Patient JW is a 30-year-old female patient who presents at the clinic with fatigue, pallor, and paresthesia in extremities. She was diagnosed with general anxiety disorder and heartburn and has been a strict vegan for the last five years. Her current medication regiment is fluoxetine 20mg daily, and Tums as needed.  Her lab results are shown below with normal values in parentheses. 

RBC: 3 x 10⁶ cells/µL (3.92-5.13)

Hgb: 10 g/dL (12-15.5)

HCT: 30.5% (35.5-44.9)

MCV: 108 fL/cell (80-96)

RDW: 18.6% (12.2-16.1)

Vitamin B12: 120 pg/mL (160-950)

Folic Acid: 7 ng/mL (2.7-17)

Which of the following statements are true. Select all that apply. 

A. Patient by labs has macrocytic anemia

B. Patient is at risk for pernicious anemia

C. Daily dose of 1000-2000 mcg oral cyanocobalamin is an acceptable option for this patient 

D. Folic acid supplementation is needed in this patient 

E. Oversupplementation with calcium salts may cause anemia

Answers with rationale:

Answers A, B and C are correct.

Generally, females who have Hgb less than 12 with a MCV greater than 100 have macrocytic anemia, making answer A correct. Most common macrocytic anemias are Vitamin B12 and Folate deficiency. Pernicious anemia is due to autoantibodies decreasing intrinsic factors that aid in absorbing B12 or can occur due to diet in some circumstances. Our patient may have pernicious anemia based on her history she most likely has decreased B12 (cyanocobalamin) due to dietary deficiencies. Strict vegan patients will not likely begin to show symptoms of vitamin B12 deficiency until years after inadequate dietary intake due to long lasting vitamin B12 stores in the body.  IM form of Vitamin B12 supplementation would be the best formulation for a patient with pernicious anemia due to lack of GI absorption; however, for this patient any formulation would be acceptable to begin. This patient's folic acid level is with in normal limits making answer D incorrect. Also, for this patient it would be important to ask how often she is having to use antacid because this could potentially affect absorption of her other medications or supplementation. Answer E is incorrect as this has not been demonstrated. 

NAPLEX Competencies Covered

1.1 – From instruments, screening tools, laboratory, genomic or genetic information, or diagnostic findings

1.4 – From medical records: treatment adherence, or medication-taking behavior; chief complaint, medication history, medical history, family history, social history, lifestyle habits, socioeconomic background

1.5 – Signs or symptoms of medical conditions, healthy physiology, etiology of diseases, or pathophysiology

1.6 – Risk factors or maintenance of health and wellness

3.4 – Drug dosing or dosing adjustments; duration of therapy

3.5 – Drug route of administration, dosage forms, or delivery systems