Anemia and Myelodysplastic Disorders in Older Adults- PLM Reynolds GET IT Program Hedieh Davanloo, MD Assistant Professor of Medicine UNTHSC/TCOM Photography courtesy of UNT Health Science Center 1

Case #1 A 78 year old retired hairdresser presented to your office for her annual exam. She has noted some increased fatigue. Her physical examination is unchanged from one year ago. Her CBC consists of the following: Hgb 11/Hct 30.2 ;MCV 73.8 ; Platelets 518,000 ; RDW 20.2 Describe the components of the CBC and discuss normal vs. abnormal values 5/12/2018

RBC 4.2 - 5.4 Hematocrit 42 - 52% Hemoglobin 12 - 16 MCV 81 - 89 RDW 11.5 - 14.5 Reticulocyte count 0.5 - 1.5 5/12/2018

44 Correct Answer: D and then C, because D & C is the initial work up for iron deficiency anemia. E is wrong because bone marrow is too aggressive at this point and there is no signs of hypothyroidism. There is a high suspicion of iron deficiency secondary to increase RDW and the low MCV. Case #1 A 78 year old retired hairdresser presented to your office for her annual exam. She has noted some increased fatigue. Her physical examination is unchanged from one year ago. Her CBC consists of the following: Hgb 11/Hct 30.2 MCV 73.8 Platelets 518,000 RDW 20.2 What test(s) would you order next? Why? A) TSH B) CMP C) Ferritin D) Iron/TIBC E) Bone Marrow 5/12/2018

Correct Answer: A, serum ferritin shows iron stores Correct Answer: A, serum ferritin shows iron stores. If the iron deficiency stores are low but in chronic disease and hepatitis their stores are not affected but their bodies can not use their stores because of the disease. Case #1 A 78 year old retired hairdresser presented to your office for her annual exam. She has noted some increased fatigue. Her physical examination is unchanged from one year ago. Her CBC consists of the following: Hgb 11/Hct 20.2 MCV 73.8 Platelets 518,000 RDW 20.2 What is the importance of serum ferritin? A) Reflects the body iron stores Elevated levels occur in iron deficiency C) Lower than expected levels in anemia of chronic disease D) Lower than expected levels in hepatitis 5/12/2018 5

Correct Answer: C, Because of low iron levels, low ferritin levels and normal TSH level, which exclude hypothyroidism and anemia of chronic disease. In the case there is no mention or any clues to sickle cell anemia or thalessemia. Case #1 A 78 year old retired hairdresser presented to your office for her annual exam. She has noted some increased fatigue. Her physical examination is unchanged from one year ago. Her CBC consists of the following: Hgb 11/Hct 20.2 MCV 73.8 Platelets 518,000 RDW 20.2 Fe 12 TIBC 481 Ferritin 8 TSH 1.65 Reticulocyte Count 1.0 Absolute Retic count 48,700 What is the most likely diagnosis? A) Anemia of Chronic Disease B) Hypothyroidism C) Iron Deficiency D) Sickle Cell Anemia E) Thalessemia 5/12/2018

Correct Answer: E ultimately will need to happen but could do UA and hemaccult if + would make you followup sooner. Case #1 A 78 year old retired hairdresser presented to your office for her annual exam. She has noted some increased fatigue. Her physical examination is unchanged from one year ago. Her CBC consists of the following: Hgb 11/Hct 30.2 MCV 73.8 Platelets 518,000 RDW 20.2 Fe 12 TIBC 481 Ferritin 8 TSH 1.65 Reticulocyte Count 1.0 Absolute Retic count 48,700 What is test(s) would be most appropriate as a next step: A) Hemaccult of stool B) Urinalysis C) Bone Marrow D) Serum Electrophoresis E) Colonoscopy 5/12/2018

Case # 2 89 year old retired farmer presents to your office complaining of generalized weakness. Physical Exam and neurologic examination is age appropriate He lives with his wife in a rural community and is independent in ADL’s and IADL’s. He rarely drives except to church on Sundays. He has avoided doctors most of his life. He takes no medications except over the counter calcium, Vit D and Aspirin 81mg daily 5/12/2018

Facilitator should go through each laboratory results and have the students explain normal vs. abnormal ranges. Case # 2 89 year old retired farmer presents to your office complaining of generalized weakness. Physical Exam and neurologic examination is age appropriate He lives with his wife in a rural community and is independent in ADL’s and IADL’s. He rarely drives except to church on Sundays. He has avoided doctors most of his life. He takes no medications except over the counter calcium, Vit D and Aspirin 81mg daily Laboratory Tests: Hgb- 11.9 g/dL Hct 35% MCV 102 mm3 Serum B12 200 pg/mL (Low Normal) Methylmalonic Acid 300 nmol/L (Increased) Homocysteine 18 micromol/L (Increased) RBC Folate Normal Ferritin 250 ng/mL Explain these laboratory tests and the Results 5/12/2018

Correct Answer: A, E is wrong because there is no iron deficiency anemia. Laboratory findings show a deficiency in B12 and you will try oral route before you go to injectable forms. C & D are too invasive and not cost effective. Case # 2 89 year old retired farmer presents to your office complaining of generalized weakness. What treatment approach is most appropriate? A) Prescribe oral Vitamin B12 1000 micrograms per day B) Administer Vitamin B12 1000 micrograms IM weekly for 8 weeks, followed by 1000micrograms IM monthly C) Administer a Schilling Test D) Recommend upper and lower endoscopy E) Prescribe iron sulfate 325mg TID 5/12/2018

Case #3 75-year-old female resident of a Assisted living facility, Staff report the following over the last month : - Increased mental sluggishness - Slight increase in confusion - Loss of energy - Decreased participation in activities offered PMH: HTN, Osteoarthritis, Osteoporosis,GERD Medications: Ibuprofen, Lisinopril, Omeprazole, Alendronate, Calcium w/D 5/12/2018

Case #3 What laboratory test(s) can confirm your diagnosis? Labs: Hemoglobin (Hb) 10.8 mg/dL; MCV 80 Serum Creatinin 1.4 mg/dL; BUN 12 mmol/L What laboratory test(s) can confirm your diagnosis? A) Peripheral Blood Smear B) GFR C) Reticulocyte count D) Iron/TIBC E) B12 level Correct Answer: B Patient has normocytic anemia with slight increase in serum creatinin. In a geriatric patient your first approach is to calculate the GFR to more accurately estimate kidney function. Because generally low cretinin levels due to muscle loss in geriatric population cretinin alone does not show kidney function. 5/12/2018

Case #3 What treatment approach is most appropriate? A) Stop Ibuprofen B) Start B12 500 mcg tablet daily C) Stop Lisinopril D)Start Ferrous Sulfate 325 mg tablet daily E) Start Erythropoetin injections Correct Answer: A, you need to first stop nephrotoxic medicine, which in this case is Ibuprofen, lisinopril is protective so we will continue it and there is no evidence of B12 or iron deficiency. E. would be the next step depending on the hemoglobin level. 5/12/2018

Discuss anemia due to renal failure and endocrine function of the kidney. Depending on the hemoglobin level you might want to treat with erythropoetin. You will also look for nephrotoxic medications and treat renal failure. Case #4 A 75 year old retired Dean of the Osteopathic Medical School of the Pacific Islands comes to the office for a routine examination. He is on hemodialysis for CKD. His PMHx includes long term DM, type 2, PVD and CAD Medications include insulin, metoprolol and calcitrol Physical Examination is unchanged from his baseline exams Laboratory results include: BUN 20 mg/dL creatinine 6.5 mg/dL Hgb 9.5 g/dL Discuss the causes of his anemia ? Discuss possible treatments for his anemia ? 5/12/2018

Case #5 What test(s) would you order next? Why? 67-year-old female with Rheumatic heart disease comes to your office complaining of chronic fatigue and shortness of breath upon exertion and tongue redness and fissuring. Physical examination suggested signs of jaundice and Systolic ejection murmur. WBC 4.5 x109; HGB 10.0 g/dL ;HCT 31 %; MCV 90 fl; PLT 255 x 109/L What test(s) would you order next? Why? A)Hemaccult of stool B)Ferritin C)Peripheral smear D)Serum Electrophoresis E)Colonoscopy Correct Answer: C, Jaundice indicates that just hemolytic anemia, the first step would be to look at the peripheral smear and see if there is any signs of hemolysis. 5/12/2018

Case #5 A peripheral blood smear showed numerous fragmented erythrocytes and poikilocytes. 5/12/2018

Case #5 Lactate dehydrogenase was elevated at 316 IU/l, haptoglobin was less than 7.3 mg/dl, Total and un- conjugated hyperbilirubinemia and hemosiderinuria was evident. What is your Diagnosis? 5/12/2018

to red blood cell trauma (Macroangiopathic hemolytic anemia) Case #5 Hemolytic anemia due to red blood cell trauma and intravascular hemolysis (Macroangiopathic hemolytic anemia) 5/12/2018

Case #5 After an aortic valve replacement, fragmentation on the peripheral blood smear dramatically disappeared. 5/12/2018

Case #6 A 78 year-old Caucasian woman is feeling tired during the day and sleeping more than she did in the past. Medical History: Has Osteoarthritis, has been treated for hypertension and chronic obstructive pulmonary disease for the past several years and has chronic hepatitis. Social History: The patient is a retired office worker. She lives alone in her apartment. She was never married and has no children. She quit smoking 30 years ago and denies any alcohol intake. HG 9.2 g/dl; HCT27.5%; MCV 95; Retic count 6; Platelets 500,000; WBC 11x 103/mm3 What is most likely diagnosis? A) Iron deficiency anemia B) B12 deficiency anemia C)Anemia of Chronic Disease D)Hemolysis E)Folate deficiency Correct Answer: C, patient has normocytic anemia which excludes iron deficiency and B12 folate deficiency. There are no clues on hemolysis in the case. 5/12/2018

Case #7 75 year old retired teacher with history of gastric surgery developed anemia, her physician decided to maintain the patient on vitamin B12 (Cyanocobalamine) shots. She comes for annual exam and reports that these shots do nothing to reverse her symptoms any more. Her laboratory work up shows: HG 7.8 g/dl; HCT26.5%; MCV 119 fL; RDW 17.5; WBC 3.2 Platelets 55,000 What do you want to do next? A) Bone Marrow aspiration B)Peripheral smear C)B12 level D)Folate level E)Methylmalonic acid level Correct Answer: A, this is macrocytyc anemia, see the next diagram for the work up of macrocytic anemia. The patient with previous B12 deficiency has started to fail B12 treatment, so you need to work it up further through bone marrow biopsy. Myelodysplastic anemia may present first like a B12 deficiency. 5/12/2018

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Questions! 5/12/2018