Evaluation and Management of Anemia in Family Practice

1. Anemia In Family Practice Evaluation and Management of Anemia in Family Practice Dr Marie Andrades Assistant Professor Department of Family Medicine The Aga Khan University

2. Anemia In Family Practice Hemoglobin below the normal reference level for the age and sex of the individual • 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

3. Anemia In Family Practice Prevalence: South East Asia70% • National Health Survey Pakistan • children < 5 years 60% • Adolescent 47% • Adult women 43% • Adult men 19% • In Elderly, commonest anemia are iron deficiency & chronic disease

4. Anemia In Family Practice Clinical Features (symptoms): • Infants • Irritability, restlessness • Anorexia, sleepiness • Behavioral changes • School going children

5. Anemia In Family Practice Clinical Features (symptoms): • Common • Fatigue/Muscle weakness • Headache/Lack of concentration • Faintness/dizziness • Exertional dyspnoea/palpitation • Angina/intermittent claudication

6. Anemia In Family Practice Clinical Features (signs): Non-specific • pallor, tacycardia, flow mummer Specific • koilonychia, angular stomatitis, glossitis • neuropathy, dementia, paraplegia • jaundice, bone deformities, leg ulcer

7. Anemia In Family Practice History: • Physiological • Inadequate intake • Blood loss • Malabsorption • Comorbids • Drug history • Family history

8. Anemia In Family Practice Consequences of iron deficiency: Children with Hb < 10g/dl have reduced cognitive & psychomotor function despite a return to normal hematological status Reduced immunity and growth failure Deficiency in dopamine receptors

9. 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

10. Anemia In Family Practice Classification of Anemia (Mean Corpuscular volume): • Microcyctic – MCV < 80 fL • Macrocytic – MCV > 100 fL • Normocytic – MCV 80 – 100 fL

11. Anemia In Family Practice Microcytic Anemia • Iron deficiency • Hemoglobinopathy • Sideroblastic • Lead poisoning • Occasionally chronic disease

12. Anemia In Family Practice • If no obvious cause • Serum Ferritin: • < 15ug/l: Iron deficiency • Normal or: Serum Iron / Increased Total Iron binding capacity(TIBC)

13. Anemia In Family Practice Evaluation continued.. Target cells Basophilic stippling Thallasemia Increased Normal Increased Sideroblast Increased Normal Diamorphic Hypo/normo chromic Chronic disease Decreased Decreased

14. Anemia In Family Practice Evaluation continued.. 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

15. Anemia In Family Practice Rx of iron deficiency: Children Elemental iron 3-6mg/kg/day, contd.. 4-6 months Check Hb at 4 weeks Adults Ferrous sulphate/gluconate/fumarate Iron polymaltose complex Elemental iron 200mg/day Parental Iron Normal Hb/PatientHbXwt(kg)X2.2

16. Anemia In Family Practice Diet for Iron Deficiency: In adults, limit milk intake - 500 mL/day Avoid excess caffeine Eat iron-rich foods Protein foodsVegetables  Meats  Greens  Fish & Shelfish  Dried peas & beans  Eggs Fruits Grains  Dried fruit  Iron-fortified breads  Juices Dry cereals  Most fresh fruits  Oatmeal cereal

17. 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

18. Anemia In Family Practice Evaluation continued... Macrocytes present With megaloblast MCV>120 B12 deficiency, Folic acid deficiency Drugs (cytotoxic, anticonvulsant, antibiotic) Without megaloblast MCV 100-120 Liver disease, Alcoholism Hypothyroidism, Myelodysplastic disorders

19. 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)

20. 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

21. 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

22. Anemia In Family Practice Normocytic anemia (causes): Increased RBC loss/destruction acute blood loss, hypersplenism, hemolytic disease Decreased RBC production primary cause i.e bone marrow disorders secondary cause i.e CRF, liver disease, chronic disease Over-expansion of plasma volume pregnancy, overhydration

23. 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 withleucopenia/thrombocytopenia/blast cell bone marrow exam Elevated retic count Direct Coombs test: +ve autoimmune HA -ve mechanical or other HA

24. Anemia In Family Practice Conclusion: • Evaluation based on MCV • Microcytosisis due to iron deficiency unless proven otherwise • Megaloblast help in differentiating cause of macrosytosis • CBC and reticulocyte count essential for normocytic anemia