Anemia recommended treatment

What treatment would you recommend for this patient for treatment of anemia ... 

Recommend a specific treatment regimen for anemia considering the underlying cause of anemia and patient-specific variables. 

The National Comprehensive Cancer Network (NCCN) recommends an anemia work-up for patients with hemoglobin of less than 11 g/dL (110 g/L or 6.8 mmol/L). Patients who are symptomatic or asymptomatic with significant risk factors (e.g., extensive transfusion history, myelosuppressive chemotherapy, etc) may qualify for treatment with erythropoietic agents such as epoetin-alfa or darbepoetin. Data do not support the use of one agent over another they are both equally effective in treating this type of anemia.12 Table 63-4 provides dosing recommendations for chemotherapy-related anemia. 

Patient monitoring Because of the frequency of granulocytopenia, anemia, and thrombocytopenia, it is recommended that CBCs and platelet counts be performed frequently, especially in patients in whom ganciclovir or other nucleoside analogs have previously resulted in cytopenia, or in whom neutrophil counts are less than 1000/mcL at the beginning of treatment. Patients should have serum creatinine or Ccr values followed carefully to allow for dosage adjustment in renally impaired patients. 

Immune globulin, given intramuscularly or intravenously, is recommended in the treatment of primary humoral immunodeficiency, congenital agammaglobulinemias, common variable immunodeficiency, severe combined immunodeficiency, idiopathic thrombocytopenic purpura, and autoimmune hemolytic anemia. There are six licensed preparations of immune globulin. 

Vorinostat (Zolinza) is a histone deacetylase inhibitor that is approved for the treatment of cutaneous T-cell lymphoma in patients with progressive, persistent, or recurrent disease on or after two systemic therapies. The recommended dosing is 400 mg orally once daily. Adverse effects include pulmonary embolus, deep vein thrombosis, thrombocytopenia, anemia, and gastrointestinal disturbances. 

Anabolic steroids are also still used in refractory anemias, although with recombinant human erythropoietin now widely available they appear to be seen mainly as a means of increasing the response to erythropoietin in highly resistant cases combination treatment with erythropoietin, a glucocorticoid, and nandrolone has also been recommended for treating myelodysplastic syndromes (13). Again, in such exceptional situations the risks of anabolic steroids have to be accepted. 

Dong quai has been used in the treatment of dysmenorrhea, amenorrhea, metorrhagia, menopausal syndromes, anemia, abdominal pain, injuries, migraine headaches, and arthritis. It is believed to ensure healthy pregnancies and easy deliveries. In the U.S., dong quai is recommended primarily to alleviate problems associated with menstruation and menopause. 

DFO is generally indicated for treatment of acute iron intoxication and chronic iron overload due to transfusion depended anemias (including thalassemia). DFO is not recommended in primary hemochromatosis (PDR). 

Guidelines for the appropriate use of hemopoietic growth factors in children have been proposed by a panel of European experts, who carefully summarized the potential indications and recommendations, and concluded that adult guidelines are apphcable to children in most cases (9). The authors considered that growth factors should be used in children for only a hmited number of circumstances prophylaxis or treatment in low-risk patients treated with chemotherapy, routine use in aplastic anemia, and mobilization of peripheral blood progenitor cells in healthy pediatric donors. 

In 140 patients with Nipah vims infection there was no difference in the incidence of adverse effects between those who elected to have ribavirin treatment and those who refnsed (12). Dosing was based on recommendations nsed to achieve the same approximate concentrations as those seen with 100-1200 mg/day in the treatment of hepatitis C. Anemia occnrred in 37% of the ribavirin-treated patients and in the same nnmber of controls, suggesting that ribavirin was eqnally well tolerated in the two groups. 

Felbamate. Felbamate is an adjuvant anticonvulsant, containing the warning that its use is associated with a marked increase in the incidence of aplastic anemia and that patients being started on the drug should have liver function tests performed before therapy is initiated. Animal studies have revealed a statistically significant increase in hepatic cell adenomas in high dose studies (18). It is postulated that this cancer was induced by toxic by-products urethane and methyl carbamate. Felbamate is not recommended as first-line therapy and is indicated for those patients who respond inadequately to alternative treatments and whose epilepsy is so severe that a substantial risk of aplastic anemia or liver failure is deemed acceptable in light of the benefits provided by its use. 

Triamterene has been reported to cause photosensitivity reactions, increase in uric acid concentration, and blood dyscrasias.91 Nephrolithiasis may occur in susceptible patients. Megaloblastic anemia has been reported in patients with depleted folic acid stores such as those with hepatic cirrhosis. In a study conducted on rats, daily treatment of the animals with doses of 1.5, 3 and 4.5 mg/lOOg over the period of three weeks caused severe degenerative changes of renal cortical and medullary tubules resembling osmotic nephrosis.93 Reversible acute renal failure from combined triamterene and indomethacin in healthy subjects is reported.94 It is recommended that this potentially nephrotoxic association be avoided. 

Felbamate, proprietary name Felhatol, was approved for primary or adjunctive therapy of partial seizures. Its use is limited to those patients who fail other drug treatments, because felbamate carries with it a substantial risk of aplastic anemia and hver failure that is not related to the blood level. Biweekly monitoring of complete blood count, serum ammotransferases, and bilirubin is recommended to detect early onset of these side effects. Felbamate is particularly effective in control of Lennox-Gastaut syndrome. 

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