When patients have anemia, supplements often get prescribed. To many of our polypharmacy patients, excessive prescribing can lead to an increase in pill burden that may not always be necessary. When looking at deprescribing supplements, anemia is an excellent disease state to reassess. Vitamin B12, iron, and folic acid are excellent targets for deprescribing supplements in anemia.
First, let’s remember how these supplements play a role in the production of red blood cells and the maintenance of normal hemoglobin levels.
- Folic Acid: Without enough folic acid, red blood cells remain large (Megaloblastic anemia), immature, and dysfunctional (called megaloblasts).
- Vitamin B12 is required for DNA synthesis in rapidly dividing cells, including red blood cell (RBC) precursors in the bone marrow. Deficiency in B12 can lead to enlarged red blood cells and megaloblastic anemia (similar to folic acid deficiency)
- Iron is a key component of hemoglobin, the protein in red blood cells that binds and carries oxygen from the lungs to tissues. Deficiency can lead to a shrinkage in the size of red blood cells also called microcytic anemia (excellent board exam nugget).
The first thing I look at is a CBC. If hemoglobin is within normal range, that gives me a good reason to review the supplements the patient is taking. The next thing to consider is assessing labs. Folic acid, B12, and iron labs can all be assessed to see if they are within normal limits. If they are, a review of patient history is also important to make sure the patient doesn’t have a compelling diagnosis (see below) that may predispose them to deficiency.
Another consideration is tolerability. Folic acid and B12 are typically well tolerated at usual dosages. Iron, however, can cause GI upset and constipation. This may be another reason to consider discontinuation, especially if anemia has been compensated and labs are within normal limits.
Other Considerations in Deprescribing Anemia Supplements
Acute blood loss or anemia due to chronic GI losses may require ongoing supplementation and is an important risk factor to consider when determining if long term supplementation is important. Another factor is medication use. There are numerous medications that can cause vitamin and supplement deficiencies. I’ve outlined some of the most common medication-induced deficiencies in this previous blog post: Top 10 Medications that Deplete Vitamins and Minerals. Patients with malabsorption syndrome, bariatric surgery history, or other conditions that may impair vitamin absorption also may be candidates to continue long term supplementation.
0 Comments