Chẩn đoán điều trị thiếu máu thiếu sắt trẻ em 2019

CHẨN ĐOÁN VÀ ĐIỀU TRỊ THIẾU MÁU THIẾU SẮT Hội nghị Khoa học Nhi khoa Bệnh viện Nhi Đồng TPHCM, 20-21/9/2019 TS BS Nguyễn Minh Tuấn Bệnh viện Nhi Đồng Khoa Y – Đại học Quốc gia TPHCM Đơn vị Nghiên cứu Lâm sàng Đại học Oxford Contents • • • • • • Definition of iron deficiency anemia Epidemiology Iron metabolism Etiology Diagnosis Management Contents • • • • • • Definition of iron deficiency anemia Epidemiology Iron metabolism Etiology Diagnosis Management ANEMIA Defined as an insufficient RBC mass to adequately deliver oxygen to peripheral tissues Wintrobes Defined as a decrease in the amount of red blood cells (RBCs) or the amount of hemoglobin in the blood It can also be defined as a lowered ability of the blood to carry oxygen Wikipedia Anemia is defined as a reduction of the total circulating red cell mass below normal limits Robbins ANEMIA Theo Tổ chức Y tế giới, gọi thiếu máu lượng hemoglobin (Hb) giới hạn sau đây: Hb bình thường Thiếu máu Trẻ sơ sinh (đủ tháng) (g/dL) 13.5 – 18.5 (Hb ≤ giới hạn) 13.5 (Hct 34%) Trẻ từ – tháng 9.5 – 13.5 9.5 (Hct 28%) Trẻ từ tháng đến tuổi 10.5-13.5 10.5 (Hct 33%) Trẻ từ – tuổi 11.0 – 14.4 11.0 (Hct 33%) Trẻ từ – 12 tuổi 11.5 – 15.5 11.5 (Hct 34%) Nam trưởng thành 13.0 – 17.0 13.0 (Hct 39%) Nữ trưởng thành (không mang thai) 12.0 – 15.0 12.0 (Hct 36%) Tuổi / giới tính IRON DEFICIENCY ANEMIA Anemia with biochemical evidence of iron deficiency based on following laboratory findings: • serum ferritin, • total iron binding capacity (TIBC), • transferrin saturation, • or transferrin receptor Contents • • • • • • Definition of iron deficiency anemia Epidemiology Iron metabolism Etiology Diagnosis Management EPIDEMIOLOGY • Globally, anemia affects 1.62 billion people , which corresponds to 24.8% of the population • IDA occurs across all populations and is associated with ✓ Diminished QOL ✓ Physical and cognitive performance, and ✓ Unfavorable clinical outcomes Classification of anemia as a problem of public health significant Anemia prevalence MANAGEMENT Therapeutic goals Short term • Resolution of symptoms • Replenish iron stores Long term • Improve quality of life (QOL) • Prevention of recurrences • Better growth and development (children) Treatment options Pharmacological management • Oral/parenteral iron therapy Non-pharmacological • Blood transfusion MANAGEMENT Matthew W et al Am Fam Physician 2013;87(2):98-104 MANAGEMENT Dosage of oral iron therapy: 4-6mg/kg/d, t.i.d Forms: • Tablets, capsules • Sugar coated & uncoated tablets • Slow release tabs & chewable tabs • Drops & syrups—used by children AVAILABLE PRODUCTS DiPiro J Anemia In: Pharmacotherapy: A Pathophysiological Approach, 2011 AVAILABLE PRODUCTS Forms: • Tablets, capsules • Sugar coated & uncoated tablets • Slow release tabs & chewable tabs • Drops & syrups—used by children Response to oral therapy • 12 – 24hrs: restore enzyme, improve appetite and irritability • 48 – 72hrs: reticulocytes increase, peak after – weeks • Considered as satisfactory if Hb ↑ by % per day (0.15 g %), with at least 10 % (1.5 g % ) within weeks Factors influencing iron absorption Important points to remember • Elemental iron content and not quantity of iron compound per unit dose to be considered • Sustained released preparations expensive and irrational • Liquid formulations should be put on back of tongue and swallowed • Absorption better on empty stomach but side effects more Common side effects • Gastrointestinal (GI) intolerance Nausea, vomiting, heartburn, and constipation or diarrhea ➢ Slow release or sustained release preparations may be used ➢ Combination products, e.g Ferro-DDS (ferrous fumarate/docusate), may be advantageous for certain patient population • Cause discoloration of stool • Metallic taste • Staining of teeth Parenteral iron therapy ➢ Indications for therapy • • • • Intolerance to oral route Malabsorption Long-term nonadherence Patient with significant blood loss who refuse transfusion and are intolerant to oral therapy • Chronic kidney disease (CKD) or malignancy ➢ Currently available formulations include Dextran, sodium ferric gluconate, iron sucrose, ferumoxytol ➢ Formulations differ in their molecular size, degradation kinetics, bioavailability, and side effects profile ➢ All preparations carry a risk for anaphylactic reactions but likely to a lesser extent than iron dextran Parenteral iron therapy 𝑡ℎể 𝑡í𝑐ℎ 𝑚á𝑢 × 12,5 − 𝐻𝑏 𝑏𝑛 × 3,4 × 1,2 𝑙ượ𝑛𝑔 𝑠ắ𝑡 (𝑚𝑔) = 100 rải tiêm bắp hay tĩnh mạch cách ngày hay cách tuần 2-3 tuần, ≤0,1 mg/kg/liều Thể tích máu: ml/kg 3,4: 1g Hb cần 3,4mg sắt 1,2: thêm 20% cho sắt dự trữ Iron supplementation to prevent IDA TAKE-HOME MESSAGES ➢ IDA is the most common form of anemia ➢ Four main factors contributing to IDA: • Inadequate iron intake • Decreased iron absorption • Increased iron demand or hematopoiesis • Increased iron loss ➢ Complete patient history, physical exams, and laboratory investigations ➢ Abnormal laboratory investigations: low MCV, serum iron, and ferritin ➢ Treatment of IDA consists of dietary supplementation and administration of oral iron preparations ➢ Complete therapeutic response requires iron supplementation for months after Hct and ferritin levels normalize ... Robbins ANEMIA Theo Tổ chức Y tế giới, gọi thiếu máu lượng hemoglobin (Hb) giới hạn sau đây: Hb bình thường Thiếu máu Trẻ sơ sinh (đủ tháng) (g/dL) 13.5 – 18.5 (Hb ≤ giới hạn) 13.5 (Hct 34%) Trẻ từ... deficiency anemia Epidemiology Iron metabolism Etiology Diagnosis Management Contents • • • • • • Definition of iron deficiency anemia Epidemiology Iron metabolism Etiology Diagnosis Management ANEMIA... Classification of anemia as a problem of public health significant Anemia prevalence Contents • • • • • • Definition of iron deficiency anemia Epidemiology Iron metabolism Etiology Diagnosis Management IRON