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

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

Anemia In Family Practice

Prevalence:
South East Asia 70% 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

Anemia In Family Practice

Clinical Features
(symptoms):
Infants Irritability, restlessness Anorexia, sleepiness Behavioral changes
School going children

Anemia In Family Practice

Clinical Features
(symptoms):
Common Fatigue/Muscle weakness Headache/Lack of concentration Faintness/dizziness

Exertional dyspnoea/palpitation
Angina/intermittent claudication

Anemia In Family Practice

Clinical Features
(signs):
Non-specific pallor pucat, tacycardia, flow mummer Specific koilonychia, angular stomatitis, glossitis neuropathy gangguan saraf, dementia pusing, paraplegia

Anemia In Family Practice

History:
Physiological

animia yang bukan penyakit mis pada wanita hamil Inadequate intake kurang asupan

Comorbids

Drug history Family historyheredite r mis talasemia, G6PD

Anemia In Family Practice

Consequences of iron deficiency: akibat2 yang ditimbulakan oleh kekurangan besi

Children with Hb < 10g/dl have reduced pengurangan cognitive kecerdasan & psychomotor keterampilan function despite a return to normal hematological status

Reduced immunity and growth failure Deficiency in dopamine receptors

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

Anemia In Family Practice

Classification of Anemia (Mean Corpuscular volume):

Microcyctic

MCV < 80 fL
MCV > 100 fL MCV 80 100 fL

Macrocytic Normocytic

Anemia In Family Practice

Microcytic Anemia

Iron deficiency

Hemoglobinopathy penyakit

yang menyerang Hb seperti talasemia

Sideroblastic Lead poisoning

Anemia In Family Practice

If no obvious cause
Serum Ferritin:
< 15ug/l : Normal or : Increased Iron deficiency Serum Iron / Total Iron binding capacity(TIBC)

Apabila ditemukan mikrositik pada hapusan darah maka dilakukan pemeriksaan serum

Anemia In Family Practice

Evaluation continued..
Serum Iron TIBC Iron Decreased deficiency Thallasemi a
Increased karena hematopoesis inefektif sehingga meningkatkan absorsi besi di saluran cerna

Peripheral smear
Hypochromic

Increased Normal Increased

Target cells
Basophilic stippling

Sideroblast
Chronic disease

Increased karena kerusakannya pada molekul porfirin bukan pada besinya

Normal

Diamorphic

Decreased akibat makrofag menimbun dan menahan besi sehingga eritrosit kekurangan besi. Alasan makrofag menahan besi adalah untuk menghambat pertumbuhan bakteri sebab bakteri dapat tumbuh subur jika

Decreased Hypo/normo chromic

Anemia In Family Practice

Evaluation continued..
Thallesemia
Mentzer index: MCV/RBC count. <13 Hb Electrophoresis pemeriksaan uji hemoglobin. Segala hemoglinopati dapat dideteksi melalui pemeriksaan ini

Sideroblastic anemia
Bone marrow exam

Iron deficiency anemia in men/post menopausal women

Anemia In Family Practice

Children

Rx of iron deficiency:

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

Anemia In Family Practice

Diet for Iron Deficiency:

In adults, limit milk intake - 500 mL/day Avoid excess caffeine Eat iron-rich foods Protein foods Vegetables
Meats Fish & Shelfish Eggs Greens Dried peas & beans

Fruits
Dried fruit Juices Most fresh fruits

Grains
Iron-fortified breads Dry cereals Oatmeal cereal

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

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

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 (crohns, bacterial overgrowth, tape worm)

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

Anemia In Family Practice

Folic acid deficiency (causes & Rx)

Malnutrition

Anticonvulsants Old age Rx:

Oral folate I mg/day reduces artherosclerosis if associated with elevated homocysteine levels

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

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 with

leucopenia/thrombocytopenia/blast cell bone marrow exam

Elevated retic count

Direct Coombs test: +ve autoimmune HA -ve mechanical or other HA

Anemia In Family Practice

Conclusion:
Evaluation based on MCV Microcytosis is due to iron deficiency unless proven otherwise Megaloblast help in differentiating cause of macrosytosis CBC and reticulocyte count essential for normocytic anemia