1. Evaluation and Management of Anemia in Family Practice
Dr Marie Andrades
Assistant Professor
Department of Family Medicine
The Aga Khan University

2. Anemia In Family Practice
Hemoglobin below the normal reference level for the age and sex of the individual
Reference range:
1-3 days: g/dl
6 months to 2 years: g/dl
Adult Men: g/dl
Adult Women: g/dl

3. Anemia In Family Practice
Prevalence:
South East Asia 70%
National Health Survey Pakistan
children < 5 years %
Adolescent %
Adult women 43%
Adult men %
In Elderly, commonest anemia are iron deficiency & chronic disease

4. Anemia In Family Practice Clinical Features (symptoms):
Infants
Irritability, restlessness
Anorexia, sleepiness
Behavioral changes
School going children

5. Anemia In Family Practice Clinical Features (symptoms):
Common
Fatigue/Muscle weakness
Headache/Lack of concentration
Faintness/dizziness
Exertional dyspnoea/palpitation
Angina/intermittent claudication

6. Anemia In Family Practice Clinical Features (signs):
Non-specific
pallor, tacycardia, flow mummer
Specific
koilonychia, angular stomatitis, glossitis
neuropathy, dementia, paraplegia
jaundice, bone deformities, leg ulcer

7. Anemia In Family Practice
History:
Physiological
Inadequate intake
Blood loss
Malabsorption
Comorbids
Drug history
Family history

8. Anemia In Family Practice Consequences of iron deficiency:
Children with Hb < 10g/dl have reduced cognitive & psychomotor function despite a return to normal hematological status
Reduced immunity and growth failure
Deficiency in dopamine receptors

9. Anemia In Family Practice Recommendations for Screening in 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

10. Anemia In Family Practice
Classification of Anemia (Mean Corpuscular volume):
Microcyctic – MCV < 80 fL
Macrocytic – MCV > 100 fL
Normocytic – MCV 80 – 100 fL

11. Anemia In Family Practice
Microcytic Anemia
Iron deficiency
Hemoglobinopathy
Sideroblastic
Lead poisoning
Occasionally chronic disease

12. Anemia In Family Practice
If no obvious cause
Serum Ferritin:
< 15ug/l : Iron deficiency
Normal or : Serum Iron / Increased Total Iron binding capacity(TIBC)

13. Anemia In Family Practice
Evaluation continued..
Serum Iron
TIBC
Peripheral smear
Iron deficiency
Decreased
Increased
Hypochromic
Thallasemia
Increased
Normal Increased
Target cells Basophilic stippling
Sideroblast
Increased
Normal
Diamorphic
Chronic disease
Decreased
Decreased
Hypo/normo chromic

14. Anemia In Family Practice
Evaluation continued..
Thallesemia
Mentzer index: MCV/RBC count. <13
Hb Electrophoresis
Sideroblastic anemia
Bone marrow exam
Iron deficiency anemia in men/post menopausal women
Gastro-intestinal endoscopy
Barium studies

15. Anemia In Family Practice
Rx of iron deficiency:
Children
Elemental iron 3-6mg/kg/day, contd months
Check Hb at 4 weeks
Adults
Ferrous sulphate/gluconate/fumarate
Iron polymaltose complex
Elemental iron 200mg/day
Parental Iron
Normal Hb/PatientHbXwt(kg)X2.2

16. Diet for Iron Deficiency:
Anemia In Family Practice
Diet for Iron Deficiency:
In adults, limit milk intake mL/day
Avoid 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

17. Macrocytic anemia (evaluation):
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

18. Anemia In Family Practice
Evaluation continued...
Macrocytes present
With megaloblast MCV>120
B12 deficiency, Folic acid deficiency
Drugs (cytotoxic, anticonvulsant, antibiotic)
Without megaloblast MCV
Liver disease, Alcoholism
Hypothyroidism, Myelodysplastic disorders

19. Anemia In Family Practice Vitamin B12 deficiency (causes)
Nutritional
Malabsorption states
food bound (prolonged use of gastric acid blockers)
lack of intrinsic factor/parietal cells (pernicious anemia,atrophic gastritis, gastrectomy)
Ileal disease (crohn’s, bacterial overgrowth, tape worm)

20. Anemia In Family Practice
Vitamin B12 deficiency (Rx)
Oral: mcg/day for weeks
1000 mcg/day for life
Intramuscular:1000 mcg alternate days to a total of 3-5 mg
1000 mcg every 3 months
Intranasal: Nascobal

21. Anemia In Family Practice Folic acid deficiency (causes & Rx)
Malnutrition
Anticonvulsants
Old age
Rx:
Oral folate I mg/day reduces artherosclerosis if associated with elevated homocysteine levels

22. Anemia In Family Practice Normocytic anemia (causes):
Increased RBC loss/destruction
acute blood loss, hypersplenism, hemolytic disease
Decreased RBC production
primary cause i.e bone marrow disorders
secondary cause i.e CRF, liver disease, chronic disease
Over-expansion of plasma volume
pregnancy, overhydration

23. 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 with leucopenia/thrombocytopenia/blast cell
bone marrow exam
Elevated retic count
Direct Coombs test: +ve autoimmune HA
-ve mechanical or other HA

24. Anemia In Family Practice
Conclusion:
Evaluation based on MCV
Microcytosis is due to iron deficiency unless proven otherwise
Megaloblast help in differentiating cause of macrosytosis
CBC and reticulocyte count essential for normocytic anemia