The 50-Year-Old Patient Evaluation & Management Plan

Anemia testing is quite widespread in clinical practice and is one of the most often observed laboratory abnormalities in primary care. Anemia is a term that refers to a variety of conditions characterized by insufficient red blood cell (RBC) count or function (Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J., 2019).

Iron-deficiency anemia diagnostic tests are reasonably straightforward to perform and are routinely available to primary care practitioners. Serum ferritin is a good indicator of iron deficiency in patients who do not have severe liver disease. A ferritin serum concentration of less than 30 mg/L is deemed abnormal. As ferritin levels decrease, the total iron-binding capacity (TIBC) increases above normal levels (Dunphy et. al., 2019). The goal of anemia of chronic disease (ACD) diagnostic tests is to distinguish it from iron-deficiency anemia. ACD, unlike iron deficiency anemia, is characterized by a low serum iron level and a low TIBC. In patients with ACD, serum transferrin levels are either normal or elevated. Finally, as in iron deficiency anemia, the practitioner should predict low transferrin saturation. Because the patient hemoglobin level is less than 10 g/dL, erythropoietin (EPO) levels can be measured (Cleveland Clinic, 2018).

Typically, the anemia associated with anemia of chronic disease is mild. Treating the underlying condition that causes the anemia is the initial step in treating most chronic disease-related anemia. Treating these disorders frequently resolves the anemia and accompanying symptoms. When anemia is severe (hemoglobin 8.0 g/dL), blood transfusions may be required (Cleveland Clinic, 2018). The choice to transfuse the patient requires careful consideration of the patient’s entire clinical situation and hemodynamic state. Transfusing, for example, a patient with volume-sensitive comorbidities, such as congestive heart failure with decreased kidney function within the last year, requires extreme vigilance because of the risk of fluid overload and high output cardiac failure.

This form of anemia does not have a specific treatment. The practitioner may choose to concentrate only on treating the underlying condition. If symptoms worsen, a blood transfusion or injections of a synthetic hormone made naturally by the kidneys (erythropoietin) may help boost red blood cell synthesis and alleviate fatigue. The patient may require subcutaneous medication administration that increases erythropoiesis, such as erythropoietin alfa or darbepoetin alfa. Dosage is determined by the patient’s tolerance and hematological requirements. Erythropoietin alfa ( Epogen, Procrit ) 50-100 units/kg IV/SC is given three times weekly and then dose adjusted according to therapeutic response.

Two to six weeks after increasing the dose of these erythropoietic medications, it is recommended that the patient’s hemoglobin be checked twice weekly. The administration should be discontinued if hemoglobin levels surpass 12 g/dL or increase by more than 1 g/dL in two weeks. Additionally, just as diabetic patients learn to self-inject insulin, patients can learn to self-inject these drugs subcutaneously (Dunphy et al., 2019).

Because the patient requires erythropoietin injections, she should be kept on a 30-day follow-up regimen until her hemoglobin level has stabilized, which should last roughly six months after medication initiation. While it may not be possible to prevent chronic disease-related anemia, the patient may be able to aid herself by making some dietary modifications. She should consume an adequate amount of iron, folate, and vitamin B-12 (also called cobalamin) (Dunphy et al., 2019). She might incorporate chicken or turkey, beans, spinach, fortified breakfast cereals, or enhanced bread in her diet. Additionally, the patient must understand the value of timely clinical laboratory evaluations, return follow-up visits, and recognizing signs and symptoms of recurrent anemia and potential iron overload that should be reported to the clinic, such as weight loss, loss of appetite, swelling of the lower leg, and skin yellowing.

References

Cleveland Clinic. (2018). Anemia of chronic disease. https://my.clevelandclinic.org/health/diseases/14477-anemia-of-chronic-disease (Links to an external site.).

Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2019). Primary Care: Art and Science of Advanced Practice Nursing (5th ed.).