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Anemia, Megaloblastic: Treatment & Medication

Author: James L Harper, MD, Associate Professor, Department of Pediatrics, Division of Hematology/Oncology and Bone Marrow Transplantation, Associate Chairman for Education, Department of Pediatrics, University of Nebraska Medical Center; Assistant Clinical Professor, Department of Pediatrics, Creighton University; Director, Continuing Medical Education, Children's Memorial Hospital; Pediatric Director, Nebraska Regional Hemophilia Treatment Center
Contributor Information and Disclosures

Updated: Sep 9, 2009

Treatment

Medical Care

Treatment of megaloblastic anemia depends on the underlying cause.

  • Folate deficiency
    • Folate deficiency due to dietary deficiency or increased demands is best treated with folate supplements.
    • Folate deficiency caused by the use of sulfa drugs or other antifolate medications may be addressed by folate supplementation or by reducing or eliminating the drug.
    • Folate deficiency due to celiac sprue requires treatment of the underlying disorder and folate supplements.
  • B-12 deficiency
    • B-12 deficiency is often more complex because of the nature of B-12 deficiency in childhood.
    • B-12 supplements can be administered orally, even for intrinsic factor (IF) deficiency, using higher doses.
    • Often, B-12 deficiency must be treated with parenteral supplements if high-dose oral B-12 supplements are unsuccessful.
    • For those children with congenital disorders that lead to B-12 deficiency, supplementation is a lifelong necessity; therefore, concern regarding a regimen that is tolerable over time is essential to maintaining compliance.
    • Recent data, albeit from small trials, suggests that oral B-12 supplementation is as effective as parenteral supplementation in patients with nutritional deficiency. Patients with IF deficiency or who have undergone intestinal surgery should be considered for parenteral therapy because of impaired secretion or absorption of IF.

Surgical Care

  • Carefully monitor for the onset of megaloblastic anemia due to impaired absorption of B-12 or folic acid following surgical illnesses that involve the stomach, jejunum, or ileum.

Consultations

  • Gastroenterologist
    • Consultation with a pediatric gastroenterologist to evaluate for inflammation of the ileum or jejunum and assist in treatment planning is often helpful for patients with newly diagnosed Crohn disease or celiac sprue.
    • Gastroenterologists may also be needed to evaluate the extent of liver disease, which may manifest with macrocytic erythrocytes.
  • Hematologist: Consider consulting a hematologist to evaluate the bone marrow for evidence of other marrow diseases that can manifest with macrocytic anemia and thrombocytopenia.

Diet

  • A diet rich in green, leafy vegetables is essential for normal intake of folic acid.
  • Because vitamin B-12 is contained exclusively in animal products (meat), vitamin supplementation is the only means of appropriate vitamin B-12 intake in humans choosing vegetarian diets.

Medication

Vitamins

Vitamins are organic substances required by the body in small amounts for various metabolic processes. Vitamins may be synthesized in small or insufficient amounts in the body or not synthesized at all, thus requiring supplementation. Use folic acid and vitamin B-12 supplements as indicated.


Folic acid (Folvite)

A member of the vitamin B group. Folic acid is reduced in the body to THF, which is a coenzyme for various metabolic processes including purine and pyrimidine nucleotides synthesis essential for DNA. Important cofactor for enzymes used in production of red blood cells.

Adult

1 mg PO/IM/SC qd initially until symptoms resolve, then 0.4 mg/d PO

Pediatric

Infants: 15 mcg/kg/d PO/IM/SC; alternatively, 50 mcg/d
7-13 years: 1 mg/d PO/IM/SC initially, then 0.1-0.15 mg/d
>13 years: Administer as in adults

Increase in seizure frequency and subtherapeutic levels of phenytoin reported when used concurrently

Pregnancy

A - Fetal risk not revealed in controlled studies in humans

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Pregnancy category C if dose exceeds RDA; benzyl alcohol is present in some products as preservative and has been associated with fatal gasping syndrome in premature infants; resistance to treatment may occur in patients with alcoholism and deficiencies of other vitamins


Cyanocobalamin (Crystamine, Crysti 1000, Cyomin, Nascobal)

Deoxyadenosylcobalamin and hydroxocobalamin are active forms of vitamin B-12 in humans. Vitamin B-12 is synthesized by microbes but not humans or plants. Vitamin B-12 deficiency may result from IF deficiency (pernicious anemia), partial or total gastrectomy, or diseases of the distal ileum.

Adult

100-1000 mcg IM qd for 1-2 wk, followed by 100-1000 mcg IM once every mo for life
Alternatively, 500 mcg (ie, 1 spray) intranasally in 1 nostril qwk

Pediatric

10-50 mcg/d IM for 5-10 d, followed by 100-250 mcg/dose q2-4 wk

Aspirin, ascorbic acid, chloramphenicol, cimetidine, colestipol, PO contraceptives, omeprazole, or ranitidine may interfere with bioavailability

Documented hypersensitivity; hereditary optic nerve atrophy

Pregnancy

A - Fetal risk not revealed in controlled studies in humans

Precautions

Pregnancy category C if dose exceeds RDA; severe hypokalemia may result in vitamin B-12 megaloblastic anemia (may be fatal) because of increased cellular potassium requirements when anemia corrects; pharmacist should assemble nasal spray and prime pump before dispensing

More on Anemia, Megaloblastic

Overview: Anemia, Megaloblastic
Differential Diagnoses & Workup: Anemia, Megaloblastic
Treatment & Medication: Anemia, Megaloblastic
Follow-up: Anemia, Megaloblastic
Multimedia: Anemia, Megaloblastic
References
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References

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Further Reading

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Keywords

vitamin B-12 deficiency, folate deficiency, folic acid deficiency, tetrahydrofolic acid deficiency, THF, vitamin deficiency, gastrointestinal disease, megaloblastic anemia, anemia, DNA synthesis defect, folate deficiency, purine biosynthesis, thrombocytopenia, leukopenia, celiac sprue, B-12 deficiency, folate, vitamin B-12, B-12, cobalamin deficiency, thiamine-responsive megaloblastic anemia, Lesch-Nyhan syndrome, HIV infection, AIDS, learning disorders, treatment, diagnosis

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Contributor Information and Disclosures

Author

James L Harper, MD, Associate Professor, Department of Pediatrics, Division of Hematology/Oncology and Bone Marrow Transplantation, Associate Chairman for Education, Department of Pediatrics, University of Nebraska Medical Center; Assistant Clinical Professor, Department of Pediatrics, Creighton University; Director, Continuing Medical Education, Children's Memorial Hospital; Pediatric Director, Nebraska Regional Hemophilia Treatment Center
James L Harper, MD is a member of the following medical societies: American Academy of Pediatrics, American Association for Cancer Research, American Federation for Clinical Research, American Society of Hematology, American Society of Pediatric Hematology/Oncology, Council on Medical Student Education in Pediatrics, and Hemophilia and Thrombosis Research Society
Disclosure: Nothing to disclose.

Medical Editor

Sharada A Sarnaik, MBBS, Professor of Pediatrics, Wayne State University School of Medicine; Director, Sickle Cell Center, Attending Hematologist/Oncologist, Children's Hospital of Michigan
Sharada A Sarnaik, MBBS is a member of the following medical societies: American Association of Blood Banks, American Association of University Professors, American Society of Hematology, American Society of Pediatric Hematology/Oncology, New York Academy of Sciences, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Steven K Bergstrom, MD, Assistant to the Chairman, Department of Pediatrics, Division of Hematology-Oncology, Kaiser Permanente Medical Center of Oakland
Steven K Bergstrom, MD is a member of the following medical societies: Alpha Omega Alpha, American Society of Clinical Oncology, American Society of Hematology, American Society of Pediatric Hematology/Oncology, Children's Oncology Group, and International Society for Experimental Hematology
Disclosure: Nothing to disclose.

CME Editor

Samuel Gross, MD, Professor Emeritus, Department of Pediatrics, University of Florida; Clinical Professor, Department of Pediatrics, University of North Carolina; Adjunct Professor, Department of Pediatrics, Duke University
Samuel Gross, MD is a member of the following medical societies: American Association for Cancer Research, American Society for Blood and Marrow Transplantation, American Society of Clinical Oncology, American Society of Hematology, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Chief Editor

Max J Coppes, MD, PhD, MBA, Senior Vice President, Children's National Medical Center (Center for Cancer and Blood Disorders); Director, Center for Cancer and Immunology Research, Children's Research Institute, Children's National Medical Center; Professor of Medicine, Oncology, and Pediatrics, Georgetown University
Max J Coppes, MD, PhD, MBA is a member of the following medical societies: American Association for Cancer Research, American Society of Pediatric Hematology/Oncology, and Society for Pediatric Research
Disclosure: Nothing to disclose.

 
 
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