Nursing

1. Chapter 55
Anemia Drugs

2. Hematopoiesis (1 of 2)
 Formation of new blood cells
 Red blood cells (RBCs)
 White blood cells (WBCs)
 Platelets

3. Hematopoiesis (2 of 2)
 RBCs
 Manufactured in bone marrow
 Immature RBCs are reticulocytes.
 Lifespan is 120 days.
 More than one third of an RBC is made of
hemoglobin.
 Heme: red pigment; contains iron
 Globin: protein chain

4. Hemoglobin Molecule

5. Anemias
 Maturation defects
 Cytoplasmic
 Nuclear
 Excessive destruction of RBCs (hemolytic
anemias)
 Intrinsic RBC abnormalities
 Extrinsic mechanisms

6. Underlying Causes

7. RBC Cytoplasmic Maturation

8. RBC Nuclear Maturation Defects

9. Intrinsic and Extrinsic Factors

10. Erythropoiesis-Stimulating Agents
(1 of 2)
 epoetin alfa (Eprex®)
 Biosynthetic form of the natural hormone
erythropoietin
 Used for treatment of anemia associated with end-
stage renal disease, chemotherapy-induced anemia,
and anemia associated with zidovudine therapy
 Medication is ineffective without adequate body iron
stores and bone marrow function.
 Most patients receiving epoetin alfa need to also
receive an oral iron preparation.

11. Erythropoiesis-Stimulating Agents
(2 of 2)
 epoetin alfa
 Longer-acting form of epoetin is called darbepoetin
(Aranesp®)
 Contraindications: drug allergy; uncontrolled
hypertension; hemoglobin levels that are above 100
mmol/L for cancer patients and 130 mmol/L for
patients with kidney disease; head and neck cancers;
risk of thrombosis
 Most frequent adverse effects: hypertension, fever,
headache, pruritus, rash, nausea, vomiting, arthralgia,
and injection site reaction

12. Iron (1 of 4)
 Essential mineral in the body
 Oxygen carrier in hemoglobin and myoglobin
 Stored in the liver, spleen, and bone marrow
 Deficiency results in anemia

13. Iron (2 of 4)
 Dietary sources: meats, certain vegetables and
grains
 Dietary iron must be converted by gastric juices
before it can be absorbed.

14. Iron (3 of 4)
 Some foods enhance iron absorption.
 Orange juice
 Veal
 Fish
 Ascorbic acid
 Some foods impair iron absorption.
 Eggs*
 Corn
 Beans*
 Cereal products containing phytates
* Also common dietary sources of iron.

15. Iron (4 of 4)
 Supplemental iron may be given as a single
drug or as part of a multivitamin preparation.
 Oral iron preparations are available as ferrous
salts.
 ferrous fumarate (Femiron®), ferrous gluconate,
ferrous sulphate (FeSO4)
 Parenteral
 iron dextran (Dexiron®, Infufer®)
 iron sucrose (Venofer®)
 ferric gluconate (Ferrlecit®)
 ferumoxytol (Feraheme®)

16. Iron: Indications
 Prevention and treatment of iron deficiency
syndromes
 Administration of iron alleviates the symptoms of
iron deficiency anemia, but the underlying cause
of the anemia should be corrected.

17. Iron: Adverse Effects
 Most common cause of pediatric poisoning
deaths
 Causes nausea, vomiting, diarrhea,
constipation, and stomach cramps and pain
 Causes black, tarry stools
 Liquid oral preparations temporarily discolour
teeth.
 Injectable forms cause pain upon injection.

18. Iron Toxicity
 Symptomatic and supportive measures
 Suction and maintenance of the airway; correction of
acidosis; control of shock and dehydration with IV
fluids or blood, oxygen, and vasopressors
 In patients with severe symptoms of iron
intoxication, such as coma, shock, or seizures,
chelation therapy with deferoxamine mesylate is
initiated.

19. Parenteral Iron (1 of 2)
 Iron dextran (Dexiron, Infufer)
 May cause anaphylactic reactions, including major
orthostatic hypotension and fatal anaphylaxis
 A test dose of 25 mg of iron dextran is administered
before injection of the full dose, and then the
remainder of dose is given after 1 hour.
 Used less frequently now; replaced by newer
products ferric gluconate and iron sucrose

20. Parenteral Iron (2 of 2)
 ferric gluconate (Ferrlecit)
 Indicated for repletion of total body iron content in
patients with iron deficiency anemia who are
undergoing hemodialysis
 Risk of anaphylaxis is much less than with iron
dextran, and a test dose is not required.
 Doses higher than 125 mg are associated with
increased adverse events, including abdominal pain,
dyspnea, cramps, and itching.

21. Folic Acid (1 of 2)
 Water-soluble, B-complex vitamin
 Essential for erythropoiesis
 Primary uses
 Folic acid deficiency
 During pregnancy, to prevent neural tube defects
 Malabsorption syndromes are the most common
causes of deficiency.

22. Folic Acid (2 of 2)
 Should not be used until actual cause of anemia
is determined
 May mask symptoms of pernicious anemia,
which requires treatment other than folic acid
 Untreated pernicious anemia progresses to
neurological damage.

23. Cyanocobalamin (Vitamin B12)
 Used to treat pernicious anemia and other
megaloblastic anemias
 Administered orally or parentally.
 Usually administered by deep intramuscular
injection to treat pernicious anemia

24. Nursing Implications (1 of 9)
 Assess patient history and medication history,
including drug allergies.
 Assess potential contraindications.
 Assess baseline laboratory values, especially
hemoglobin, hematocrit, reticulocytes, and
others.
 Obtain nutritional assessment.

25. Nursing Implications (2 of 9)
 Ferrous salts are contraindicated for patients
with ulcerative colitis, peptic ulcer disease, liver
disease, and other gastrointestinal disorders.
 Keep away from children, because oral forms
may look like candy.
 Iron dextran is contraindicated in all anemias
except for iron-deficiency anemia.

26. Nursing Implications (3 of 9)
 For liquid iron preparations, follow the
manufacturer’s guidelines on dilution and
administration.
 Instruct the patient to take liquid iron
preparations through a straw to avoid staining
tooth enamel.

27. Nursing Implications (4 of 9)
 Oral forms of iron should be taken between
meals for maximum absorption but may be taken
with meals if gastrointestinal distress occurs.
 Oral forms should be given with juice but not
with milk or antacids.

28. Nursing Implications (5 of 9)
 To avoid esophageal corrosion, patients should
remain upright for up to 30 minutes after taking
oral iron doses.
 Patients should be encouraged to eat foods high
in iron and folic acid.

29. Nursing Implications (6 of 9)
 For iron dextran, a small test dose should be
given.
 If there is no reaction after 1 hour, the remainder of
the dose can be given.
 Administer the dose deeply into a large muscle mass,
using the Z-track method.

30. Nursing Implications (7 of 9)
 Give IV doses of iron dextran carefully and
according to the manufacturer’s instructions.
 Have resuscitative equipment available in case
of an anaphylactic reaction.

31. Nursing Implications (8 of 9)
 Determine the cause of anemia before
administering folic acid.
 Administer oral folic acid with food.
 Folic acid is available for both oral and injectable
use

32. Nursing Implications (9 of 9)
 Monitor therapeutic responses.
 Improved nutritional status
 Increased weight, activity tolerance, well-being
 Absence of fatigue
 Monitor adverse effects.