Pharmacotherapy of Iron deficiency anemia

1. Anaemia , haematinics &
haematopoietic growth factors
SGD

2. SLO
• Explain the pharmacokinetic of Iron
• Mechanism of Iron absorption
• Factors which affect Iron absorption
• What are Fe stores in the body
• Iron metabolism and excretion
• Dietary sources of Fe
• Enumerate Fe preparation – Oral & parenteral
• Explain the ADRs of oral Fe preparation
• Acute Fe poisoning
• What are the indication of parentral Fe
• What is Z technique of Fe injection?
• Vit b12- metabolic functions, utilization
• Preparation of Vit b12
• Therapeutic uses & side effects of Vit B12
• FA – Metabolic functions & utilization & therapeutic uses
• Erythropoietin – uses & side effects

3. CASE 1
• A 15-year-old girl presented with severe
macrocytic anaemia (haemoglobin, 7.1 g/dL;
mean corpuscular volume, 116 fL) in addition to
leucopenia and thrombocytopaenia
(pancytopenia). Laboratory investigations
revealed severe vitamin B12 (cobalamin) level are
normal . In the follow-up laboratory
examinations, leucocyte and platelet counts
normal. At the end of 2 months, laboratory
findings, including haemoglobin level, were all
within the normal range.

4. Cont’d
Identify the case?
Prescribed the proper treatment?
Iron deficiency anaemia
T/T –
Rx
Tablet ferrous fumerate 300mg
BD daily for 15 days
or
Ferrous ascorbate 100mg
OD daily for 15 days
Review after 15 days
If not getting aequate response than
Inj iron sucrose ( i.v ) 50mg in 2.5 ml over 5
min once daily to once weekly

5. Case 2
• A 16-year-old girl presented with severe
anaemia (haemoglobin, 7.1 g/dL; mean
corpuscular volume, 116 fL) in addition to
leukopenia and thrombocytopenia
(pancytopenia). Local doctor has prescribed
some iron tablet , on next day she complains of
pain abdomen and loose motion.

6. • Describe the case? And suggest her?

7. • Pain abdomen & loose motion from iron tablet
• Rx
– Syrup iron preparation Ferrous Fumerate 100 mg
• 10ml X 1 ( Daily OD after FOOD)
Review after 15 days
Or
Inj iron dextrans 100mg in 2ml for i.m /i.v
or
Inj Ferric carboxymaltose
50mg/ml ( i.v)

8. Case 3
• A 10-year-old vegetarian boy presented with
easy fatigue, breathlessness and pain in the
legs on walking, noted during the past few
weeks. His Hb levels are 9.0gm/dl microcytic
hypochromic anaemia. The vegetarian patient
had not consumed any food of animal origin
for many years. Besides, the family only rarely
ate fresh fruits or vegetables.
• No fever was noted. In the physical
examination, the patient looked pale and weak.

9. T/T – Megaloblastic anaemia
• Rx
– Intramuscular cyanocobalamin to be started
(0.5 µg/kg/day for 2 days
– followed by 100 µg/day for 2 days and 1000 µg/day
for 1 week;
– 1000 µg cyanocobalamin weekly for 1 month,
– and would receive it once every month for 6 months).
• Second week of therapy, oral iron (ferrous
glycine sulfate; 4 mg/kg/day of elemental iron)
and folic acid (5 mg/day) initiate
• (due to the expected increase in iron utilisation
and borderline serum folic acid level (tested as
2.8 ng/mL 5 days after treatment initiation),
respectively.

10. Case 4
• Lady aged 40 years consults for treatment of
anaemia that is not improving with medicine
prescribed by a local doctor. She told that she is
suffering from weakness, fatigue & occasional
giddiness for last 4-5 months.
• She went to a local doctor 2 months ago who got
her blood tested, which showed Hb was 7.5g/dl.
Liquid medicine was prescribed, that she has been
taking 1 tablespoonful daily without any benefit.
She also revealed that she suffers from heart burn,
and has been talking a tablet rabeperazole 20mg
once daily for the last 2-3 years.

11. Cont’d
• What could be the reason for her failure to
improve with oral iron therapy that she has
been taking?
• Can she still be treated with oral iron,or does
she require parenteral iron therapy?
– What treatment would be appropriate for her?

12. ANS
• A)There are several reasons for anaemia
– Ferric ammonium citrate 160mg( iron content
20%) would provide just 32 mg of elemental
iron/day
– Inadequate to treat iron deficiency, bioavailability
is lower compare to other ferrous salts
– Gastric acid required to reduce ferric iron to
ferrous iron and facilitate iron absorption

13. Cont’d
• B) Proper selection of oral iron therapy
required
– Injectable iron preparation is helpful in improving
anaemia with proper dose.
• Ferrous salt with high iron content like ferrous
sulfate or ferrous fumerate ( both 33% iron)
with increasing dose 200mg 3 times a
day/day.
• Selection of food is also important ( avoid with
milk containing items.

14. Rx
- Tablet ferrous fumerate 300mg
300mg X 2 for 15 days (BD daily for 15 days)
or
-Ferrous ascorbate 100mg
100mg X 1 for 15 days ( OD daily for 15 days)
• Review after 15 days
If not getting adequate response than
• Inj iron sucrose ( i.v ) 50mg in 2.5 ml over 5
min once daily to once weekly

15. Case 5
• A 18-year-old female presented with easy
fatigue, breathlessness and pain in the legs on
walking, noted during the past few weeks. On
laboratory findings Hb was 8.5gm/dl, iron
ferritin level 3 mg/dl, other laboratory
parameters are NAD. Physician has prescribed
tablet iron and tablet calcium at different time
but patient was taking both tablet iron and
calcium simultaneously. No improvement on
Hb level as noted.

16. • Describe the case?
• Suggest proper prescription?

17. ANS
• Drug interaction of iron and calcium
• Calcium have chelating property with iron
• Rx
– Tablet ferrous ascorbate 100mg + folic acid 15mg
1 tablet OD after food ( in morning) for 15 days
– Tablet calcium carbonate 500mg+ vit d3 500 iu
1 tablet OD in the evening after food for 15 days
Review after 15 days

18. Case 6
• A 05-year-old boy accidentially consumed
some syrup. Initially presented at primary
health center with abdominal pain, vomiting,
diarrhea, and shock. As history given by
mother child has taken the syrup iron half
bottle. He was further investigated;
hemoglobin was 9.1 g/dl and total white blood
cell count was 11,900/cumm but his
conditioned was deterioted.

19. • Describe the case?
• Prescribed treatment for him?

20. • Iron toxicity case
• Chelation therapy with desferrioxamine was started,
– and supportive measures to be done.
• Rx
– Inj desferrioxamine 0.5 -1 g ( 50mg/kg in children)
repeated 4-12 hourly or
– Inj desferrioxamine 0.5 -1 g ( if shock is present) 10-15
mg/kg/hrs
– Till serum iron falls below 300 ug/dl.
Alternatively
– CALCIUM edetate may be used if desferrioxamine not
available
– Supportive measure with fluid and electrolyte balance
maintained & acidosis should be corrected
– Respiratory support
– Inj diazepam i.v ( to control convulsions)

21. Case 7
• A lady aged 65years consults for treatment of anaemia
that is not improving with medicine prescribed by a
local doctor. She told that she is suffering from
weakness, fatigue & occasional giddiness for last 4-5
months.
• She went to local doctor 2 months ago who got her
blood tested, which showed Hb was 6.5 g/dl. A liquid
iron preparation medicine was prescribed, that she has
been taking 1 tablespoonful daily without any benefit.
On further examination she was diagnosed with CKD
with Sr creatinine 1.6mg/dl with weakness, fatigue ,
palpitaion and severe anaemia.

22. • What could be the reason for her failure to
improve with oral iron therapy
• Suggest proper prescription?

23. • Drug with choice – Erythropoietin ( EPO)
• EPO produced by peritubular cells of kidney
that is essential for normal erythropoiesis.
• Rx
– Epoetin 25- 100 U/kg s.c or i.v 3 times a week(
max 600 U/kg/week raises haematocrit and
haemoglobin
– ( Hemax 2000 IU/ml and 4000 IU/ml )

24. Case 8
• A lady aged 25 years with pregnancy consults for
treatment of her anaemia. She told that she is
suffering from weakness, fatigue & occasional
giddiness for last 1months.
• On laboratory examination which showed Hb was
8.5g/dl and vit B12 8 ugm. Her folic acid level is
less than normal,. Repeat blood testing showed
Hb to be 8.8g/dl, haematocrit was 27%, PCV &
MCV also decreased. RBCs were microcytic-
hypochromic and detailed examination showed no
evidence of bleeding from any site

25. • What could be the reason for microcytic
hypochromic anaemia ?
• Suggest proper prescription?

26. • Iron deficiency anaemia
• Need of iron in increase during pregnancy
• Folic acid required to prevent NTD
• Nutritional requirement increases during
pregnancy
• Rx
– Cap Ferrous fumarate 300 mg + Folic 1.5mg+
Cyanocobalamin 15mcg
– Green leafy vegetables & fruits
– Review after 1 month

27. •Thank you