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, tacycardia, flow mummer Specific koilonychia, angular stomatitis, glossitis neuropathy, dementia, paraplegia jaundice, bone deformities, leg ulcer

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

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

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 Thallasemia Increased Normal Increased Target cells Basophilic stippling Sideroblast Increased Normal Diamorphic Chronic disease Decreased Decreased Hypo/normo chromic

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

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

Diet for Iron Deficiency: 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  Greens  Fish & Shelfish  Dried peas & beans  Eggs Fruits Grains  Dried fruit  Iron-fortified breads  Juices Dry cereals  Most fresh fruits  Oatmeal cereal

Macrocytic anemia (evaluation): 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 (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/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