small amounts required to be absorbed daily

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Iron storage & transport

Hb in circulating red cells Bound to protein in macrophages called FERRITIN
Excess storage as haemosiderin Some ferritin found in serum & can be measured Mainly in liver, spleen & bone marrow

Transport in plasma is by TRANSFERRIN

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Investigation of iron status

Serum iron Serum transferrin or iron binding capacity
Main iron transporting protein in the circulation

Serum ferritin
Reflects bodys iron stores

Serum Iron
Concentration doesnt fall until bodys iron stores are depleted
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Serum iron
Low serum iron not specific for iron deficiency in the presence of inflammatory disease & some other chronic diseases (eg infection, malignancy), these also cause a drop in serum iron

Therefore cant use serum iron alone to diagnose iron deficiency Diagnostic error avoided by simultaneous measurement of transferrin & ferritin
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Transferrin
Carrier protein which binds most of the iron present in serum Synthesis is inversely proportional to body iron stores
Transferrin concentration increases when iron stores are reduced

Levels also fall during inflammatory processes

Low serum iron + low transferrin is NOT diagnostic of iron deficiency (often associated with ACD)

Can also be expressed as Total Iron Binding Capacity (TIBC)

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Ferritin
Primary iron storage protein Markedly reduced in iron deficiency anaemia Most sensitive index of early iron deficiency
Low levels detected when iron stores exhausted but before the serum iron is affected

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Summary of lab data in iron deficiency anaemia

Decreased: RBC Hb Hct MCV MCH MCHC Serum iron ferritin
Increased: Transferrin Erythropoietin Unchanged Reticulocyte count

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Time frame
First change is loss of storage iron (decreased ferritin) If deficiency continues, loss of serum iron follows
Stimulates increase in transferrin

When enough iron is depleted to affect erythropoiesis, anaemia develops

Microcytic (low MCV), hypochromic (low MCH)

Clinical presentation: progressively worsening weakness, fatigue, pallor, SOB, tachycardia, palpitations, numbness, tingling, glossitis
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Treatment of iron deficiency anaemia (I: oral)

Dietary supp.plus therapeutic iron. Nonmeat iron is poorly absorbed, beverages like dairy and tea should be avoided after meals, ascorbic acid and orange juice are encouraged. Therapy: Oral preferred unless high doses needed or oral not tolerated Many iron salts available, supplement different amounts of elemental iron Ferrous salt preferred because more readily absorbed Generally given as ferrous sulphate > 325mg dried FeSo4=105mg iron Side effects common; mainly GI (nausea, abd. pain, constipation, diarrhoea, dark stools)

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Oral Iron TX
Drugs that decrease iron absorption: Ca++, Mg, Al-containing drugs, tetracyclines, H-2 antagonists Drugs affected by iron: levodopa, flouroquinolones, tetracyclines form chelates (complexes), levothyroxine efficacy is reduced.

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Treatment of iron deficiency anaemia (II: parenteral)

Iron Dextran:
Indications
> When oral therapy is contraindicated > When enteric absorption of iron is defective > When patient non-compliance or persistent gastrointestinal intolerance makes oral therapy impractical.

Has been associated with fatal anaphylaxis

> Test dose required

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Iron polymaltose (Dextran)

Administered IM or IV IV infusion recommended only when IM impractical or unacceptable
Suitable for use in hospitals only

Formula for calculating dose (in PI) 2mL IM alt days until total dose given OR whole dose as IV infusion

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Dosing table for iron polymaltose (from PI)

Body weight Kg 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 mL 3 6 10 13 16 19 25 27 30 32 34 36 38 40 42 45 47 49 Hb 60 g/L Ampoules 1.5 3 5 6.5 8 9.5 12.5 13.5 15 16 17 18 19 20 21 22.5 23.5 24.5 mL 3 6 9 11 14 17 23 24 26 28 30 32 33 35 37 39 41 43 Hb 75 g/L ampoules 1.5 3 4.5 5.5 7 8.5 11.5 12 13 14 15 16 16.5 17.5 18.5 19.5 20.5 21.5 mL 3 5 7 10 12 15 20 22 23 24 26 27 29 30 32 33 34 36 Hb 90 g/L ampoules 1.5 2.5 3.5 5 6 7.5 10 11 11.5 12 13 13.5 14.5 15 16 16.5 17 18 mL 2 4 6 8 11 13 18 19 20 21 22 23 24 25 26 27 28 29 Hb 105 g/L ampoules 1 2 3 4 5.5 6.5 9 9.5 10 10.5 11 11.5 12 12.5 13 13.5 14 14.5

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Iron sucrose
Fewer adverse effects than iron polymaltose Does not require a test dose Primarily used for IDA in haemodialysis patients and for patients hypersensitive to iron polymaltose Dose: 100mg IV over 5mins 1-3 times/week

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Laboratory assessment of anaemia

Patient with anaemia -low Hb/RBC Macrocytic High MCV Normocytic Microcytic Low MCV

Possible causes: Vit B12 deficiency Folate deficiency Drug induced BM toxicity

Possible causes: Acute blood loss anaemia Haemolytic anaemia Anaemia of chronic disease Chronic renal failure

Possible causes: Iron deficiency Anaemia of chronic disease

Helpful lab tests: Vitamin levels Schillings test

Helpful lab tests: Retic count Antiglobulin test

Helpful lab tests: Iron studies RDW

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Normocytic anaemia
3 main causes:
Acute blood loss anaemia Haemolytic anaemia Anaemia of chronic disease (chronic renal failure)

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Acute blood loss anaemia

Dramatic drop in RBCs & Hb MCV, MCH, MCHC unchanged If patient has normal bone marrow, response is increased production of RBCs
Associated with increase in reticulocyte count

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Haemolytic anaemia
Lysis of erythrocytes-reduced life span of RBC
Decreased RBC, Hb, Hct Increased Lactate dehydrogenase

Red cell indices remain unchanged Reticulocytosis Free Hb increased (ie Hb unattached to RBCs) Can be genetic or acquired-Examples: sickle cell anemia, thalassemias, G-6-phosphate deficiency Acquired: Autoimmune, infectious, drugs and chemicals Antiglobulin tests positive if immune mediated haemolytic anaemia
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Antiglobulin tests
Commonly called Coombs tests Immune haemolytic anaemias caused by binding of antibodies &/or complement to erythrocyte cell membrane 2 types of tests
Direct antiglobulin tests (DAT) used to detect Abs bound to erythrocytes Indirect antiglobulin test (IAT) used to detect Abs present in serum

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Hemolytic Anemia
Genetic
Sickle cell disease > Recessive hereditary condition affecting afro and caribbean ethnicity > The membrane of RBC containing Hb S (normal Hb A) is damaged leading to crescent-shaped cells which are less flexible and hence impaired blood flow through the circulation. > Patients with the severe form have chronic anemia, arthralgia, anorexia, fatigue and splenomegaly. > These patients have more crises precipitated by infection, dehydration, hypoxia, acidosis and fever. These crises include infarcts of body organs and long bones which can be very painful.
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Sickle cell

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Sickle cell Contd

Management: Pneumococcal vaccine and haemophilus influenza vaccine or low dose prophylactic antibiotic therapy are indicated in patients with repeated infections. Transfusions are common but are complicated by iron overload and the risk of blood-borne virus transmissions. Removal of offending agent, antibiotics at the first sign of infection, hydration and effective pain management are mainstay of treatment. Morphine is pain reliever of choice.

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Thalassemias
Many mutations in hemoglobin (alpha, beta chain) have been identified causing a range from mild to severe manifestations > occur mainly in mediterranean, north African and Middle Eastern populations The anemia causes erythropoetin production to increase and results in bone marrow proliferation, in severe cases bone deformity and growth retardation occur. The spleen is acively involved in removal of mature abnormal cells from the circulation leading to its enlargement.

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Thalassemias
Many patients are transfusion-dependent which may cause iron overload. Splenoctomy can help some patients. Erythropoeitin and hydroxyurea have been used but more clinical data needed Genetic counselling programs are available in many countries

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Glucose-6-phosphate dehydrogenase deficiency

Enzyme has a major role in keeping hemoglobin in a reduced form to help RBCs keep up with oxidative stress. many different forms, mild-severe
> About 15% of black Americans, common in the Middle East > Usually anemia occurs when exposed to trigger factor like stress, fever, fava beans but more severe form exists without the factor leading to chronic anemia > Removal of offending agent, patient hydration and may be transfusions are necessary

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Iron Overload
Can lead to tissue damage and so should be corrected with chelating agents: they bind free and ferritin-bound iron and helps excrete them Deferoxamine given in IV and may be SQ infusions are indicated. A newer oral chelating agent (deferiprone) has been introduced and is reserved for patients intolerant of the IV formulation as it causes neuropathy.

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Anaemia of chronic disease

Can also cause microcytic anaemia
Differentiated from iron deficiency anaemia by normal ferritin Serum iron & transferrin low

Pathogenesis not understood

Erythrocyte lifespan shortened Bone marrow doesnt increase production to compensate Iron utilisation impaired

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Chronic renal failure

Anaemia is a common feature of CRF Due primarily to reduced production of erythropoietin by the kidneys Treated with erythropoietin or darbopoietin (erythropoietic agents)
Given 2-3xweek SQ injections, simplified to higher dose (40,000units) once/week injection Must give with enough iron to enable red cell production
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