evaluation and management of anemia in family practice anemia in family practice dr marie andrades...
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Evaluation and Management of Anemia in Family Practice
Anemia In Family Practice
Dr Marie AndradesAssistant Professor
Department of Family MedicineThe Aga Khan University
Hemoglobin below the normal reference level for the age and
sex of the individual
Anemia In Family Practice
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
Prevalence:
Anemia In Family Practice
South East Asia 70%
National Health Survey Pakistanchildren < 5 years 60%Adolescent 47%Adult women 43%Adult men 19%
In Elderly, commonest anemia are iron deficiency & chronic disease
Clinical Features (symptoms):
Anemia In Family Practice
Infants• Irritability, restlessness• Anorexia, sleepiness• Behavioral changes
School going children
Clinical Features (symptoms):
Anemia In Family Practice
Common• Fatigue/Muscle weakness• Headache/Lack of concentration• Faintness/dizziness
Exertional dyspnoea/palpitation
Angina/intermittent claudication
Clinical Features (signs):
Anemia In Family Practice
Non-specific• pallor, tacycardia, flow mummer
Specific• koilonychia, angular stomatitis, glossitis• neuropathy, dementia, paraplegia• jaundice, bone deformities, leg ulcer
History:
Anemia In Family Practice
Physiological Inadequate intake Blood loss Malabsorption
Comorbids Drug history Family history
Consequences of iron deficiency:
Anemia In Family Practice
Children with Hb < 10g/dl have reduced cognitive & psychomotor function despite a return to normal hematological status
Reduced immunity and growth failureDeficiency 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
Macrocytic – MCV > 100 fL
Normocytic – MCV 80 – 100 fL
Anemia In Family Practice
Microcytic Anemia
Iron deficiency
Hemoglobinopathy
Sideroblastic Lead poisoning Occasionally chronic disease
Anemia In Family Practice
• If no obvious cause
• Serum Ferritin:• < 15ug/l : Iron deficiency
• Normal or : Serum Iron / Increased Total Iron binding capacity(TIBC)
Anemia In Family Practice
Evaluation continued..Serum Iron TIBC Peripheral
smear
Iron deficiency
Decreased Increased Hypochromic
Target cells Basophilic stippling
Normal Increased
IncreasedThallasemia
DiamorphicNormalIncreasedSideroblast
Hypo/normo chromic
DecreasedDecreasedChronic disease
Anemia In Family Practice
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
Evaluation continued..
Anemia In Family Practice
Rx of iron deficiency:Children
Elemental iron 3-6mg/kg/day, contd.. 4-6 months
Check Hb at 4 weeks
AdultsFerrous sulphate/gluconate/fumarate
Iron polymaltose complex
Elemental iron 200mg/day
Parental IronNormal Hb/PatientHbXwt(kg)X2.2
Anemia In Family Practice
Diet for Iron Deficiency:In adults, limit milk intake - 500 mL/day
Avoid excess caffeineEat iron-rich foods
Protein foods Vegetables Meats Greens Fish & Shelfish Dried peas & beans Eggs
Fruits Grains Dried fruit Iron-fortified breads Juices Dry cereals Most fresh fruits 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>120B12 deficiency, Folic acid deficiency
Drugs (cytotoxic, anticonvulsant, antibiotic)
Without megaloblast MCV 100-120Liver 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 (crohn’s, 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/dayreduces artherosclerosis if associated with elevated homocysteine levels
Anemia In Family Practice
Normocytic anemia (causes):
Increased RBC loss/destructionacute blood loss, hypersplenism, hemolytic disease
Decreased RBC productionprimary cause i.e bone marrow disorders
secondary cause i.e CRF, liver disease, chronic disease
Over-expansion of plasma volumepregnancy, 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
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