Dr. M.J. Bazos, MD Patient Handout

ANEMIA, FOLATE DEFICIENCY


About Your Diagnosis

The term folate deficiency anemia means that low blood counts are caused by a deficiency of folic acid in the body. It is also called megaloblastic anemia because the blood cells become larger in this anemia. Folic acid is a vitamin needed by the body for making DNA (deoxyribonucleic acid), which is the basic genetic material in all cells. Megaloblastic anemia also can result from lack of vitamin B12. The factors that lead to folic acid deficiency are dietary deficiency, defective absorption of ingested folate, increased need for folate, and inability of the body to use available folate. The main cause of folate deficiency is a folatepoor diet. This commonly occurs among elderly persons, poor persons, and persons with alcoholism. Patients undergoing hemodialysis or hyperalimentation also can have folate deficiency. Malabsorption of folate commonly occurs in diseases of the small intestine, such as tropical sprue, nontropical sprue, regional enteritis, leukemic or lymphomatous infiltration of the small intestine, Whipple’s disease, scleroderma, amyloidosis, and diabetes mellitus. Folate deficiency is most common among women who have given birth multiple times. Folate needs increase five- to tenfold during pregnancy because of transfer of folate to the growing fetus. Poor diet, infection, and coexisting hemolytic anemia also may contribute to folate deficiency. Folate deficiency also occurs in conditions such as hemolytic anemia, and exfoliative dermatitis because of increased folate requirements. Patients taking antiepileptic drugs can have folate deficiency anemia. The incidence of folate deficiency varies in different parts of the world. This disorder is not hereditary. It is always caused by deficiency of folic acid in the body. It cannot be transmitted from one person to another. The serum folate level is the single most useful
laboratory test in the diagnosis of this disorder. Other blood tests reveal abnormalities suggestive of folic acid deficiency anemia. This is a manageable disorder. Folic acid supplementation is the mainstay of treatment.

Living With Your Diagnosis
Fatigue, palpitation, progressive loss of appetite, shortness of breath, lightheadedness, and mental depression are the principal symptoms of folate deficiency anemia. Inflammation of the tongue and gums, vomiting, and diarrhea occur frequently. There are no neurologic findings in this type of megaloblastic anemia. A complete blood cell count reveals a low hemoglobin level. The red blood cells look larger than normal on a blood smear. The peripheral white blood cells are hypersegmented. The serum folate level is the single most useful laboratory test in the diagnosis of folate deficiency anemia. Red blood cell folate concentration does not fall into subnormal range until all of the body stores have become depleted. Red blood cell folate levels are low among more than half of patients with vitamin B12 deficiency anemia; therefore it cannot be used to differentiate folate deficiency and vitamin B12 deficiency anemia.

Treatment
It is easy to manage folate deficiency anemia. Blood counts start improving in 2 to 3 weeks after treatment begins. Once the diagnosis is made, every attempt should be made to find and manage the problem causing anemia. Folate is usually given orally 1 to 5 milligrams daily, although 1 milligram is usually enough. At this dose, the anemia is corrected even among patients with malabsorption. Pregnant women should take a 1 milligram folate supplement daily. Patients start feeling better after taking folic acid for a few weeks. There are no side effects of the treatment. Megaloblastic anemia can be caused by vitamin B12 deficiency, and therapeutic doses of folic acid partly correct the hematologic abnormalities in vitamin B12 deficiency. However, the neurologic symptoms can progress with disastrous results. Therefore, it is important to have both folate and vitamin B12 measured early in the evaluation of megaloblastic anemia.

The DOs
• Take folic acid supplements as prescribed.
• Eat a healthful diet that includes foods high in folate, such as green leafy vegetables, meat, and cereals.
• If you are pregnant, take a daily folic acid supplement in addition to your multivitamin. Folate deficiency can cause several congenital fetal abnormalities.
• Increase your physical activity gradually. There are no restrictions for exercise as long as you do not feel tired.
• Talk to your physician about taking a folate supplement if you are taking any of the following medications: phenytoin (eg, Dilantin), antibiotics, chemotherapeutic agents, or oral contraceptives.

The DON’Ts
• Do not use medications more frequently than recommended.
• Refrain from drinking alcoholic beverages, because they can aggravate anemia.
• Avoid foods such as pastry and soft drinks because they tend to displace more nutritious foods.
• Do not overcook your food, because excessive cooking can destroy folic acid.
• Avoid physical exertion to the point of fatigue.

When to Call Your Doctor
• If you experience numbness, problems with balance, or any visual disturbances during treatment.

Websites:
Med Web Hematology: http://www.gen.emory.edu/medweb.hematology.html
MedMark Hematology: http://medmark.bit.co.kr/hemato.html