Anemia

DRUGS
FOR
IRON DEFICIENCY ANEMIA
PATKI
11/21/2019 PATKI 1

ANAEMIA
• Decrease in oxygen carrying capacity of blood is called
anaemia.
• Oxygen carrying capacity of blood is determined by
hemoglobin content of cells.
• Reduction in blood hemoglobin levels &
no of circulating erythrocytes are characteristic
features of anaemia.
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 The haematopoietic machinery – present in the bone
marrow.
 It is primarily involved in the formation of cellular
components of the blood – erythrocytes, leucocytes &
thrombocytes.
 For proper functioning – needs
 Exogenous nutrients – Iron, vitB12 & folic acid called
haematinics.
 Endogenously derived growth factors – (G-CSF), (GM-
CSF), Erythropoietin, thrombopoietins, IL-1,3,5,6,7,11
etc.
 Reduction in the supplies of any of these nutrients –
results in deficiency of normal blood cells.
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CLASSIFICATION OF ANAEMIAS
 ANAEMIAS due to dietary deficiency or
malabsorption of factors essential for normal blood
formation .
e.g: iron ,folic acid , vitamin B12,vit C ,pyridoxine
 DUE TO BLOOD LOSS - menorrhagia ,GI loss,
hookworm infestation.
 DUE TO EXCESSIVE BLOOD DESTRUCTION
thalassemia, sickle cell ,auto immune hemolytic
anaemia.
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 DUE TO APLASIA OR HYPOPLASIA OF BONE
MARROW
- Anti cancer drugs and chloramphenicol
 DUE TO DEFICIENCIES OF ERYTHROPOIETIN
- Chronic renal disease
 UNCERTAIN ORIGIN
- Infection, rheumatoid arthritis ,malignant disease
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HAEMATINICS
 These are the substances required in the
formation of blood, and are used for the
treatment of anemias.
- Iron, vitB12 & folic acid
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 Most common disorder in clinical practice.
 Charectarized by a decrease in the O2 carrying
capacity of the blood due to reduced
concentration of Hb or RBCS
Iron deficiency anemia
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 IRON DEF ANAEMIA CHARACTERISED BY-
 MICROCYTOSIS (presence of small erythrocytes).
 HYPO CHROMIA ( poorly filled with haemoglobin).
 POIKILOCYTOSIS (bizzare shaped cells).
 ANISOCYTIOSIS (different shapes).
 Iron def has adverse effects on brain function,
mental performance & ,behavioral abnormalities.
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Pink of your
health
11/21/2019 PATKI 10

DISTRIBUTION OF IRON IN THE BODY
 Iron(Fe) is the essential body constituent .
 Total body iron in an adult –
2.5 – 5 g (average 3.5g).
 It is more in men - (50mg/kg)
Than in women (38mg/kg)
 It is distributed as follows :
 Hemoglobin (Hb) – 66%
 Iron stores ferritin and Haemosiderin – 25%
 Myoglobin ( in muscles) – 3%
 Parenchymal iron (in enzymes etc) – 6%
11/21/2019 PATKI 11

Loss of 100ml of blood (containing 15g Hb) means loss of
50mg elemental iron.
To raise Hb level of blood by 1g/dl about 200mg of iron is
needed.
Daily requirement of iron
 Adult male – 0.5 – 1 mg (13mg/kg)
 Adult female – 1 – 2 mg (21mg/kg)
(Menstruating)
 Infants – 60mg/kg
 Children – 25 mg/kg
 Pregnancy – 3.5 mg (80mg/kg)
(Last 2 trimesters)
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DIETARY SOURCES OF IRON
 Rich → liver, egg yolk, oyster, drybeans, dry fruits, wheat germ,
yeast.
 Medium → meat, chicken, fish, spinach, banana, apple.
 Poor → milk and its products, root vegetables.
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Iron absorption
 Average daily diet contains- 10-20mg of iron.
 Absorption occurs all over the intestine, but more in the
upper part.
 There are two major forms of dietary iron.
 Heme iron, found primarily in red meats, is the most easily
absorbed form.
 Majority of dietary iron is in ferric form.
 It is reduced to ferrous form before absorption.
 Absorption occurs through 2 separate iron transporters in
the intestinal mucosal cells.
 Divalent metal transporter – 1 (DMT 1)
 Ferroportin
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 FACTORS FACILITATING FE ABSORPTION
 Acid: By favouring dissolution and reduction of ferric form.
 Reducing substances – Ascorbic acid.
 Meat – By increasing Hcl secretionand providing heme iron.
FACTORS IMPEDING FE ABS
 Alkalies – (Antacids) Renders iron insoluble, oppose its
reduction.
 Phosphates (rich in egg yolk)
 Phytates (maize, wheat) by complexing iron
 Tetracyclines
 Prescence of other foods in stomach.
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MUCOSAL BLOCK
 It is a mechanism to prevent entry of excess iron in the body
 Iron reaching inside mucosal cell is eigther transported to
plasma or oxidised to ferric form and complexed with
apoferritin to form ferritin.
 The ferritin stored on the mucosal cells is lost when they are
shed (life span 2-4 days).
 This is called ferritin curtain.
 Thus the amount of iron entering into the body is governed
by the iron status of the body and the erythropoietic activity.11/21/2019 PATKI 17

Transport, utilization, storage and excretion.
 Free iron is highly toxic.
 It is converted to ferric form and complexed with a
glycoprotein - transferrin (TF).
 Iron is transported in to erythropoietic and other cells by
attachment of transferrin to transferrin receptors (TFRS)
which is engulfed by endocytosis.
 Iron dissociates from complex and is utilised for Hb
synsthesis while TF and TFR return to cell surface to carry
fresh loads.11/21/2019 PATKI 18

Cont…
 Iron is stored in reticulo endothelial cells in liver, spleen
bone morrow, also in hepatocytes & myocytes as ferritin
and haemosiderin.
 Daily excretion – 0.5mg daily (adult male) mainly as
exfoliated G.I mucosal cells some RBC’s and in bile,
desquamated skin.
 In menstruating women – monthly menstrual loss may be
averaged to 0.5-1 mg/day.
 Excess iron is required during pregnancy for expansion of
RBC mass, transfer to foetus and loss during delivery
totaling about 700mg .
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PREPARATIONS AND DOSAGE
Oral iron
This is the preferred route of iron administration.
 Because
 Dissociable Ferrous salts are inexpensive.
 Have high iron content
 Better absorbed than ferric salts.
Some oral iron preparations
 Ferrous sulphate – cheapest LIVOGEN
 Ferrous citrate-commonly used.
 Ferrous gluconate
 Ferrous fumarate.
 Colloidal ferric hydroxide
 Ferric hydroxy poly maltose11/21/2019 PATKI 21

 Sustained release preperations – not rational.
 Most of iron absorbed in upper intestine – but these
preperations release iron lower down.
 Liquid formulations – may stain teeth.
 Hence should be put back on tongue.
DOSE
 A total of 200mg of elemental iron given daily in 3
divided doses – produce maximal haematopoietic
response.
 Absorption of iron is much better when it is taken on
empty stomach – side effects are also more on empty
stomach.
 Prophylactic dose – 30 mg iron daily.
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INDICATIONS OF IRON
THERAPY
PROPHYLATIC
pregnancy ,menstruation ,blood donors .
 THERAPEUTIC
- to treat existing iron deficiency.
 Nutritional deficiency.
 Anaemia of infancy and pregnancy.
 Anaemia due to acute or chronic blood loss.
menorrhagia ,peptic ulcer, hookworm infestation.
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ADVERSE EFFECTS OF ORAL IRON
 Adverse effects are related to elemental iron
content.
1. Epigastric pain
2. Heart burn
3. Nausea & vomiting
4. Staining of teeth
5. Metallic taste
6. Bloating, colic
7. Constipation
11/21/2019 PATKI 24

PARENTERAL IRON
 INDICATIONS
1. Oral iron is not tolerated - bowel upset is more.
2. Failure to absorb iron – mal absorption,
Inflammatory bowel disease.
3. Non compliance to oral iron.
4. In prescence of severe deficiency with chronic
bleeding.
 Parenteral iron therapy needs calculation of the total
iron requirement of the pt.
 Iron requirement (mg) = 4.4 X body wt (kg) X Hb
deficit (g/dl)
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PARENTERAL IRON THERAPY
 PREPARATIONS:
Iron sucrose
 IRON DEXTRAN for IMIV use {imferon} contra
indicated in early pregnancy.
 IRON SORBITOL CITRIC ACID COMPLEX{JECTOFER} for
IM injection
(urine turns black –iron sulfide formation).
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 IRON CARBOHYDRATE COMPLEX {UNIFERON}
- iron ,dextran sorbitol citric acid .
- Given IM , each ml contains 50 mg of elemental
iron.
 Injection made by Z technique.
 Test dose of 25 mg is given followed by 100 mg .
 IV infusion is given at the rate of 10 drops per
minute.
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IV Route
 Iron dextran
 Ferrous –sucrose
 Sodium ferric gluconate
After a test dose with 0.5ml, 2ml to be given over
10min.
Alternatively dose diluted in 500ml glucose/saline –
to be infused over 6-8hrs.
 Should be stopped if pt complains of giddiness,
paraesthesias and tightness in the chest.
11/21/2019 PATKI 28

ADVERSE EFFECTS OF PARENTERAL IRON
LOCAL –
pain at injection site
pigmentation of skin,
sterile abscess.
SYSTEMIC –
fever,
head ache,
joint pains,
flushing,
palpitation,
chest pain,
dyspnoea,
lymphnode enlargement.
11/21/2019 PATKI 29

USES
IRON DEFICIENCY ANEMIA
 Most imp indication for medicinal iron.
CAUSES:
1. Nutritional deficiency
2. Chronic bleeding from G.I tract (common cause)
(ulcers, hook worm infestation)
3. Repeated attacks of malaria.
4. Chr. inflammatary diseases.
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 A rise in Hb level by 0.5 – 1g/dl per week is an
optimum response to iron therapy
 It takes 1-3 months – depending on severity to
correct anemia and 2-3 months to replenish stores-
because after correction of anemia iron absorption
is slow.
 MEGALOBLASTIC ANEMIA
AS AN ASTRINGENT – ferric chloride – used in throat
paint.
11/21/2019 PATKI 31

ACUTE IRON POISONING
 It occurs mostly in infants and children.
 10-20 iron tablets or equivalent of the liquid
preperation (>60mg/kg iron) may cause serious
toxicity.
 Very rare in adults.
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 Manifestations
 Vomiting
 Abdominal pain
 Haemetemesis
 Diarrhoea
 Cyanosis
 Lethargy
 Dehydration
 Acidosis
 Convulsions & finally shock
 Cardio vascular collapse.
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Pareneteral iron dose
 4.4 x body weight x Hb deficit ( g/ dl)
 150 x Hb deficit (g/dl) + 600 mg
 Iv infusion in 500 ml of 5% dextrose over
6-8 hours.
11/21/2019 PATKI 34

 Treatment – should be prompt
1) To prevent further absorption of iron from the gut.
 Induce vomiting / perform gastric lavage with sod.
Bicarbonate sol- To render iron insoluble.
 Give egg yolk and milk orally- To complex iron
 Activated charcoal does not absorb iron.
2) To bind and remove already absorbed iron.
 Desferroxamine (an iron chelating apent) – is the IM –
0.5-1g repeated 4-12 hrly.
 DTPA or calcium edetate – also used.
3) Supportive measures
 Fluid electrolyte balance maintained.
 Acidosis corrected by IV infusion
11/21/2019 PATKI 35

ANAEMIA OF CHRONIC
DISEASE
 It occurs in pts with chronic infections (TB),
Inflammatory disease (rheumatoid arthritis), cancer,
trauma.
 Hypoferrimia, in presence of bone marrow iron
overload is a constant feature.
 There is deficient delivery of iron to developing RBC.
 Anaemia does not respond to iron therapy.
11/21/2019 PATKI 36

ERYTHROPOIETIN
 Epoetin a&b has molecular weight 36,000.
 It is synthesized by kidney in response to hypoxemia.
 Given by IV route.
 Plasma half life is - 6-8 HRS.
 Adverse Effects:
- Hypertension, rise in hematocrit values..
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Therapeutic uses
 Anaemia of end stage renal failure.
 To permit autologous blood transfusion.
 Anemia due to anticancer drugs and HIV infection.
11/21/2019 PATKI 38

THANK YOUdrpatki@gmail.com
11/21/2019 PATKI 39

Anemia

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