Post on 14-Apr-2018
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Evaluation and Management of
Anemia in Family Practice
Anemia In Family Practice
Dr Marie AndradesAssistant Professor
Department of Family Medicine
The Aga Khan University
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Hemoglobin below the normalreference 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
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Prevalence:
Anemia In Family Practice
South East Asia70%
National Health Survey Pakistanchildren < 5 years 60%
Adolescent 47%
Adult women 43%Adult men 19%
In Elderly, commonest anemia are
iron deficiency & chronic disease
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Clinical Features(symptoms):
Anemia In Family Practice
Infants
Irritability, restlessness
Anorexia, sleepiness
Behavioral changes
School going children
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Clinical Features(symptoms):
Anemia In Family Practice
Common
Fatigue/Muscle weakness
Headache/Lack of concentration
Faintness/dizziness
Exertional dyspnoea/palpitation
Angina/intermittent claudication
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Clinical Features(signs):
Anemia In Family Practice
Non-specific
pallor pucat, tacycardia, flow
mummer
Specific
koilonychia, angular stomatitis,
glossitis
neuropathy gangguan saraf, dementia
pusing, paraplegia
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History:
Anemia In Family Practice
Physiologicalanimia yang
bukan penyakit
mis pada wanitahamil
Inadequate intake
kurang asupan
Comorbids
Drug history
Family
historyherediter mis talasemia,
G6PD
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Consequences of iron deficiency:akibat2 yang ditimbulakan oleh
kekurangan besi
Anemia In Family Practice
Children with Hb < 10g/dl havereduced pengurangan cognitive
kecerdasan & psychomotor
keterampilan function despite a returnto normal hematological status
Reduced immunity and growth failure
Deficiency in dopamine receptors
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Anemia In Family Practice
Recommendations for Screeningin 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
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Anemia In Family Practice
Classification of Anemia(Mean Corpuscular volume):
Microcyctic MCV < 80 fL
Macrocytic MCV > 100 fL
Normocytic MCV 80100 fL
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Anemia In Family Practice
Microcytic Anemia
Iron deficiency
Hemoglobinopathy penyakit
yang menyerang Hb seperti
talasemia
Sideroblastic
Lead poisoning
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Anemia In Family Practice
If no obvious cause
Serum Ferritin: < 15ug/l : Iron deficiency
Normal or: Serum Iron /Increased Total Iron binding capacity(TIBC)
Apabila ditemukan mikrositik pada hapusan
darah maka dilakukan pemeriksaan serum
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Anemia In Family Practice
Evaluation continued..Serum Iron TIBC Peripheral
smear
Irondeficiency
Decreased Increased Hypochromic
Target cellsBasophilic
stippling
Normal
Increased
Increased karena hematopoesis
inefektif sehingga meningkatkan
absorsi besi di saluran cernaThallasemi
a
DiamorphicNormalIncreased karena kerusakannya pada
molekul porfirin bukan pada besinyaSideroblast
Hypo/normo
chromic
DecreasedDecreased akibat makrofag
menimbun dan menahan besi
sehingga eritrosit kekurangan
besi. Alasan makrofag menahan
besi adalah untuk menghambatpertumbuhan bakteri sebab
bakteri dapat tumbuh subur jika
Chronic
disease
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Anemia In Family Practice
Thallesemia
Mentzer index: MCV/RBC count.
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Anemia In Family Practice
Rx of iron deficiency:Children
Elemental iron 3-6mg/kg/day, contd.. 4-6 months
Check Hb at 4 weeksAdults
Ferrous sulphate/gluconate/fumarate
Iron polymaltose complex
Elemental iron 200mg/day
Parental Iron
Normal Hb/PatientHbXwt(kg)X2.2
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Anemia In Family Practice
Diet for Iron Deficiency:In adults, limit milk intake - 500 mL/dayAvoid 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
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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
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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
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Anemia In Family Practice
Vitamin B12 deficiency(causes)
Nutritional
Malabsorption statesfood 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)
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Anemia In Family Practice
Vitamin B12 deficiency (Rx)
Oral: 1000-2000 mcg/day for 2
weeks1000 mcg/day for life
Intramuscular:1000 mcg alternate days to a
total of 3-5 mg1000 mcg every 3 months
Intranasal: Nascobal
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Anemia In Family Practice
Folic acid deficiency(causes & Rx)
Malnutrition
Anticonvulsants
Old age
Rx:
Oral folate I mg/day
reduces artherosclerosis if associated withelevated homocysteine levels
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Anemia In Family Practice
Normocytic anemia(causes):Increased RBC loss/destruction
acute blood loss, hypersplenism, hemolytic diseaseDecreased RBC production
primary cause i.e bone marrow disorders
secondary cause i.e CRF, liver disease, chronicdisease
Over-expansion of plasma volume
pregnancy, overhydration
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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
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Anemia In Family Practice
Conclusion:
Evaluation based on MCV
Microcytosisis due to iron deficiencyunless proven otherwise
Megaloblast help in differentiating cause
of macrosytosis
CBC and reticulocyte count essential for
normocytic anemia