anemia is a very common marker of underlying diseases. it's sometimes gone under diagnosed due to lack of knowledge. here's an overview of the different types and causes of anemia and the pharmacists approach in addressing such problem.

1. Presented by: Farah Al Souheil
Presented to: Dr. Diana Malaeb

2. Advanced Pharmacy Practice Experience
Fall 2019-2020
Management of Anemia in Community
Setting
Feb 6, 2020
Lebanese International University
School of Pharmacy

3. Outline
i. Definition
ii. Quick facts
iii. Symptoms
iv. Classification
v. Causes
vi. High Risk Population
vii. Anemia workup
viii. Non-pharmacologic Treatment
ix. Pharmacologic Treatment
x. Patient Education
xi. Conclusion
xii. References
3

4. Definition
• Anemia is defined by WHO as hemoglobin
concentration:
< 13g/dl for
adult males &
postmenopausal
women
•< 12 g/dl for premenopausal
women
•< 11 g/dl for children 6
months to 6 years
4
Goodnough LT, Schrier SL. Evaluation and management of anemia in the elderly. Am J Hematol. 2014 Jan;89(1):88-96

5. Musallam KM, Tamim HM, Richards T, Spahn DR, Rosendaal FR, Habbal A, et al. Preoperative anaemia and postoperative outcomes in
non-cardiac surgery: a retrospective cohort study. Lancet. 2011 Oct 15;378(9800):1396-1407. 41
Quick Facts
Of patients with GFR<30 ml/min have anemia with Hgb <10
mg/dl
Of patients undergoing major non-cardiac surgery are
anemic
Of hospitalized patients will develop a hospital-acquired
anemia (HAA)
Of ICU patients develop anemia by the third ICU day
People around the world are anemic with 50% iron deficiency
anemia
5

6. Symptoms
6
Hypotension Splenomegaly
Angina & MI
if severe
anemia
Fainting if
severe anemia
https://www.vectorstock.com/royalty-free-vector/anemia-symptoms-icons-vector-21452683

7. Classification
8
[chart]. (n.d.). Retrieved from http://narta.innovations2019.org/types-of-anemia-chart/pin-on-college-life.html

8. Causes
Microcytic Anemia
• Late iron deficiency
• Sideroblastic anemia
• Transferrin deficiency
• Copper deficiency/ zinc
poisoning
• Thalassemia
Macrocytic Anemia
• Megaloblastic anemia
• Liver disease
• Myelodysplastic syndrome
• Normal newborn
• Hypothyroidism
• Medications that interfere with
nuclear maturation
(Hydroxyurea, methotrexate,
AZT, trimethorim)
Normocytic normal
morphology
• Hemorrhage
• Chronic disease
• Excess alcohol
• Bone marrow suppression
Normocytic abnormal
morphology
• Hemoglobinopathy
• Hemolytic anemia
9
ANEMIA. (2010, August 1). Retrieved from https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/539721

9. High Risk Population
10
James L Harper. (2019, September 7). ANEMIA. Retrieved from https://www.medscape.com/answers/202333-153172/what-populations-
are-at-high-risk-for-iron-deficiency-anemia
Blood donation
>2 units/year in
women
>3 units/year
in men

10. Anemia Workup
• Initiate when Crcl< 60 ml/min or hgb<11 g/dl
Hgb/ Hct MCV
Reticulocyte
count
Total iron &
total binding
capacity
Ferritin Stool guaiac
11Anemia Testing Algorithm Lab Test Selection. (n.d.). Retrieved from https://arupconsult.com/algorithm/anemia-testing-algorithm

11. Importance of Treatment
Decrease
morbidity &
mortality
Decrease LV
hypertrophy
Increase
exercise
tolerance &
productivity
Maintain
physical &
cognitive
development
in pediatrics
12
Silverberg DS , et al. (n.d.). The importance of anemia and its correction in the management of severe congestive heart failure. - PubMed
- NCBI. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/12453537

12. Hb dangerously low (< 7 g/dL)
When to Treat as an Inpatient?
Patients at high risk of cardiopulmonary symptoms
Active, uncontrollable blood loss
Ischemic end-organ failure (eg, neurologic
ischemic symptoms, angina, tachycardia in
patients with heart failure or COPD)
13
Evan M. Braunstein. (2019, February). Treatment of Anemia. Retrieved from https://www.merckmanuals.com/professional/hematology-and-
oncology/approach-to-the-patient-with-anemia/treatment-of-anemia

13. Drug Indication Benefits
ESA EPO deficiency
(Anemia of chronic
disease)
Hb increase, QOL
improvement
Oral Iron ID anemia (ferritin< 30
ng/ml
Increase Hb and iron
IV iron Anemia of chronic
disease
Increase response to ESA
Lactoferrin Anemia of chronic
disease
Increase response to ESA,
reduce inflammation
Corticosteroids Hemolytic anemia Suppress the immune system
Antithymocyte
globulin &
cyclosporine
Aplastic anemia Suppress the immune system
Vitamins (B9 &
B12)
Macrocytic anemia Correct vitamin deficiency
Treatment Options
14Antonio Macciò. (2012, October 3). (PDF) Management of Anemia of Inflammation in the Elderly. Retrieved from
https://www.researchgate.net/publication/232612155_Management_of_Anemia

14. Treatment Algorithm
15
Ingo Beyer. (2014, June 21). Table 1 Anemia in the elderly: overview. Retrieved from https://www.researchgate.net/figure/Anemia-in-
the-elderly-overview_tbl1_43347737

15. 16
Iron Deficiency
Anemia

16. Non- pharmacologic Treatment
17Franziska Spritzler. (2020, January 27). Retrieved from https://www.healthline.com/nutrition/11-healthy-iron-rich-foods

17. Pharmacologic Treatment
18

18. Oral Iron
• Iron-deficiency anemia prevention 3 consecutive months/ year
• Iron-deficiency anemia treatment In the absence of inflammation or
significant ongoing blood loss
60-200mg of iron in 2-3 divided doses for three month
Geriatrics: Lower doses (15 to 50 mg elemental iron/day)
>6 months should be avoided except in patients with continuous bleeding or
menorrhagia
60 minutes after oral ibandronate
30 minutes after alendronate/risedronate
Avoid coadministration with cefdinir
4 hours after Levothyroxine
Hemochromatosis, hemolytic anemia, peptic ulcer, or ulcerative colitis
19
UpToDate. (n.d.). Retrieved from https://www.uptodate.com/contents/ferrous-fumarate-drug-
information?search=iron&source=panel_search_result&selectedTitle=1~140&usage_type=panel&display_rank=1

19. Oral Iron
20
Advantages
Extremely low risk of
serious adverse events
Cheap and effective
Disadvantages
Gastrointestinal side effects
are common
Low compliance
Inadequate for severe or
ongoing blood loss
Requires administration for
several months
Total costs is higher
Cont’d
UpToDate. (n.d.). Retrieved from https://www.uptodate.com/contents/ferrous-fumarate-drug-
information?search=iron&source=panel_search_result&selectedTitle=1~140&usage_type=panel&display_rank=1

20. Oral Iron
21
Ferrous fumarate 33% elemental iron Tablet only
Ferrous gluconate
10 to 14% elemental
iron
Tablet only
Ferrous sulfate
Off Label: RLS
20 to 30% elemental
iron
Drops and oral
solution, elixir and
solution, syrup, tablet,
ER tablet
Polysaccharide-iron
complex
More expensive but
lacks metallic taste
33% elemental iron Capsule, Elixir
UpToDate. (n.d.). Retrieved from https://www.uptodate.com/contents/ferrous-fumarate-drug-
information?search=iron&source=panel_search_result&selectedTitle=1~140&usage_type=panel&display_rank=1
Cont’d

21. Oral Iron
22
Metallic taste
Nausea /
vomiting
flatulence
Constipation/
diarrhea
Epigastric
distress
Itching
Dental
discoloration
Black/green
or tarry
stools
Cont’d
UpToDate. (n.d.). Retrieved from https://www.uptodate.com/contents/ferrous-fumarate-drug-
information?search=iron&source=panel_search_result&selectedTitle=1~140&usage_type=panel&display_rank=1

22. Food-Iron Interaction
Phytate: Main inhibitor of iron absorption
• Dose dependent and starts at very low
Poly phenols
• Cereals, tea, coffee, and wine
Calcium
• Negative effects on heme and non heme iron absorption
• Dose dependent inhibitory effects
Animal proteins (Milk proteins, egg proteins, and albumin)
Heavy metals (lead, cobalt, manganese, zinc and arsenic in food or in
supplements
23
Cont’d
UpToDate. (n.d.). Retrieved from https://www.uptodate.com/contents/ferrous-fumarate-drug-
information?search=iron&source=panel_search_result&selectedTitle=1~140&usage_type=panel&display_rank=1

23. Parenteral Iron
WHO model recommends a ferrous salt form
rather than Ferric state form due to better
bioavailability (10-15%) than ferric form (5%)
Indications:
• Intolerance to oral Fe
• Gastrointestinal/bariatric surgery
• Dialysis and non-dialysis-associated chronic kidney disease
• Inadequate response to oral iron (e.g., inflammation, ESA
administration)
24

24. Advantages
Effective for most patients
More rapid correction of anemia
Large doses (up to 1000 mg elemental
iron) in a single infusion
High compliance
No GI side effects
Disadvantages
Requires monitored IV infusion
Rare cases of allergic reactions
Requires specialized equipment and
personnel
Initial costs may be higher
Parenteral Iron
25
Cont’d

25. Erythropoiesis Stimulating Agents (ESA)
Epoetin alfa, epoetin beta, and darbepoetin
Indications
• CKD patients with (Hb) <10 g/dL + (TSAT) >25% and ferritin >200 ng/mL.
• Anemia due to chemotherapy in cancer patients except for epoetin beta
• Anemia due to zidovudine
• Non-cardiac, non-vascular surgery
Contraindication
• Active malignancy or a recent history of malignancy
• Stroke
• Caution in renal disease: target hemoglobin levels between 10 and 12 g/dL
Younger CKD patients may have anemia at higher Hb level & ESA maybe
initiated at Hb levels of 10 g/dL or even higher
Administer iron before giving an ESA if TSAT ≤25% and ferritin ≤500 ng/mL
26
UpToDate. (n.d.). Retrieved from https://www.uptodate.com/contents/epoetin-alfa-including-biosimilars-of-epoetin-alfa-drug-
information?search=epoetin%20alfa&source=panel_search_result&selectedTitle=1~35&usage_type=panel&kp_tab=drug_general&display_rank=1

26. ESA Titration
27
CG39 Anaemia management in chronic kidney disease - Welcome ... (2010, October 20). Retrieved from
https://www.slideshare.net/ringer21/cg39-anaemia-management-in-chronic-kidney-disease-welcome
Cont’d
Hb does not
increase by >1
g/dL after 4 weeks
Increase dose by
25%
Hb increases >1
g/dL in any 2-
week period
Reduce dose by
≥25%
Titrate every 4
weeks
Inadequate or lack
of response over a
12-week
escalation period
Discontinue
treatment

27. ESA
Hypertension, Rash, Coagulation, Leukopenia,
Weight loss, Hyperglycemia, Hypokalemia,
Retinopathy of prematurity (ROP),Seizure,
Cardiovascular events, Myalgia
Transferrin saturation and serum ferritin (prior to
and during treatment)
Hb (weekly after initiation and after titration)
BP, signs of seizures , renal function
Increase the risk of death, MI, stroke, venous
thromboembolism
Increase the risk of tumor progression or
recurrence
28
Cont’d
UpToDate. (n.d.). Retrieved from https://www.uptodate.com/contents/epoetin-alfa-including-biosimilars-of-epoetin-alfa-drug-
information?search=epoetin%20alfa&source=panel_search_result&selectedTitle=1~35&usage_type=panel&kp_tab=drug_general&display_rank=1

28. Darbepoetin
29
Cont’d
UpToDate. (n.d.). Retrieved from https://www.uptodate.com/contents/darbepoetin-alfa-drug-
information?search=darbepoetin&source=panel_search_result&selectedTitle=1~52&usage_type=panel&kp_tab=drug_general&display_rank=1
Darbepoetin Dose
• On dialysis:
• 0.45 mcg/kg weekly
• 0.75 mcg/kg every 2 weeks
• Not on dialysis:
• 0.45 mcg/kg every 4 weeks
• Cancer:
• 2.25 mcg/kg weekly
• 500 mcg once every 3
weeks until completion of a
chemotherapy course
Epoetin Dose
• On dialysis:
• 50 to 100 units/kg tiw
• Not on dialysis:
• 50 to 100 units/kg qw
• Cancer:
• 150 units/kg tiw
• 40,000 units qw
• Discontinue following
completion of chemotherapy

29. 30
Vitamin B12 Deficiency
Anemia

30. Non-Pharmacologic Treatment
31
Cont’d
(2018, December 20). Retrieved from https://www.health.harvard.edu/staying-healthy/the-a-list-of-b12-foods

31. Pharmacologic Treatment
Causes
• Malabsorption, atrophic gastritis, metformin use, chronic acid reducing medication use
Hydroxocobalamine
• 1000 mcg by deep SQ or IM injection once weekly for one month followed by 1000 mcg once per
month
Oral cobalamine 1-2%
• 1000 to 2000 mcg daily Absorbed by diffusion
Pernicious anemia and other chronic causes of deficiency are treated indefinitely
Off-label use
• Recurrent aphthous ulcers
Warning
• Hypokalemia, thrombocytosis, heavy ethanol consumption >2 weeks may impair vitamin B12
absorption
32
Cont’d
UpToDate. (n.d.). Retrieved from https://www.uptodate.com/contents/cyanocobalamin-vitamin-b12-drug-
information?search=cyanocobalamine&source=panel_search_result&selectedTitle=1~148&usage_type=panel&kp_tab=drug_general&display_rank=1

32. 33
Folic Acid
Deficiency Anemia

33. Non-Pharmacologic Treatment
34
Cont’d
Rachael Link. (2018, May 22). Retrieved from https://www.healthline.com/nutrition/foods-high-in-folate-folic-acid

34. Pharmacologic Treatment
• Folic acid
35
Cont’d
UpToDate. (n.d.). Retrieved from https://www.uptodate.com/contents/folic-acid-drug-
information?search=folic%20acid&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
• 1-5 mg qd over 4 months to replace body stores
• Higher dose is recommended in hemolysis, malabsorption, alcoholism
Oral
•0.4 to 1 mg/day
SubQ:
• Methanol poisoning
• Prevention of gingival hyperplasia due to phenytoin
• Drug- induced deficiency (phenytoin, phenobarbital, primidone, methotrexate,
pyrimethamine, trimethoprim)
Off-label
• 400 microgram daily starting week 16
Prophylaxis dose in pregnancy

35. 36
Anemia of Chronic
Kidney Disease

36. Treatment Guideline
37
Besarab, A., Coyne, D. Iron supplementation to treat anemia in patients with chronic kidney disease. Nat Rev Nephrol 6, 699–710 (2010).
https://doi.org/10.1038/nrneph.2010.139
Cont’d

37. 38
Anemia During
Pregnancy

38. Pharmacologic Treatment
39
ID anemia
• Pregnancy 16-30 weeks
• PO ferrous sulfate 300mg tds
• Pregnancy after 30 weeks
• IM 250mg qod
• IV infusion ferrous succinate 1 amp in 100ml d5w qod
• Anemia after 35 weeks pregnancy
• pRBC
B9 deficiency anemia
• Mild: 5 mg Folic acid daily
• Severe: pRBC followed by 1mg FA IM daily for a week
Pernicious anemia
• Mild: cyanocobalamine IM 250 microgram/ month
• Severe: pRBC followed by cyanocobalamine IM 100 microgram/day for 1 week
Warda Osama. (2013, May 9). Anemias during pregnancy warda [compatibility mode]. Retrieved from
https://www.slideshare.net/OSAMAWARDA/anemias-during-pregnancy-warda-compatibility-mode
Cont’d

39. 40
Anemia in Elderly

40. Anemia in Elderly
41UpToDate. (n.d.). Retrieved from https://www.uptodate.com/contents/ferrous-fumarate-drug-
information?search=iron&source=panel_search_result&selectedTitle=1~140&usage_type=panel&display_rank=1
Often caused by “anemia of chronic disease” or associated with
inflammation
Iron stores are usually normal or increased, with a serum ferritin
>50 ng/mL and a decreased total iron binding capacity
The reticuloendothelial system is not able to reclaim available iron
store
Cont’d

41. Fabiana Busti, atascia Campostrini, Nicola Martinelli. (2014, April 23). Iron deficiency in the elderly population, revisited in the hepcidin
era. Retrieved from https://www.frontiersin.org/articles/10.3389/fphar.2014.00083/full
Treatment Guideline
42
Cont’d

42. 43
Anemia in Pediatrics

43. Anemia in Pediatrics
44
MARY WANG. (2016, February 15). Iron Deficiency and Other Types of Anemia in Infants and Children. Retrieved from
https://www.aafp.org/afp/2016/0215/p270.html
Defined as a hgb level that is 2 SD below the mean for age
AAP and WHO recommend routine screening at 12 months of age
Affects one-half of children younger than five years
Delayed cord clamping can improve iron status in infancy, especially for at-risk
populations (i.e preterm or small for gestational age)
An initial reticulocyte count is needed to determine bone marrow function
ID anemia is the most common type
Workup: iron indices, Hgb electrophoresis, lead measurement
Cont’d

44. Iron Requirements in Pediatrics
45
MARY WANG. (2016, February 15). Iron Deficiency and Other Types of Anemia in Infants and Children. Retrieved from
https://www.aafp.org/afp/2016/0215/p270.html
AGE
IRON SUPPLEMENTATION OR
REQUIREMENT
Preterm (< 37 weeks' gestation) infants: 1 to
12 months
2 mg per kg per day supplementation if
exclusively breastfed
1 mg per kg per day supplementation if using
iron-fortified formula
Term infants: 4 to 6 months to 12 months 1 mg per kg per day supplementation if
exclusively breastfed
Supplementation not needed if using iron-
fortified formula
Toddlers 1 to 3 years Requires 7 mg per day; modify diet and/or
supplement if anemic
Children 4 to 8 years Requires 10 mg per day; modify diet and/or
supplement if anemic

45. 46
Other Treatment
Options

46. Punarnavadi Mandura
Ayurvedic herbo-mineral
preparation
Used as an ID anemia
correcting agent in all ages
Also used in Diabetic
Nephropathy
Included in ASHA drugs kit
for the management of IDA
at community level
47
Janmejaya Samal, and Ranjit Kumar Dehury. (n.d.). A Review of Literature on Punarnavadi Mandura: An Ayurvedic Herbo-Mineral
Preparation. Retrieved from https://www.phcogj.com/article/138

47. Other Herbs
Alfalfa, dandelion root
or leaf, burdock, and
yellowdock
For mild cases of anemia,
they may help bring
levels of hemoglobin into
normal range
Interact with warfarin
and other blood-thinning
medications, Lithium,
and digoxin
48
Complementary and Alternative Medicine Penn State Hershey Medical CenterAnemia Penn State Hershey Medical Center. (n.d.).
Retrieved from https://pennstatehershey.adam.com/content.aspx?productid=107&pid=33&gid=000009

48. Patient Education
Follow up and
evaluate patients
with ID anemia
for a source of
blood loss
Educate patients
on oral iron
about the
possible side
effects &
mitigation
strategies & the
possibility of
transitioning to
IV iron
Patient
education
increases the
likelihood of
patient
compliance
49

49. Conclusion
Anemia is a
very common
presentation of
an underlying
disease
It’s important
to address both
the cause and
anemia
Find people at
risk, intervene
and follow up
50

50. References
• Musallam KM, Tamim HM, Richards T, Spahn DR, Rosendaal FR, Habbal A, et al.
Preoperative anaemia and postoperative outcomes in non-cardiac surgery: a retrospective
cohort study. Lancet. 2011 Oct 15;378(9800):1396-1407. 41.
• Corwin HL, Gettinger A, Pearl RG, Fink MP, Levy MM, Abraham E, et al. The CRIT
Study: Anemia and blood transfusion in the critically ill--current clinical practice in the
United States. Crit Care Med. 2004 Jan;32(1):39-52.
• Jenny M. Debenito, BCOP; Sarah J. Billups et al. Impact of a Clinical Pharmacy Anemia
Management Service on Adherence to Monitoring Guidelines, Clinical Outcomes, and
Medication Utilization. (2014, July 1).
https://www.researchgate.net/publication/263432856_Impact_of_a_Clinical_Pharmacy_An
emia_Management_Service_on_Adherence_to_Monitoring_Guidelines_Clinical_Outcome
s_and_Medication_Utilization/link/54f89a6b0cf28d6deca2bb02/download
• Complementary and Alternative Medicine Penn State Hershey Medical CenterAnemia Penn
State Hershey Medical Center. (n.d.). Retrieved from
https://pennstatehershey.adam.com/content.aspx?productid=107&pid=33&gid=000009
51

51. There’s a need for
blood transfusions
every 2 seconds
Help trauma
patients, cancer
patients, people with
chronic illnesses
Only 3% of us
actually donate
38% of the
population in the US
are eligible to donate
blood
52