Anaemia in General Practice

Mary Frances McMullin

m.mcmullin@qub.ac.uk
 Outline
• Signs and symptoms of anaemia
• Classification
• Microcytic
• Normocytic
• Macrocytic
• Data examples
 Definition of anaemia
• Anaemia is defined as a reduction in the
haemoglobin concentration of the blood
• This results in a decreased oxygen carrying
capacity
 Symptoms of anaemia
• Shortness of breath on exercise
• Weakness and lethargy
• Palpitations and headaches
• Cardiac failure, angina, intermittent
claudication and confusion
• Visual disturbances due to retinal
haemorrhages
 Factors effecting symptoms of
anaemia
• Speed of onset
• Severity of anaemia
• Age
• Haemoglobin O2 dissociation curve
 Signs of anaemia
• Pallor
• Hyperdynamic circulation, tachycardia,
bounding pulse, cardiomegaly
• Congestive cardiac failure
• Retinal haemorrhages
 Classification of Anaemia:
Microcytic Hypochromic
• MCV <80fl
• MCH <27pg
 Microcytic anaemia
Ferritin <25ug/L
• Iron deficiency
 Microcytic anaemia
Ferritin >25ug/L
• Thalassaemia
• Sideroblastic anaemia (some cases)
• Anaemia of chronic disease (some cases)
• Lead poisoning
 Classification of Anaemia:
Normocytic Normochromic
• MCV 80-100fl
• MCH >26pg
 Normochromic normocytic
anaemia
• Often incidental finding in systemic disorders
• May be first manifestation of a systemic disorder
• Many haemolytic anaemias
• Anaemia of chronic disease (some cases)
• After acute blood loss
• Bone marrow failure, e.g. Post-chemotherapy,
infiltration by carcinoma etc
 Classification of Anaemia:
Macrocytic
• MCV >100fl
• Megaloblastic: vitamin B12 or folate
deficiency
• Non-megaloblastic: alcohol, liver disease,
myelodysplasia, aplastic anaemia
 Iron deficiency anaemia
• Assess for
• Dietary Iron deficiency
• Malabsorption- coeliac
• Chronic blood loss
• Gastrointestinal
• Menorrhagia
 Treatment of Iron Deficiency

• Ferrous sulphate 200mg three times a day

(cheapest) on an empty stomach
• Continue until stores are replaced-usually 6
months
 Follow up-Iron deficiency
• Adolescents and pre- • Follow-up: refer only
menopausal females if specific indication
• GI symptoms and no • Refer to
diagnosis gastroenterologist
• Menstrual problem • Refer to gynaecologist
 Failure of Response to Oral Iron
• Continuing blood loss
• Failure to take tablets
• Wrong diagnosis-thalassaemia trait, sideroblastic anaemia
• Mixed deficiency-associated vitamin B12 or folate
deficiency
• Another cause for the anaemia, e.g. malignancy,
inflammation
• Malabsorption
• Use of a slow release preparation
 Microcytic anaemia
Ferritin >25ug/L
• Thalassaemia • Consider referral to
haematologist
• Sideroblastic anaemia • Refer to haematologist
• Anaemia of chronic
disease (usually
normocytic)
• Lead poisoning • Assess exposure
(usually normocytic) history: measure
urinary lead
 Thalassaemia Trait
• Microcytic anaemia
• High red cell count
• Normal MCHC
• Usually non-Caucasian
 Treatment of Thalassaemia Trait

• Reassurance
• Evaluation of iron status
• Antenatal/ genetic counselling
 Normocytic anaemia
• Often an incidental finding in systemic disorders
• May be first manifestation of systemic disorder
• May be an early manifestation of a microcytic or
macrocytic anaemia
• Detailed history and examination required to guide
investigation/referral
• Unexplained normocytic anaemia----refer to
haematologist
 Vitamin B12
• Normal daily intake • 7-30mg
• Main foods • Animal produce only
• Cooking • Little effect
• Minimal daily requirement • 1-2mg
• Body stores • 2-3mg (enough for 2-4yrs)
• Absorption
• site • Ileum
• mechanism • Intrinsic factor
• limit • 2-3mg
• Usual therapeutic form • Hydroxocobalamin
 Pernicious Anaemia

• Autoimmune attack on the gastric mucosa

leading to atrophy of the stomach
• Females> males
• Associated autoimmune diseases
• Tends to occur in families
 Folic Acid
• Normal daily intake • 200-250mg
• Main foods • Most liver, greens, yeast
• Cooking • Easily destroyed
• Minimal daily requirement • 100-150mg
• Body stores • 10-12mg (4mths supply)
• Absorption
• site • Duodenum and jejunum
• mechanism • Converted to methylTHF
• limit • 50-80% of dietary intake
• Usual therapeutic form • Folic acid
 Causes of Folic Acid Deficiency
• Nutritional -old age, poverty, diet etc
• Malabsorption- tropical sprue, coeliac disease, Crohn’s
disease
• Excess utilization
• Physiological-pregnancy, lactation, prematurity
• Pathological-haemolytic anaemia, myelofibrosis,
malignant disease, inflammatory disease
• Drugs-anticonvulsants
• Mixed-liver disease, alcoholism, intensive care
 Megaloblastic Anaemia: Clinical
• Insidious onset of symptoms and signs of anaemia
• Lemon yellow jaundice
• Glossitis, angular stomatitis
• Purpura
• Neuropathy-subacute combined degeneration of
the cord (neuropathy affecting the peripheral
sensory nerves and posterior and lateral columns)
 Megaloblastic Anaemia: Treatment

• Vitamin B12 1000mg/day x 6, intramuscular

• Folic acid 5mg per day, oral
• May need folic acid, iron, potassium supplements
and diuretics
• Continue 1000mg once every 3 mths for life
 Investigation in primary care
• History and examination
• FBP
• Ferritin
• B12 and Folate
 Data Interpretation (1)
• Haemoglobin (g/dl)
• Haematocrit (PCV) (%)
• Red cell count (x 1012/L)
• Mean cell haemoglobin
(pg)
• Mean cell volume (fl)
• Mean cell haemoglobin
concentration (g/dl)
• 7.5 (11.5-16.5)
• 30 (0.37-0.47)
• 2.35 (3.8-5.8)
• 22 (27-32)
• 65 (76-100)
• 26 (32-36)
 Data Interpretation (2)
• Haemoglobin (g/dl)
• Haematocrit (PCV) (%)
• Red cell count (x 1012/L)
• Mean cell haemoglobin
(pg)
• Mean cell volume (fl)
• Mean cell haemoglobin
concentration (g/dl)
• 11.4 (11.5-16.5)
• 0.404 (0.37-0.47)
• 6.25 (3.8-5.8)
• 20.5 (27-32)
• 64.6 (76-100)
• 31.7 (32-36)
 Further results (2)
• Haemoglobin F- 0.3% • <1%
• Hb A2 - 2.5% • 1.5-3.5
• Ferritin 135ug/L
• Homozygous for alpha
3.7 deletion
• Homozygous for alpha
+ thalassaemia
 Data Interpretation (3)
• Haemoglobin (g/dl)
• Haematocrit (PCV) (%)
• Red cell count (x 1012/L)
• Mean cell haemoglobin
(pg)
• Mean cell volume (fl)
• Mean cell haemoglobin
concentration (g/dl)
• 8.2 (11.5-16.5
• 0.25 (0.37-0.47)
• 2.7 (3.8-5.8)
• 34 (27-32)
• 120 (76-100)
• 34 (32-36)
 Department of Haematology
Belfast City Hospital

Anaemia in Adults – Hospital Referral Guidelines:

1. Microcytic anemias (MCV <76 fL): Check serum ferritin

(a) Ferritin < 25 ug/L Fe deficiency anaemia:
Assess for: Dietary Fe deficiency
Malabsorption – esp. coeliac disease
Chronic gastrointestinal bleeding
Menorrhagia
Treat with oral Fe
Adolescents & pre-menopausal females: Follow-up
Refer only if specific indication
Others - GI symptoms or no diagnosis: Refer to gastroenterologist
Menstrual problem: Refer to gynaecologist
(b) Ferritin >25 ug/L
Thalassaemias } Refer to haematologist
Sideroblastic anaemias }
Anaemia of chronic disease (usually normocytic) See below
Chronic lead poisoning (usually normocytic) Assess exposure history
Measure urinary lead
2. Macrocytic anaemias (MCV >100fL): Check serum B12 & folate
(a) Normal B12 & folate
Assess for: Liver disease
Alcohol excess
Hypothyroidism
Pregnancy
Drugs
(b) Low B12 or folate
Investigate & treat as appropriate
Discuss &/or refer to haematologist if difficulties arise
(c) All tests normal or no clear diagnosis: Refer to haematologist
3. Normocytic anaemia (MCV 76-100 fL):
Often an incidental finding in systemic disorders
May be the first manifestation of a systemic disorder
May be an early manifestation of a microcytic or macrocytic anaemia
Detailed history & examination required to guide investigation/referral
Unexplained normocytic anaemia: Refer to haematologist

RJG Cuthbert, August 2006

 Useful information

• Anaemia in Adults-Hospital referral

guidelines
• British Society of Haematology –
www.bsg.org.uk
• NHS guidance on the investigation and
treatment of anaemias-
www.prodigy.nhs.uk/guidance