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{{Macrocytic anemia}}
{{Macrocytic anemia}}
{{CMG}}; {{AE}}
{{CMG}} {{shyam}}; {{AE}}{{ADS}} {{OK}}


==Overview==
==Overview==
[Therapy] is recommended among all patients who develop [disease name].
In patients with deficiencies of [[vitamin B12|vitamin b12]] and [[folate]] causing [[megaloblastic anemia]], medical therapy involves supplementation with [[cyanocobalamine]] and [[folic acid]] respectively based on the severity and the cause. In some cases, potassium levels can decrease ([[hypokalemia]]) in the acute phase as new cells are being generated rapidly, and this may require potassium supplementation. A [[reticulocytosis]] begins in 3-5 days and peaks in 10 days. The [[hematocrit]] will rise within 10 days. If it does not, another disorder should be suspected. Hypersegmented [[polymorphonuclear cells]] disappear in 10-14 days.
 
OR
 
Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].
 
OR
 
Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].
 
OR
 
Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].
 
OR
 
Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].


==Medical Therapy==
==Medical Therapy==
*Pharmacologic medical therapy is recommended among patients which don't improve on dietary measures.<ref name="pmid23301732">{{cite journal |vauthors=Stabler SP |title=Clinical practice. Vitamin B12 deficiency |journal=N. Engl. J. Med. |volume=368 |issue=2 |pages=149–60 |date=January 2013 |pmid=23301732 |doi=10.1056/NEJMcp1113996 |url=}}</ref>  
*Pharmacologic medical therapy is recommended for patients who do not improve on dietary measures.<ref name="pmid23301732">{{cite journal |vauthors=Stabler SP |title=Clinical practice. Vitamin B12 deficiency |journal=N. Engl. J. Med. |volume=368 |issue=2 |pages=149–60 |date=January 2013 |pmid=23301732 |doi=10.1056/NEJMcp1113996 |url=}}</ref><ref name="pmid29264027">{{cite journal |vauthors=Nagao T, Hirokawa M |title=Diagnosis and treatment of macrocytic anemias in adults |journal=J Gen Fam Med |volume=18 |issue=5 |pages=200–204 |date=October 2017 |pmid=29264027 |pmc=5689413 |doi=10.1002/jgf2.31 |url=}}</ref>
 
* '''Vitamin B12 deficiency'''
* '''Vitamin B12 deficiency'''
** '''Mild'''  
** '''Mild'''  
 
*** Parenteral regimen
**** Parenteral regimen
**** Preferred regimen (1): [[Cyanocobalamin Injection|Cyanocobalamin]] 1000 μg IM q24h for 7 days, then q weekly for 4-8 weeks <ref name="pmid23301732" />
***** Preferred regimen (1): [[Cyanocobalamin Injection|Cyanocobalamin]] 1000 μg IM q24h for 7 days, then q weekly for 4-8 weeks <ref name="pmid23301732" />
*** Oral regimen
**** Oral regimen
**** Preferred regimen (1): [[Cyanocobalamin Injection|Cyanocobalamin]] 500-1000 μg PO q24h<ref name="pmid23301732" />  
***** Preferred regimen (1): [[Cyanocobalamin Injection|Cyanocobalamin]] 500-1000 μg PO q24h<ref name="pmid23301732" />  
** '''Severe'''
*** '''Severe'''
*** Parenteral regimen
**** Parenteral regimen
**** Preferred regimen (1):[[Cyanocobalamin Injection|Cyanocobalamin]] 1000 μg IM q24h for 7 days, then q weekly for 4-8 weeks <ref name="pmid23301732" /><nowiki/>
***** Preferred regimen (1):[[Cyanocobalamin Injection|Cyanocobalamin]] 1000 μg IM q24h for 7 days, then q weekly for 4-8 weeks <ref name="pmid23301732" /><nowiki/>
*** Oral regimen
**** Oral regimen
**** Preferred regimen (1): [[Cyanocobalamin Injection|Cyanocobalamin]]1000-2000 μg PO q24h<ref name="pmid23301732" />
***** Preferred regimen (1): [[Cyanocobalamin Injection|Cyanocobalamin]]1000-2000 μg PO q24h<ref name="pmid23301732" />
** '''Pernicious anemia'''
**
*** Parenteral regimen
*** '''Pernicious anemia'''
**** Preferred regimen (1):[[Cyanocobalamin Injection|Cyanocobalamin]] 1000 μg IM q24h for 7 days, then q weekly for 4-8 weeks <ref name="pmid23301732" />
**** Parenteral regimen
**** Alternative regimen (1): [[Cyanocobalamin Injection|Cyanocobalamin]] 100-1000 μg IM  q24h for 1-2 weeks and then 1-3 months<ref name="pmid12643357">{{cite journal |vauthors=Oh R, Brown DL |title=Vitamin B12 deficiency |journal=Am Fam Physician |volume=67 |issue=5 |pages=979–86 |date=March 2003 |pmid=12643357 |doi= |url=}}</ref>
***** Preferred regimen (1):[[Cyanocobalamin Injection|Cyanocobalamin]] 1000 μg IM q24h for 7 days, then q weekly for 4-8 weeks <ref name="pmid23301732" />
*** Oral regimen
***** Alternative regimen (1): [[Cyanocobalamin Injection|Cyanocobalamin]] 100-1000 μg IM  q24h for 1-2 weeks and then 1-3 months<ref name="pmid12643357">{{cite journal |vauthors=Oh R, Brown DL |title=Vitamin B12 deficiency |journal=Am Fam Physician |volume=67 |issue=5 |pages=979–86 |date=March 2003 |pmid=12643357 |doi= |url=}}</ref>
**** Preferred regimen (1): [[Cyanocobalamin Injection|Cyanocobalamin]]1000-2000 μg PO q24h<ref name="pmid23301732" />  
**** Oral regimen
** '''Gastric bypass'''
***** Preferred regimen (1): [[Cyanocobalamin Injection|Cyanocobalamin]]1000-2000 μg PO q24h<ref name="pmid23301732" />  
*** Parenteral regimen
*
**** Preferred regimen (1):[[Cyanocobalamin Injection|Cyanocobalamin]] 1000 μg IM or SQ q monthly<ref name="pmid28392254">{{cite journal |vauthors=Parrott J, Frank L, Rabena R, Craggs-Dino L, Isom KA, Greiman L |title=American Society for Metabolic and Bariatric Surgery Integrated Health Nutritional Guidelines for the Surgical Weight Loss Patient 2016 Update: Micronutrients |journal=Surg Obes Relat Dis |volume=13 |issue=5 |pages=727–741 |date=May 2017 |pmid=28392254 |doi=10.1016/j.soard.2016.12.018 |url=}}</ref>
*** '''Gastric bypass'''
**** Alternative regimen (1): [[Cyanocobalamin Injection|Cyanocobalamin]] 1000 μg IM  q monthly<ref name="pmid23301732" />
**** Parenteral regimen
*** Oral regimen
***** Preferred regimen (1):[[Cyanocobalamin Injection|Cyanocobalamin]] 1000 μg IM or SQ q monthly<ref name="pmid28392254">{{cite journal |vauthors=Parrott J, Frank L, Rabena R, Craggs-Dino L, Isom KA, Greiman L |title=American Society for Metabolic and Bariatric Surgery Integrated Health Nutritional Guidelines for the Surgical Weight Loss Patient 2016 Update: Micronutrients |journal=Surg Obes Relat Dis |volume=13 |issue=5 |pages=727–741 |date=May 2017 |pmid=28392254 |doi=10.1016/j.soard.2016.12.018 |url=}}</ref>
**** Preferred regimen (1): [[Cyanocobalamin Injection|Cyanocobalamin]] 350-500μg PO q24h<ref name="pmid28392254" />  
***** Alternative regimen (1): [[Cyanocobalamin Injection|Cyanocobalamin]] 1000 μg IM  q monthly<ref name="pmid23301732" />
**** Alternative regimen (1): [[Cyanocobalamin Injection|Cyanocobalamin]] 1000-2000 μg PO q24h<ref name="pmid23301732" />   
**** Oral regimen
* '''Folate deficiency'''
***** Preferred regimen (1): [[Cyanocobalamin Injection|Cyanocobalamin]] 350-500μg PO q24h<ref name="pmid28392254" />  
***** Alternative regimen (1): [[Cyanocobalamin Injection|Cyanocobalamin]] 1000-2000 μg PO q24h<ref name="pmid23301732" />  '''Pediatric'''
** Parenteral regimen
** Parenteral regimen
*** Preferred regimen (1): [[drug name]] 50–75 mg/kg IV q24h for 14 (14–21) days (maximum, 2 g)
*** Preferred regimen (1):[[Folic Acid]] 0.4-1 mg IV q 24h and maintenance dose 0.4 mg q 24h<ref name=":0">{{cite book | last = DiPiro | first = Joseph | title = Pharmacotherapy : a pathophysiologic approach | publisher = McGraw-Hill Education | location = New York | year = 2017 | isbn = 9781259587481 }}</ref>
*** Alternative regimen (1): [[drug name]] 150–200 mg/kg/day IV q6–8h for 14 (14–21) days (maximum, 6 g per day)
*** Alternative regimen (2):  [[drug name]] 200,000–400,000 U/kg/day IV q4h for 14 (14–21) days (maximum, 18–24 million U per day)
** Oral regimen
** Oral regimen
*** Preferred regimen (1): [[drug name]] 50 mg/kg/day PO q8h for 14 (14–21) days  (maximum, 500 mg per dose)
*** Preferred regimen (1): [[Folic Acid]] 1-5 mg PO q 24h<ref name=":0" />
*
*** Alternative regimen (1): [[Folic Acid]] 1-15 mg PO q 24h<ref name=":0" />
* [[Folate]] is administered 1mg QD.  Higher doses may be required in malabsorptive syndromes.  It is empirically given to those with SCD and those on HD.
* B12 must be given as a load then maintenance.  Most advocate 1000 mcg IM Qweek x4 then 100mcg/month.
* [LDH]] falls in 2 days. [[Hypokalemia]] requiring replacement can occur in the acute phase as new cells are being generated rapidly.
* A [[reticulocytosis]] begins in 3-5 days and peaks in 10 days.  The HCT will rise within 10days.  If it does not, suspect another disorder.  Hypersegmented PMNs disappear in 10-14 days.
* Neurologic abnormalities may take up to 6 months to resolve if ever.  The longer the disease has been present, the worse is the prognosis for recovery.
* Persons with PA have a 2x risk of gastric CA (in some studies).  Screen for occult blood.
 
=====Contraindicated medications=====


{{MedCondContrAbs
===Expectations after Medical Therapy===
[[Hypokalemia]] requiring replacement can occur in the acute phase as new cells are being generated rapidly. In some cases, potassium supplementation may be necessary.
* A [[reticulocytosis]] begins in 3-5 days and peaks in 10 days. Hematocrit will rise within 10 days. Hypersegmented neutrophils disappear in 10-14 days.
* Neurologic abnormalities may take up to 6 months to resolve if ever. The longer the disease has been present, the worse is the prognosis for recovery. Tertiary prevention measures may need to be implemented to help prevent the disability from neurologic abnormalities.


|MedCond = Macrocytic Anemia|Sulfamethoxazole/Trimethoprim (oral)}}
=====Contraindicated Medications=====
*Sulfamethoxazole/Trimethoprim (oral)
*Pyrimethamine
*Methotrexate


==References==
==References==

Latest revision as of 23:59, 2 December 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Shyam Patel [2]; Associate Editor(s)-in-Chief: Amandeep Singh M.D.[3] Omer Kamal, M.D.[4]

Overview

In patients with deficiencies of vitamin b12 and folate causing megaloblastic anemia, medical therapy involves supplementation with cyanocobalamine and folic acid respectively based on the severity and the cause. In some cases, potassium levels can decrease (hypokalemia) in the acute phase as new cells are being generated rapidly, and this may require potassium supplementation. A reticulocytosis begins in 3-5 days and peaks in 10 days. The hematocrit will rise within 10 days. If it does not, another disorder should be suspected. Hypersegmented polymorphonuclear cells disappear in 10-14 days.

Medical Therapy

  • Pharmacologic medical therapy is recommended for patients who do not improve on dietary measures.[1][2]
  • Vitamin B12 deficiency
    • Mild
      • Parenteral regimen
        • Preferred regimen (1): Cyanocobalamin 1000 μg IM q24h for 7 days, then q weekly for 4-8 weeks [1]
      • Oral regimen
    • Severe
      • Parenteral regimen
        • Preferred regimen (1):Cyanocobalamin 1000 μg IM q24h for 7 days, then q weekly for 4-8 weeks [1]
      • Oral regimen
    • Pernicious anemia
      • Parenteral regimen
        • Preferred regimen (1):Cyanocobalamin 1000 μg IM q24h for 7 days, then q weekly for 4-8 weeks [1]
        • Alternative regimen (1): Cyanocobalamin 100-1000 μg IM q24h for 1-2 weeks and then 1-3 months[3]
      • Oral regimen
    • Gastric bypass
  • Folate deficiency
    • Parenteral regimen
      • Preferred regimen (1):Folic Acid 0.4-1 mg IV q 24h and maintenance dose 0.4 mg q 24h[5]
    • Oral regimen

Expectations after Medical Therapy

Hypokalemia requiring replacement can occur in the acute phase as new cells are being generated rapidly. In some cases, potassium supplementation may be necessary.

  • A reticulocytosis begins in 3-5 days and peaks in 10 days. Hematocrit will rise within 10 days. Hypersegmented neutrophils disappear in 10-14 days.
  • Neurologic abnormalities may take up to 6 months to resolve if ever. The longer the disease has been present, the worse is the prognosis for recovery. Tertiary prevention measures may need to be implemented to help prevent the disability from neurologic abnormalities.
Contraindicated Medications
  • Sulfamethoxazole/Trimethoprim (oral)
  • Pyrimethamine
  • Methotrexate

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 Stabler SP (January 2013). "Clinical practice. Vitamin B12 deficiency". N. Engl. J. Med. 368 (2): 149–60. doi:10.1056/NEJMcp1113996. PMID 23301732.
  2. ↑ Nagao T, Hirokawa M (October 2017). "Diagnosis and treatment of macrocytic anemias in adults". J Gen Fam Med. 18 (5): 200–204. doi:10.1002/jgf2.31. PMC 5689413. PMID 29264027.
  3. ↑ Oh R, Brown DL (March 2003). "Vitamin B12 deficiency". Am Fam Physician. 67 (5): 979–86. PMID 12643357.
  4. ↑ 4.0 4.1 Parrott J, Frank L, Rabena R, Craggs-Dino L, Isom KA, Greiman L (May 2017). "American Society for Metabolic and Bariatric Surgery Integrated Health Nutritional Guidelines for the Surgical Weight Loss Patient 2016 Update: Micronutrients". Surg Obes Relat Dis. 13 (5): 727–741. doi:10.1016/j.soard.2016.12.018. PMID 28392254.
  5. ↑ 5.0 5.1 5.2 DiPiro, Joseph (2017). Pharmacotherapy : a pathophysiologic approach. New York: McGraw-Hill Education. ISBN 9781259587481.

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