management of anemia in community setting

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 P ractice Experience Fall 2019-2020 Management of Anemia in C ommunity Setting Feb 6, 2020 Lebanese International University School of Pharmacy

3. Outline Definition Quick facts Symptoms Classification Causes High Risk Population Anemia workup Non-pharmacologic Treatment Pharmacologic Treatment Patient Education Conclusion References 3

4. Definition Anemia is defined by WHO as hemoglobin concentration: 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 5

6. Symptoms 6 https://www.vectorstock.com/royalty-free-vector/anemia-symptoms-icons-vector-21452683

7. Classification 7 [chart]. ( n.d. ). Retrieved from http://narta.innovations2019.org/types-of-anemia-chart/all-types-of-anemia-with-full-anemia-definition-chart-and.html

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

9. Causes 9 ANEMIA. (2010, August 1). Retrieved from https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/539721

10. 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

11. Anemia Workup Initiate when Crcl < 60 ml/min or hgb <11 g/dl 11 Anemia Testing Algorithm Lab Test Selection. ( n.d. ). Retrieved from https://arupconsult.com/algorithm/anemia-testing-algorithm

12. Importance of Treatment 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

13. Hb dangerously low (< 7 g/ dL ) When to Treat as an Inpatient? 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

14. 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 14 Antonio Macciò . (2012, October 3). (PDF) Management of Anemia of Inflammation in the Elderly. Retrieved from https://www.researchgate.net/publication/232612155_Management_of_Anemia

15. 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

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

18. Pharmacologic Treatment 18

19. Oral I ron 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

20. Oral Iron 20 C ont’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

21. Oral I ron 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, e lixir and solution, s yrup, 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 C ont’d

22. Oral Iron 22 C ont’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. Food-Iron Interaction 23 C ont’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

24. Parenteral Iron 24

25. Parenteral Iron 25 C ont’d

26. Erythropoiesis Stimulating A gents ( ESA) 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

27. ESA T itration 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 C ont’d

28. ESA 28 C ont’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

29. Darbepoetin 29 C ont’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

30. 30

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

32. Pharmacologic Treatment 32 C ont’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

33. 33

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

35. Pharmacologic Treatment Folic acid 35 C ont’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

36. 36

37. 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 C ont’d

38. 38

39. Pharmacologic Treatment 39 Warda Osama. (2013, May 9). Anemias during pregnancy warda [compatibility mode]. Retrieved from https:// www.slideshare.net/OSAMAWARDA/anemias-during-pregnancy-warda-compatibility-mode C ont’d

40. 40

41. Anemia in Elderly 41 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 C ont’d

42. 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 C ont’d

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44. 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 C ont’d

45. 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

46. 46

47. Punarnavadi Mandura 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

48. Other Herbs 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

49. Patient Education 49

50. Conclusion 50

51. 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_Anemia_Management_Service_on_Adherence_to_Monitoring_Guidelines_Clinical_Outcomes_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