Putting Prevention into Practice: Screening for Iron Deficiency Anemia

 in 2009, the article featured on this site provides important information on screening for iron deficiency anemia in pregnant women and young children. Written by Iris R. Mabry-Hernandez, MD, MPH, of the Agency for Healthcare Research and Quality, the piece begins with the case study of a 25-year-old pregnant woman with a family history of anemia who asks if she should be taking an iron supplement. After reading the case study, visitors can test their knowledge of the subject by answering three questions and reading the explanations for each.

One of several features articles featured on the website for the National Anemia Action Council, this page helps patients determine whether they should consider taking iron injections to treat an iron deficiency. Visitors can also learn why the body needs iron, what happens when iron levels drop too low, what are the side effects of over-the-counter iron pills, what types of patients are eligible for iron injections, what are the different forms of injections, what are the possible side effects, and how doses are managed. Links are also included to other informative pages, such as “Anemia FAQs,” “Anemia and Nutrition: The Importance of Iron,” and “A Patient’s Guide to Oral Iron Supplements.”

Because this site is offered by the National Heart Lung and Blood Institute, part of the National Institutes of Health, you can be sure that the content is reliable. Recommend this resource to patients who aren’t familiar with iron-deficiency anemia, “a common, easily treated condition.” Here, they can obtain information about the causes of iron-deficiency anemia, signs and symptoms of both anemia and iron-deficiency anemia, the tests and procedures used to diagnose the conditions, treatment options available, and how iron-deficiency anemia can be prevented in infants, young children, and women.

The ability to accurately diagnose the reason for anemia, one of the most common findings in clinical medicine, is a “critical element of patient evaluation.” In this webcast, Robert T. Means, Jr., MD, of the University of Kentucky, will discuss how physicians can more effectively develop a logical approach the diagnosis of anemia, and learn to distinguish anemia syndromes which can be managed in the primary care practice from those requiring a specialist referral.

Improving Upon the Established Practice Parameter for CKD-Related Anemia: Where Are We in Maintaining Target Hemoglobin Levels?

In this two-part activity, experts from the University of Pennsylvania School of Medicine will discuss current issues pertaining to the management of chronic kidney disease-related anemia. Included is an overview of available therapies for the treatment of CKD-related anemia; a discussion of the various factors that may be responsible for hemoglobin variability and hyporesponsiveness to erythropoiesis stimulating agents; and an assessment of the risk of cardiovascular disease in patients with CKD-related anemia and how inflammation and ESA treatment might impact the risk.

Sickle Cell and the Influence of Chronic Therapies on Bone Mineral Density

This Medical University of South Carolina podcast describes an observational study of bone health in adult and pediatric patients with sickle cell anemia, who have been shown to have high rates of osteoporosis. Liz Walsh, MD, a fellow in pediatric endocrinology, also talks about why these patients tend to have weak bones, and how this can potentially be managed.

Efficacy and Safety of Intravenous Ferric Carboxymaltose in Patients with Iron Deficiency Anemia

 Vital Prospects Clinical Research Institute

 This multi-center, randomized, active-controlled study is being conducted to assess the efficacy and safety of intravenous ferric carboxymaltose (FCM) in patients with iron deficiency anemia (IDA). Subjects who meet the initial screening criteria will be given oral iron for a two-week period to test their response; those still eligible after that will then be randomized to receive an IV infusion of FCM or venofer or continue with oral ferrous sulfate. Participation in the study requires eight visits over a four-month period.

Skin and Blood Research Samples from Healthy Volunteers and Sickle Cell Anemia Patients

 Using skin and blood samples from healthy volunteers and patients with sickle cell anemia, investigators aim to “use homologous recombination to correct β-globin gene mutations in therapeutically useful cells, like autologous-induced pluripotent stem cells from sickle cell anemia patients.” They also aim to confirm genetic mutations in sickle cell anemia patients.

Motor Development in 9-month-old Infants in Relation to Cultural Differences and Iron Status

 Angulo-Barroso R, Schapiro L, Liang W, et al

To compare fine and gross motor development in 209 nine-month-old infants from urban areas of China, Ghana, and the United States (African-Americans) and consider the effects of iron status. The authors hypothesized that motor development can be influenced by cultural practices and nutritional factors, such as iron deficiency.

 Iron deficiency anemia was most common in the Ghana sample (55%); when controlling for iron status, the authors found that “Ghanaian infants displayed precocity in gross motor development and most fine-motor reach-and-grasp tasks, while African-Americans from the US performed the poorest in all tasks except bimanual coordination and the large ball. When controlling for cultural site, they found that iron status showed linear trends for gross motor milestones and fine motor skills with small objects. These results, they said, “indicate the need to consider nutritional factors when examining cultural differences in infant development.”

Optimization of Therapy for Severe Aplastic Anemia Based on Clinical, Biological and Treatment Response Parameters

Biology of Blood and Marrow Transplantation

The Blood and Marrow Transplant Clinical Trials Network convened a group of international experts in March 2010 to define the most important questions in the basic science, immunosuppressive therapy (IST), and bone marrow transplantation (BMT) of severe aplastic anemia (SAA) and propose initiatives to facilitate clinical and biologic research.

Key conclusions, according to the study, included the following: “1) new patients should obtain accurate, expert diagnosis and early identification of biological risk; 2) a population-based SAA outcomes registry should be established in North America to collect data on patients longitudinally from diagnosis through and after treatment; 3) a repository of biologic samples linked to the clinical data in the outcomes registry should be developed; 4) innovative approaches to unrelated donor BMT that decrease graft vs. host disease are needed, and 5) alternative donor transplantation approaches for patients lacking HLA-matched unrelated donors must be improved.” The researchers plan to develop initiatives and partner with advocacy and funding organizations to help address these challenges.

A Trial of Ferumoxytol for the Treatment of Iron Deficiency Anemia

This phase III, randomized trial is being conducted to evaluate the safety and efficacy of ferumoxytol compared with placebo for the treatment of iron deficiency anemia. The primary outcome measure for patients will be hemoglobin changes.

Plasma Pharmacokinetics of Two Consecutive Doses of Ferumoxytol in Healthy Subjects

 To ascertain the efficacy and safety of two doses of ferumoxytol, an iron formulation administered rapidly as two IV boluses of 510 mg each, 24 hours apart, in 58 healthy subjects.

 Researchers conducted population pharmacokinetics analysis, and determined that “a two-compartment open model with zero-order input and Michaelis-Menten elimination” best described the data. They concluded that ferumoxytol given as two consecutive 510-mg doses was well tolerated for the treatment of iron-deficiency anemia.

Although iron deficiency is a common problem that has long-term implications for children’s development and behavior, it is frequently undetected, according to a clinical report published in Pediatrics, which provides guidelines for the diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and toddlers from birth through 3 years of age.

The Role of Erythropoiesis-Stimulating Agents in the Treatment of Anemia

Although erythropoiesis-stimulating agents are the most common treatment for anemia, the guidelines associated with these agents “can cause confusion for those tasked with prescribing them, so it is imperative that clinicians be more cognizant of the treatment recommendations for different patient populations to make the proper treatment decisions.”

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ACS: Chest Pain and Acute Coronary Syndrome, Diagnosis and Treatment

This Institute for Clinical Systems Improvement guideline is designed to provide for clinicians an “analytical framework for the evaluation and treatment” of adults presenting with past or present symptoms of chest pain and/or indications of acute coronary syndrome (ACS). The goals of the guidelines are to: improve the success of emergency intervention for patients with chest pain symptoms; minimize the delay in administering fibrinolysis or angioplasty to patients with acute myocardial infarction (AMI); increase the timely initiation of treatment to reduce postinfarction mortality in patients with AMI; and increase the number of AMI patients who receive tobacco cessation advice, and who use appropriate cardiac rehabilitation postdischarge.

Originally published in American Family Physician in 2005, this article comprehensively explores the diagnosis of acute coronary syndrome, a term that “encompasses a range of thrombotic coronary artery diseases, including unstable angina and both ST-segment elevation and non—ST-segment elevation myocardial infarction. Topics addressed include physical examination of patients, interpretation of electrocardiogram results, risk stratification to determine the likelihood of ACS, characteristics of serum cardiac markers for the diagnosis of acute myocardial infarction, and a protocol that can be used by family physicians to evaluate patients with chest pain or symptoms suggesting ACS.

Direct patients with acute coronary syndrome and other cardiac conditions to this American Heart Association (AHA) site, where they can access heart-healthy recipes; learn how to more effectively manage weight and prevent obesity; read the AHA Guidelines for Physical Activity and obtain fitness tips; learn how to better manage stress; obtain information on selecting healthy fats and oils; get tips on how to quit smoking. Of the many resources offered at this site, one that might strike a chord with children and adults alike is the guide to Wii games for the Heart.

This resource from the National Library of Medicine offers three different ways for users to learn about echocardiograms; visitors can watch an interactive multimedia tutorial, view a self-guided presentation, or opt for the text version. The content remains the same throughout; easy-to-understand text and colored diagrams are used to explain how the different chambers of the heart work, how disease and certain events can affect heart function and quality of life, how an echocardiography works, and what happens during and after an echocardiography.

In this video lecture—the first in a educational series on acute coronary syndrome&mdash;Jasen Gundersen, MD, aims to provide foundation for primary care physicians by reviewing the pathophysiology and prevalence of ACS, the differential diagnosis and risk stratification, and evidence-based strategies for acute and post-ACS management. The course will also cover communication with patients concerning their ACS risk, presentation of ACS, and the importance of compliance with recommended treatment.

Antiplatelet Therapy in ACS: What’s Best Practice?

Despite guideline recommendations, only three-quarters of ACS patients are administered antiplatelet and anticoagulation therapy upon hospital discharge. In this video lecture, Clare Hawkins, MD, and Kim Eagle, MD, discuss the evidence-based recommendations for antiplatelet therapy over the continuum of care, and address common challenges facing family physicians. They also explore factors contributing to suboptimal management of ACS, including unfamiliarity with the guidelines, as well as “the relative novelty of some agents and concerns about their benefit-to-risk ratio and cost.”

Multi-Markers in the Diagnosis of Acute Coronary Syndrome

 In this study, investigators will procure four blood samples from patients who present to the emergency department with suspected ACS, and will collect data on the patient’s health history, hospital procedures, and final diagnosis. Blood samples will be sent to the sponsor organization for long-term storage and analysis in the future for novel blood markers as they become available.

A Study Assessing the REG1 Anticoagulation System Compared Heparin in Subjects with Acute Coronary Syndrome (RADAR)

 This randomized, multi-center study is being conducted to evaluate the safety and efficacy of the REG1 anticoagulation system compared to unfractionated heparin or low molecular heparin in acute coronary syndrome patients undergoing cardiac catheterization. To become eligible, patients must have been experiencing chest pain or other ischemic symptoms for a minimum of 10 minutes duration within 72 hours before anticipated cardiac catheterization.

Antiplatelet Therapy in Acute Coronary Syndrome: Applying New Science to Clinical Decisions

 Although current guidelines recommend combination antiplatelet therapies for patients with unstable angina or non-ST elevation myocardial infarctions, “there remains a significant incidence of arterial thrombosis in patients receiving currently available antiplatelet therapy, indicating the need for improved and/or alternative agents and targets.”

 Data from recent clinical trials show that new oral antiplatelet therapies, including the thienopyridine prasugrel and the investigational reversible oral adenosine diphosphate antagonist ticagrelor, “have a faster onset of action, result in a more predictable response, and provide improved efficacy compared to clopidogrel, the current standard of care.” The question remains, however, as to whether improved prevention and treatment of thrombosis can be separated from an increase in hemorrhage or bleeding. Therefore, “clinicians must continue to consider the potential risks and benefits when individualizing antiplatelet therapy for patients with ACS,” the authors wrote.

Quality of Life after Percutaneous Coronary Intervention in the Elderly with Acute Coronary Syndrome

 To explore the impact of percutaneous coronary intervention (PCI) on health-related quality of life (HRQoL), “an important but often neglected outcome measure,” in elderly patients with acute coronary syndrome.

Using data obtained from a Short Form-36 health survey at baseline and six months, researchers determined that baseline HRQoL decreased with advancing age. However, elderly patients who underwent PCI experienced the most improvement in physical health compared to younger patients. Therefore, age alone “should not deter against revascularization because of potential benefits in HRQoL.”

What Predicts Depression in Cardiac Patients: Sociodemographic Factors, Disease Severity or Theoretical Vulnerabilities?

 Depression is associated with increased cardiovascular risk in acute coronary syndrome patients, but some argue that elevated depression is actually a marker of cardiovascular disease severity. To assess depression and psychosocial vulnerabilities, a group of ACS patients completed questionnaires assessing depression and psychosocial vulnerabilities.

 Investigators found that theoretical vulnerabilities predicted depression status more effectively than either demographic or disease indices. “The presence of these proximal causes of depression suggests that depression in ACS patients is not simply a result of cardiovascular disease severity,” they wrote.

An Efficacy and Safety Study for Rivaroxaban in Patients with Acute Coronary Syndrome

 Johnson & Johnson Pharmaceutical Research & Development, LLC

The purpose of this study is to determine whether rivaroxaban in addition to standard care reduces the risks of cardiovascular death, myocardial infarction, and stroke in patients with acute coronary syndrome compared with placebo. Participants will be given rivaroxaban (2.5 mg twice daily or 5 mg twice daily) or placebo (twice daily) in addition to standard care.

Role of Orally Available Antagonists of Factor Xa in the Treatment and Prevention of Thromboembolic Disease: Focus on Rivaroxaban

 Journal of Clinical Pharmacology (September 2010)

Morell J, Sullivan B, Khalabuda M, McBride, BF

 Researchers reviewed data on seven compounds—including rivaroxaban, apixaban, betrixaban, and eribaxaban&mdash;that are orally available direct inhibitors of activated factor X currently in development for the prevention and treatment of venous thromboembolism (VTE) and for thromboprophylaxis in patients with atrial fibrillation (AF) or following an acute coronary syndrome.

 “At doses used in phase 2 and 3 clinical trials, rivaroxaban and apixaban demonstrated a predictable onset of effect, maximal plasma concentration, and half-life that was unaffected by age, renal, or hepatic disease,” they wrote. In clinical trials for the treatment and prevention of VTE, rivaroxaban and apixaban yielded equivalent or superior reductions in the development or progression of VTE compared with either low molecular weight heparin or warfarin. Trials comparing the efficacy of rivaroxaban or apixaban to standard therapy for stroke prophylaxis in patients with AF are in process.

Pharmacy Cost Sharing, Antiplatelet Therapy Utilization, and Health Outcomes for Patients with Acute Coronary Syndrome

In this retrospective outcomes study, Tomas J. Philipson, PhD, and colleagues determined that “higher copayments for prescription drugs are associated with lower utilization of antiplatelet therapy and with higher likelihood of rehospitalization among patients with ACS.”

Dose Comparisons of Clopidogrel and Aspirin in Acute Coronary Syndromes

In patients who have acute coronary syndrome or undergoing percutaneous coronary intervention, there was no significant difference between a seven-day double-dose clopidogrel regimen and the standard-dose regimen, or between higher-dose aspirin and lower-dose aspirin, according to a recent study.

Acute Coronary Syndrome

At this site, The Johns Hopkins Arthritis Center houses American College of Rheumatology (ACR) classification criteria for rheumatoid arthritis, juvenile rheumatoid arthritis, determining progression of rheumatoid arthritis, determining clinical remission in rheumatoid arthritis, and functional status in rheumatoid arthritis. The site also includes ACR guidelines for medical management of and monitoring drug therapy in rheumatoid arthritis, as well as the ACR definition of improvement in rheumatoid arthritis trials and ACR recommendations fro monitoring hepatic safety in rheumatoid arthritis patients receiving methotrexate. Physicians can also link information on identifying and treating antagonist failures in rheumatoid arthritis, drug information, and rheumatoid arthritis trial measures in clinical practice.

Arthritis Foundation: Rheumatoid Arthritis

Direct your patients with rheumatoid arthritis and their family members to this site to find reliable answers to such questions as “What is it?” “What causes it?” “What are the effects?” “How is it diagnosed” and “Who is at risk?” Treatment options are also reviewed, with key terms throughout linked to extensive information on such topics as fatigue and the cause of rheumatoid arthritis. Site visitors can also access information on arthritis that is specific to heart disease, women, diabetes, surgery, pain, alternative therapies, and self-treatment. Clicking on “cause of rheumatoid arthritis” under “What causes it?” will direct patients to an FAQ page that covers treatment, taking control, and what the future may hold for those with rheumatoid arthritis.

To “investigate the link between rheumatoid arthritis and cardiovascular disease by studying inflammation, joint disease, cholesterol abnormalities, and endothelial function.”

Clinically Important Changes in Rheumatoid Arthritis

 National Institute of Arthritis and Musculoskeletal and Skin Diseases

To explore what improvements in symptoms are important to patients, as physicians tend to evaluate improvement based on lab results, duration of morning stiffness, grip strength, number of swollen joints, and pain severity, giving less attention to whether improvements in these areas are important to the patients with rheumatoid arthritis.

To “evaluate the efficacy of an internal family systems-based arthritis self-management program in improving rheumatoid arthritis subjects' disease activity, independence and other health outcomes,” as well as “assess the efficacy of an IFS-based program in improving RA subjects' mental health symptoms.”

Combining Patient and Physician Perspectives for Better Outcomes in Rheumatoid Arthritis 

Complete this activity for a review of the prodromal symptoms that accurately predict disease progression in people with rheumatoid arthritis, how to best coax patients into accurately providing their own perspective on their disease, and how to select “appropriate treatment options and perform clinical assessments based on the outcome of both personal and patient perspectives.”

The types of disease and drug-related granulomatous infections that can occur in patients with rheumatoid arthritis, and how to reduce the risk of these and opportunistic infections in this patient population are the two main foci of this case-based lesson. Epidemiology and tuberculosis risk with TNF inhibitors are also covered.

Rheumatoid Arthritis: Tuberculosis Risk and Prevention

	This program focuses on the risk of tuberculosis in patients with rheumatoid arthritis, the rationale behind screening for tuberculosis in this population, methods of testing for exposure to tuberculosis, and the safety of biologic disease-modifying antirheumatic drugs relative to tuberculosis in patients with rheumatoid arthritis.

Rheumatoid Arthritis: What to Do about TNF Failures 

This interactive course explores therapeutic options for conventional as well as biologic medications following the failure of a TNF inhibitor in patients with rheumatoid arthritis, and factors that can influence one’s choice in a biologic agent in such situations.

Tocilizumab for Rheumatoid Arthritis: A Cochrane Systematic Review

 (October 15, 2010; published online before print)

“To compare the benefit and safety of tocilizumab to placebo in patients with rheumatoid arthritis (RA).”

Although tocilizumab was associated, in the study, with a significant increase in levels of cholesterol and the occurrence of any adverse event, no serious adverse events were associated with the agent when administered at the approved dose of 8mg/kg every four weeks. The authors concluded that “tocilizumab in combination with methotrexate/DMARD is beneficial in decreasing RA disease activity and improving function.”

Subcutaneous versus Intravenous Actemra in Moderate to Severe Active Rheumatoid Arthritis

To “compare the efficacy and safety of subcutaneous (sc) versus intravenous (iv) administration of RoActemra/Actemra (tocilizumab) in patients with moderate to severe active rheumatoid arthritis.”

versus Adalimumab in Rheumatoid Arthritis

To “evaluate the efficacy and safety of tocilizumab [RoActemra/Actemra] versus adalimumab as monotherapy in patients with rheumatoid arthritis who are intolerant of methotrexate or where continued treatment with methotrexate is considered inappropriate.”

Actemra Attempts to Break into Pediatric Market

Access a collection of reliable, online rheumatoid arthritis resources for you and your patients.

November 2010

Anemia

Acute Coronary Syndrome

Rheumatoid Arthritis