eMedicine Specialties > Hematology > Red Blood Cells and Disorders

Megaloblastic Anemia: Follow-up

Author: Paul Schick, MD, Emeritus Professor, Department of Internal Medicine, Thomas Jefferson University Medical College; Research Professor, Department of Internal Medicine, Drexel University College of Medicine; Adjunct Professor of Medicine, Lankenau Hospital, Wynnewood, PA
Contributor Information and Disclosures

Updated: Aug 26, 2009

Follow-up

Further Inpatient Care

  • Patients should be monitored for response to therapy. Although patients may feel better as soon as therapy is started, monitoring the improvements with blood counts and clinical chemistry tests is important.
    • Elevated levels of LDH and indirect bilirubin will fall rapidly.
    • Reticulocytosis should be evident within 3-5 days and peaks in 4-10 days.
    • The Hgb level should rise approximately 1 g/wk. The rise of Hgb levels is valuable for monitoring a complete response. If the Hgb does not rise approximately 1 g/wk or is not normal within 2 months, other causes of anemia should be considered.
    • Leukocyte and platelets counts are usually restored to normal within days after therapy is started, but hypersegmented neutrophils may persist for 10-14 days.
    • A fall in the LDH level and reticulocytosis are excellent parameters of a response to therapy during the early phases.
    • Iron deficiency can be caused by the consumption of iron stores for the synthesis of new RBCs and may account for an incomplete response to therapy. Iron therapy may be indicated.
  • Serum potassium levels can fall during therapy for severe cobalamin or folate deficiency and can lead to sudden death. Therefore, potassium supplements may be indicated.

Further Outpatient Care

  • The response to therapy should monitored. A prolonged elevation of the LDH level can indicate that therapy has not corrected ineffective erythropoiesis, thus indicating a failure of therapy. Lack of an adequate rise in the Hgb level and the normalization of the Hgb level indicate that another cause of anemia may be present such as iron deficiency.
  • Patients with neurological complications of cobalamin and folate deficiencies should be monitored for response to therapy.
  • The development of gastric carcinoma should be evaluated periodically because this neoplasm may occur with increased frequency in patients with pernicious anemia.

Deterrence/Prevention

  • Patients who have undergone either total or partial gastrectomies should receive lifelong monthly doses of cobalamin (1000 mcg IM).

Prognosis

  • Prognosis is good if the etiology of megaloblastosis is identified and appropriate treatment is instituted. However, patients are at risk for complications of anemia, such as cardiac impairment and hypokalemia, during therapy for cobalamin deficiency.

Patient Education

  • Patients with folate or cobalamin deficiency should receive dietary education on the choice of foods and instructions on how to prepare foods.
  • Patients should know that goat milk contains little folate.

Miscellaneous

Medicolegal Pitfalls

  • Failure to avoid treating patients with potential cobalamin deficiency with folate alone because this may lead to severe neuropsychiatric disease
  • Failure to recognize and treat incipient neuropsychiatric impairment
  • Failure to administer folate during pregnancies to avoid abnormal fetal development
  • Failure to appropriately investigate macrocytosis
 


More on Megaloblastic Anemia

Overview: Megaloblastic Anemia
Differential Diagnoses & Workup: Megaloblastic Anemia
Treatment & Medication: Megaloblastic Anemia
Follow-up: Megaloblastic Anemia
References
Further Reading
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References

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  4. Dali-Youcef N, Andres E. An update on cobalamin deficiency in adults. QJM. Jan 2009;102(1):17-28. [Medline].

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  26. Tamura T, Picciano MF. Folate and human reproduction. Am J Clin Nutr. May 2006;83(5):993-1016.

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Further Reading

Related eMedicine Topics

Clinical Trials

National Guideline Clearinghouse

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Keywords

megaloblastic anemia, megaloblastosis, anemia, cobalamin deficiency, vitamin B-12 deficiency, folate deficiency, pernicious anemia, PA, homocysteine, cobalamin neuropathy, pregnancy, neural tube defects, anemia and the elderly, blood disorder, ineffective erythropoiesis, food-cobalamin malabsorption,

gastrectomy, Zollinger-Ellison syndrome, ZES, ileal resection, regional ileitis, intestinal lymphoma, Diphyllobothrium latum, D latum, fish tapeworm, blind loop syndrome, nitrous oxide exposure, NO exposure, surgical intestinal resection, amyloidosis, Whipple disease, scleroderma, psoriasis, exfoliative dermatitis, drug reactions, chemotherapy, neurological impairment

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Contributor Information and Disclosures

Author

Paul Schick, MD, Emeritus Professor, Department of Internal Medicine, Thomas Jefferson University Medical College; Research Professor, Department of Internal Medicine, Drexel University College of Medicine; Adjunct Professor of Medicine, Lankenau Hospital, Wynnewood, PA
Paul Schick, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Society of Hematology, International Society on Thrombosis and Haemostasis, and New York Academy of Sciences
Disclosure: Nothing to disclose.

Medical Editor

Thomas H Davis, MD, FACP, Associate Professor, Fellowship Program Director, Department of Internal Medicine, Section of Hematology/Oncology, Dartmouth Medical School
Thomas H Davis, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American Association for Cancer Education, American College of Physicians, New Hampshire Medical Society, Phi Beta Kappa, and Society of University Urologists
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Ronald A Sacher, MB, BCh, MD, FRCPC, Professor, Internal Medicine and Pathology, Director, Hoxworth Blood Center, University of Cincinnati Academic Health Center
Ronald A Sacher, MB, BCh, MD, FRCPC is a member of the following medical societies: American Society of Hematology
Disclosure: Glaxo Smith Kline Honoraria Speaking and teaching; Talecris Honoraria Board membership

CME Editor

Rajalaxmi McKenna, MD, FACP, Consulting Staff, Department of Medicine, Southwest Medical Consultants, SC, Good Samaritan Hospital, Advocate Health Systems
Rajalaxmi McKenna, MD, FACP is a member of the following medical societies: American Society of Clinical Oncology, American Society of Hematology, and International Society on Thrombosis and Haemostasis
Disclosure: Nothing to disclose.

Chief Editor

Emmanuel C Besa, MD, Professor, Department of Medicine, Division of Hematologic Malignancies, Kimmel Cancer Center, Thomas Jefferson University
Emmanuel C Besa, MD is a member of the following medical societies: American Association for Cancer Education, American College of Clinical Pharmacology, American Federation for Medical Research, American Society of Hematology, and New York Academy of Sciences
Disclosure: Nothing to disclose.

 
 
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