Wilbur is Tired and His Stomach Hurts ……… Level I

Learning Objectives
After completing this case study, the reader should be able to:

 Recognize that certain drugs such as NSAIDs can cause chronic blood loss and iron
deficiency anemia (IDA).

 Identify the signs, symptoms, and laboratory manifestations of IDA.

 Select appropriate iron therapies for the treatment of IDA.

 Understand the monitoring parameters for both short- and long-term treatment of IDA.

 Inform patients of the potential adverse effects of iron therapy.

 Educate patients about the importance of adherence to their iron therapy regimen.

Patient Presentation
Chief Complaint
“I have belly pain and feel tired all the time.”

HPI
Wilbur Cox is a 67 yo man who presents to your pharmacy with the above complaint. With
further questioning, he relates the onset of his GI complaints shortly after he started self-
medicating with ibuprofen 200 mg four tablets four times a day about 6 months ago for pain
associated with “arthritis” in his right knee and ankle. His stomach pain has gotten
progressively worse over the past few months. He describes this pain as a burning sensation
that usually begins 30 minutes to 1 hour after meals and may or may not be relieved by
antacid administration. Use of over the counter ranitidine as needed has likewise not
provided much acute pain relief. Further questioning reveals a history of an ulcer
approximately 5 years ago. You suggest that he stop taking ibuprofen and all other OTC
NSAIDs and recommend that he use acetaminophen not more than 2 g per day if needed for
pain. Additionally, you contact his primary care physician to make an appointment for Wilbur
for further evaluation, and you let Wilbur know you will fax a brief note to his physician
detailing the nature of your referral.

Clinical Course
Three days later, he is evaluated by his family physician, which provides the following
additional information.

PMH
OA of the knees and ankles

PUD 5 years ago

GI bleed—approximately 7 years ago

COPD × 10 years

HTN × 10 years

FH
Mother died in childbirth; father died of cancer at age 93.

SH
Cigarette smoker—two ppd × 42 years. No alcohol; quit in 1990. He is married.

ROS
No fever or chills; (+) burning pain in stomach after meals; (–) heartburn; (+) melena; good
appetite; has one daily BM; no significant weight changes over past 5 years; (+) dry mouth;
(+) fatigue, tires easily; (–) paralysis, fainting, numbness, paresthesia, or tremor; headache
only occasionally; has myopic vision; (–) tinnitus or vertigo; has hay fever in spring; (+)
cough, sputum production (about one cup per day); (+) wheezing; denies chest pain, edema;
(+) dyspnea and orthopnea; denies nocturia, hematuria, dysuria, or history of stones; (+)
bilateral joint pain in both knees and ankles, worse on the right side, for over 5 years

Meds
Lisinopril 10 mg po daily

Tiotropium 18 mcg inhaled once daily

Formoterol 12 mcg inhaled Q 12 h

Ibuprofen 200 mg po three or four tablets three or four times a day for knee and ankle pain

Antacids po PRN for stomach pain

Prilosec OTC 20 mg PRN stomach pain

Allergies
Codeine (upset stomach)

Aspirin (upset stomach)

Physical Examination
GEN
WM in acute distress who appears his stated age

VS
BP 118/51 mm Hg, P 121 bpm, RR 22, T 36.2°C, pulse oximetry 90% in room air; Wt 78 kg,
Ht 6′1″

SKIN
Age- and sun-related lentigines and seborrheic keratoses noted

HEENT
PERRL; EOMI; conjunctivae are pale; mucous membranes pale and dry; normal funduscopic
examination with no retinopathy noted; deviated nasal septum; no sinus tenderness;
oropharynx clear

NECK/LYMPH NODES
Neck supple without masses; trachea midline; no thyromegaly, no JVD

THORAX
Breath sounds decreased bilaterally, increased anterior–posterior diameter, (+) rhonchi,
pursed-lip breathing

CV
Tachycardia with a soft systolic murmur; PMI at fifth ICS, MCL; (–) bruits

ABD
Soft, tender to palpation; no masses or organomegaly; (+) BS

GENIT/RECT
Normal external male genitalia; rectal examination (+) stool guaiac

MS/EXT
Slight knee joint enlargement, with pain and tenderness noted, and limited ROM of both
knees and ankles, worse on right side; crepitation noted at the talus–tibia junction on
dorsiflexion of the right foot; changes consistent with OA; strong pedal pulses bilaterally; no
peripheral edema; pallor of the nail beds

NEURO
A & O × 3; DTR 2+; normal gait

OTHER
Peripheral blood smear: hypochromic, microcytic red blood cells (Fig. 113-1)

\
 Labs

Na 138 mEq/L Hgb 7.2 g/dL WBC 10.7 × 103/mm3 AST 10 IU/L Ca 8.7 mg/dL
K 3.7 mEq/L Hct 25% Segs 61% ALT 23 IU/L Iron 4 mcg/dL
Cl 104 mEq/L RBC 3.77 × 106/mm3 Bands 2% T. bili 0.3 mg/dL TIBC 465 mcg/dL
CO2 27 mEq/L MCV 66.2 μm3 Lymphs 23% LDH 85 IU/L Transferrin sat 1%
BUN 12 mg/dL MCH 19 pg Monos 10% T. prot 6.3 g/dL Ferritin 5 ng/mL
SCr 0.8 mg/dL MCHC 28.7 g/dL Eos 3% Alb 3.7 g/dL B12 680 pg/mL
Glucose 90 mg/dL RDW 20.9% Basos 1% Folic acid 8.2 ng/mL
MPV 8.1 fL
Microcytosis 2+
Anisocytosis 1+

Assessment
1. Severe IDA probably of GI origin, possibly secondary to NSAID-induced gastropathy

2. OA of both knees and ankles, worse on right side

3. COPD

4. HTN

5. FULL CODE status but patient does not wish to be left on a machine if there is no hope
of recovery

Plan
Admit to hospital for further evaluation.

Strict NPO.

Infuse 4 units PRBCs.

Begin D5% NS at 82 mL/h continuous.

Begin esomeprazole 40 mg IV daily.

Morphine 2 mg IV Q 4 has needed for pain.

Consult GI service for suspected GI bleed.

Sequential compression devices bilaterally for VTE prophylaxis.

Clinical Course
The same day, the patient is seen by a gastroenterologist and undergoes both EGD and
colonoscopy. Findings included severe gastritis with multiple bleeding lesions. Stool, blood,
and biopsy tests for Helicobacter pylori were negative. Colonoscopy results were normal.

Final assessment: chronic, severe IDA secondary to bleeding gastric ulcer most likely
secondary to NSAID therapy.

Clinical Pearl
In otherwise healthy patients, a transient increase in the reticulocyte count 3–10 days after
beginning therapy can be used to confirm the correct diagnosis and treatment, and to rule
out other causes of anemia.

Therapeutic doses of iron must be given for 3–6 months to ensure repletion of all iron stores;
the serum ferritin is the best parameter for monitoring iron stores after correction of the
hemoglobin and hematocrit