Anaemia in General Practice  Â

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Anaemia in General Practice  Â

  1. 1. Anaemia in General Practice Mary Frances McMullin [email_address]
  2. 2. Outline <ul><li>Signs and symptoms of anaemia </li></ul><ul><li>Classification </li></ul><ul><li>Microcytic </li></ul><ul><li>Normocytic </li></ul><ul><li>Macrocytic </li></ul><ul><li>Data examples </li></ul>
  3. 3. Definition of anaemia <ul><li>Anaemia is defined as a reduction in the haemoglobin concentration of the blood </li></ul><ul><li>This results in a decreased oxygen carrying capacity </li></ul>
  4. 4. Symptoms of anaemia <ul><li>Shortness of breath on exercise </li></ul><ul><li>Weakness and lethargy </li></ul><ul><li>Palpitations and headaches </li></ul><ul><li>Cardiac failure, angina, intermittent claudication and confusion </li></ul><ul><li>Visual disturbances due to retinal haemorrhages </li></ul>
  5. 5. Factors effecting symptoms of anaemia <ul><li>Speed of onset </li></ul><ul><li>Severity of anaemia </li></ul><ul><li>Age </li></ul><ul><li>Haemoglobin O 2 dissociation curve </li></ul>
  6. 6. Signs of anaemia <ul><li>Pallor </li></ul><ul><li>Hyperdynamic circulation, tachycardia, bounding pulse, cardiomegaly </li></ul><ul><li>Congestive cardiac failure </li></ul><ul><li>Retinal haemorrhages </li></ul>
  7. 8. Classification of Anaemia: Microcytic Hypochromic <ul><li>MCV <80fl </li></ul><ul><li>MCH <27pg </li></ul>
  8. 9. Microcytic anaemia Ferritin <25ug/L <ul><li>Iron deficiency </li></ul>
  9. 10. Microcytic anaemia Ferritin >25ug/L <ul><li>Thalassaemia </li></ul><ul><li>Sideroblastic anaemia (some cases) </li></ul><ul><li>Anaemia of chronic disease (some cases) </li></ul><ul><li>Lead poisoning </li></ul>
  10. 11. Classification of Anaemia: Normocytic Normochromic <ul><li>MCV 80-100fl </li></ul><ul><li>MCH >26pg </li></ul>
  11. 12. Normochromic normocytic anaemia <ul><li>Often incidental finding in systemic disorders </li></ul><ul><li>May be first manifestation of a systemic disorder </li></ul><ul><li>Many haemolytic anaemias </li></ul><ul><li>Anaemia of chronic disease (some cases) </li></ul><ul><li>After acute blood loss </li></ul><ul><li>Bone marrow failure, e.g. Post-chemotherapy, infiltration by carcinoma etc </li></ul>
  12. 13. Classification of Anaemia: Macrocytic <ul><li>MCV >100fl </li></ul><ul><li>Megaloblastic: vitamin B 12 or folate deficiency </li></ul><ul><li>Non-megaloblastic: alcohol, liver disease, myelodysplasia, aplastic anaemia </li></ul>
  13. 14. Iron deficiency anaemia <ul><li>Assess for </li></ul><ul><li>Dietary Iron deficiency </li></ul><ul><li>Malabsorption - coeliac </li></ul><ul><li>Chronic blood loss </li></ul><ul><li>Gastrointestinal </li></ul><ul><li>Menorrhagia </li></ul>
  14. 16. Treatment of Iron Deficiency <ul><li>Ferrous sulphate 200mg three times a day (cheapest) on an empty stomach </li></ul><ul><li>Continue until stores are replaced-usually 6 months </li></ul>
  15. 17. Follow up-Iron deficiency <ul><li>Adolescents and pre-menopausal females </li></ul><ul><li>GI symptoms and no diagnosis </li></ul><ul><li>Menstrual problem </li></ul><ul><li>Follow-up: refer only if specific indication </li></ul><ul><li>Refer to gastroenterologist </li></ul><ul><li>Refer to gynaecologist </li></ul>
  16. 18. Failure of Response to Oral Iron <ul><li>Continuing blood loss </li></ul><ul><li>Failure to take tablets </li></ul><ul><li>Wrong diagnosis-thalassaemia trait, sideroblastic anaemia </li></ul><ul><li>Mixed deficiency-associated vitamin B 12 or folate deficiency </li></ul><ul><li>Another cause for the anaemia, e.g. malignancy, inflammation </li></ul><ul><li>Malabsorption </li></ul><ul><li>Use of a slow release preparation </li></ul>
  17. 19. Microcytic anaemia Ferritin >25ug/L <ul><li>Thalassaemia </li></ul><ul><li>Sideroblastic anaemia </li></ul><ul><li>Anaemia of chronic disease (usually normocytic) </li></ul><ul><li>Lead poisoning (usually normocytic) </li></ul><ul><li>Consider referral to haematologist </li></ul><ul><li>Refer to haematologist </li></ul><ul><li>Assess exposure history: measure urinary lead </li></ul>
  18. 20. Thalassaemia Trait <ul><li>Microcytic anaemia </li></ul><ul><li>High red cell count </li></ul><ul><li>Normal MCHC </li></ul><ul><li>Usually non-Caucasian </li></ul>
  19. 23. Treatment of Thalassaemia Trait <ul><li>Reassurance </li></ul><ul><li>Evaluation of iron status </li></ul><ul><li>Antenatal/ genetic counselling </li></ul>
  20. 24. Normocytic anaemia <ul><li>Often an incidental finding in systemic disorders </li></ul><ul><li>May be first manifestation of systemic disorder </li></ul><ul><li>May be an early manifestation of a microcytic or macrocytic anaemia </li></ul><ul><li>Detailed history and examination required to guide investigation/referral </li></ul><ul><li>Unexplained normocytic anaemia----refer to haematologist </li></ul>
  21. 26. Vitamin B 12 <ul><li>Normal daily intake </li></ul><ul><li>Main foods </li></ul><ul><li>Cooking </li></ul><ul><li>Minimal daily requirement </li></ul><ul><li>Body stores </li></ul><ul><li>Absorption </li></ul><ul><li>site </li></ul><ul><li>mechanism </li></ul><ul><li>limit </li></ul><ul><li>Usual therapeutic form </li></ul><ul><li>7-30  g </li></ul><ul><li>Animal produce only </li></ul><ul><li>Little effect </li></ul><ul><li>1-2  g </li></ul><ul><li>2-3mg (enough for 2-4yrs) </li></ul><ul><li>Ileum </li></ul><ul><li>Intrinsic factor </li></ul><ul><li>2-3  g </li></ul><ul><li>Hydroxocobalamin </li></ul>
  22. 27. Pernicious Anaemia <ul><li>Autoimmune attack on the gastric mucosa leading to atrophy of the stomach </li></ul><ul><li>Females> males </li></ul><ul><li>Associated autoimmune diseases </li></ul><ul><li>Tends to occur in families </li></ul>
  23. 29. Folic Acid <ul><li>Normal daily intake </li></ul><ul><li>Main foods </li></ul><ul><li>Cooking </li></ul><ul><li>Minimal daily requirement </li></ul><ul><li>Body stores </li></ul><ul><li>Absorption </li></ul><ul><li>site </li></ul><ul><li>mechanism </li></ul><ul><li>limit </li></ul><ul><li>Usual therapeutic form </li></ul><ul><li>200-250  g </li></ul><ul><li>Most liver, greens, yeast </li></ul><ul><li>Easily destroyed </li></ul><ul><li>100-150  g </li></ul><ul><li>10-12mg (4mths supply) </li></ul><ul><li>Duodenum and jejunum </li></ul><ul><li>Converted to methylTHF </li></ul><ul><li>50-80% of dietary intake </li></ul><ul><li>Folic acid </li></ul>
  24. 30. Causes of Folic Acid Deficiency <ul><li>Nutritional -old age, poverty, diet etc </li></ul><ul><li>Malabsorption - tropical sprue, coeliac disease, Crohn’s disease </li></ul><ul><li>Excess utilization </li></ul><ul><li>Physiological -pregnancy, lactation, prematurity </li></ul><ul><li>Pathological -haemolytic anaemia, myelofibrosis, malignant disease, inflammatory disease </li></ul><ul><li>Drugs -anticonvulsants </li></ul><ul><li>Mixed -liver disease, alcoholism, intensive care </li></ul>
  25. 31. Megaloblastic Anaemia: Clinical <ul><li>Insidious onset of symptoms and signs of anaemia </li></ul><ul><li>Lemon yellow jaundice </li></ul><ul><li>Glossitis, angular stomatitis </li></ul><ul><li>Purpura </li></ul><ul><li>Neuropathy-subacute combined degeneration of the cord (neuropathy affecting the peripheral sensory nerves and posterior and lateral columns) </li></ul>
  26. 35. Megaloblastic Anaemia: Treatment <ul><li>Vitamin B 12 1000  g/day x 6, intramuscular </li></ul><ul><li>Folic acid 5mg per day, oral </li></ul><ul><li>May need folic acid, iron, potassium supplements and diuretics </li></ul><ul><li>Continue 1000  g once every 3 mths for life </li></ul>
  27. 36. Investigation in primary care <ul><li>History and examination </li></ul><ul><li>FBP </li></ul><ul><li>Ferritin </li></ul><ul><li>B 12 and Folate </li></ul>
  28. 37. Data Interpretation (1) <ul><li>Haemoglobin (g/dl) </li></ul><ul><li>Haematocrit (PCV) (%) </li></ul><ul><li>Red cell count (x 10 12 /L) </li></ul><ul><li>Mean cell haemoglobin (pg) </li></ul><ul><li>Mean cell volume (fl) </li></ul><ul><li>Mean cell haemoglobin concentration (g/dl) </li></ul><ul><li>7.5 (11.5-16.5) </li></ul><ul><li>30 (0.37-0.47) </li></ul><ul><li>2.35 (3.8-5.8) </li></ul><ul><li>22 (27-32) </li></ul><ul><li>65 (76-100) </li></ul><ul><li>26 (32-36) </li></ul>
  29. 38. Data Interpretation (2) <ul><li>Haemoglobin (g/dl) </li></ul><ul><li>Haematocrit (PCV) (%) </li></ul><ul><li>Red cell count (x 10 12 /L) </li></ul><ul><li>Mean cell haemoglobin (pg) </li></ul><ul><li>Mean cell volume (fl) </li></ul><ul><li>Mean cell haemoglobin concentration (g/dl) </li></ul><ul><li>11.4 (11.5-16.5) </li></ul><ul><li>0.404 (0.37-0.47) </li></ul><ul><li>6.25 (3.8-5.8) </li></ul><ul><li>20.5 (27-32) </li></ul><ul><li>64.6 (76-100) </li></ul><ul><li>31.7 (32-36) </li></ul>
  30. 39. Further results (2) <ul><li>Haemoglobin F- 0.3% </li></ul><ul><li>Hb A2 - 2.5% </li></ul><ul><li>Ferritin 135ug/L </li></ul><ul><li>Homozygous for alpha 3.7 deletion </li></ul><ul><li>Homozygous for alpha + thalassaemia </li></ul><ul><li><1% </li></ul><ul><li>1.5-3.5 </li></ul>
  31. 40. Data Interpretation (3) <ul><li>Haemoglobin (g/dl) </li></ul><ul><li>Haematocrit (PCV) (%) </li></ul><ul><li>Red cell count (x 10 12 /L) </li></ul><ul><li>Mean cell haemoglobin (pg) </li></ul><ul><li>Mean cell volume (fl) </li></ul><ul><li>Mean cell haemoglobin concentration (g/dl) </li></ul><ul><li>8.2 (11.5-16.5 </li></ul><ul><li>0.25 (0.37-0.47) </li></ul><ul><li>2.7 (3.8-5.8) </li></ul><ul><li>34 (27-32) </li></ul><ul><li>120 (76-100) </li></ul><ul><li>34 (32-36) </li></ul>
  32. 41. Department of Haematology Belfast City Hospital Anaemia in Adults – Hospital Referral Guidelines: 1. Microcytic anemias (MCV <76 fL): Check serum ferritin (a) Ferritin < 25 ug/L Fe deficiency anaemia: Assess for: Dietary Fe deficiency Malabsorption – esp. coeliac disease Chronic gastrointestinal bleeding Menorrhagia Treat with oral Fe Adolescents & pre-menopausal females: Follow-up Refer only if specific indication Others - GI symptoms or no diagnosis: Refer to gastroenterologist Menstrual problem: Refer to gynaecologist (b) Ferritin >25 ug/L Thalassaemias } Refer to haematologist Sideroblastic anaemias } Anaemia of chronic disease (usually normocytic) See below Chronic lead poisoning (usually normocytic) Assess exposure history Measure urinary lead 2. Macrocytic anaemias (MCV >100fL): Check serum B12 & folate (a) Normal B12 & folate Assess for: Liver disease Alcohol excess Hypothyroidism Pregnancy Drugs (b) Low B12 or folate Investigate & treat as appropriate Discuss &/or refer to haematologist if difficulties arise (c) All tests normal or no clear diagnosis: Refer to haematologist 3. Normocytic anaemia (MCV 76-100 fL): Often an incidental finding in systemic disorders May be the first manifestation of a systemic disorder May be an early manifestation of a microcytic or macrocytic anaemia Detailed history & examination required to guide investigation/referral Unexplained normocytic anaemia: Refer to haematologist RJG Cuthbert, August 2006
  33. 42. Useful information <ul><li>Anaemia in Adults-Hospital referral guidelines </li></ul><ul><li>British Society of Haematology – www.bsg.org.uk </li></ul><ul><li>NHS guidance on the investigation and treatment of anaemias- www.prodigy.nhs.uk/guidance </li></ul>

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