Parentaral Iron Therapy Freash Thinking

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intravenous iron sucrose is a ray of hope for treating iron defeciency anemia which is still a major problem in india. It circumvents the problem of compliance and its large safety encourages its routine use in antenatal care and is highly suitable for treating postpartum anemia...

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Parentaral Iron Therapy Freash Thinking

  1. 1. Parenteral iron therapy- fresh thinking Dr.Veerendra Kumar C.M. MD.,DNB Associate Professor Dept of OBG,VIMS,Bellary
  2. 2. Pregnancy - The most dangerous journey of mankind
  3. 3. A big challenge Treating anemia
  4. 4. <ul><li>MMR in INDIA is 300/ 100000 live births </li></ul><ul><li>Anemia accounts for 65% maternal deaths </li></ul><ul><li>Bhatt R. FOGSI- WHO study. J Obstet Gynecol Ind 1997;47:207-214 </li></ul>
  5. 5. Only demons no angels <ul><li>PNMR is 9 times more </li></ul><ul><li>LBW risk is tripled </li></ul><ul><li>PT labor risk doubled </li></ul><ul><li>Placenta to birth weight ratio increased ( predecessor of adult Hypertension) </li></ul><ul><li>Poor mental & motor performance </li></ul><ul><li> Barker DJP, Br Med J 1990 ;301: 259-262. </li></ul>
  6. 6. Are we producing a defective generation?
  7. 7. A FAILED PROGRAMME <ul><li>IFA programme was started in 1970 </li></ul><ul><li>Even now -NFH survey- 84% prevalence (9.2% severe) </li></ul><ul><li>Only 10% of women consume correctly! Indian J Med Res 2006:124:173-184) </li></ul>
  8. 8. Parenteral iron -The solution? <ul><li>Most of the patients ‘psyche’ in favor of injections </li></ul><ul><li>Myths about oral therapy </li></ul>
  9. 9. Parenteral iron <ul><li>1000mg of iron given by 10 im injections P rema 1982 </li></ul><ul><li>250mg of iron 2 doses- just like 2 TT injections R bhat 1996 unacceptable incidence of serious reactions </li></ul>
  10. 10. Hazards of blood transfusion in USA <ul><li>Hemolytic reactions 1 in 40,000 </li></ul><ul><li>Non hemolytic febrile reactions 3-4% </li></ul><ul><li>Anaphylactic reactions 1 in 20,000 </li></ul><ul><li>GVHD 0.1 to 1% </li></ul><ul><li>TRALI 0.1-0.2% </li></ul><ul><li>HBV 1 in 50,000 </li></ul><ul><li>HCV 1 in 3000 </li></ul><ul><li>HIV 1 in 1,50,000 </li></ul>
  11. 11. Ray of hope ? <ul><li> (orofer-s) </li></ul>iron sucrose
  12. 12. Irrefutable evidence <ul><li>IV iron sucrose results in a much more rapid resolution of IDA and because it is administered intravenously, it circumvents the problems of compliance. Am J Obstet Gynecol 2002;88:3-10. Eur J Obstet Gynecol Reprod Biol 1996;69:121-124. </li></ul>
  13. 13. <ul><li>Main use is in chronic kidney disease NDD-CKD,HDD-CKD,PDD-CKD </li></ul><ul><li>Most dialysis pts require iv iron to maintain iron stores </li></ul>
  14. 14. Christian Breymann, Zurich <ul><li>I was severely criticized by older colleagues,…..,confident about the safety & effectiveness …glad that other groups are confirming our experience…even more convinced after 14 years Euro J Obst & Gynecol 123 (2005) Editorial </li></ul>
  15. 15. Continued…. <ul><li>“ Please do not be worried of severe anaphylaxis & unpleasant side effects…..less than 0.5% minor side effects ….not aware of any serious reaction in any country” </li></ul><ul><li>Every obstetric hospital setting should have a therapeutic scheme to treat advanced post partum anemia </li></ul>
  16. 16. Holds good even after 50 yrs! <ul><li>If oral iron does not work , switch quickly to intravenous iron, don’t waste your & your pt’s time on oral iron that does not work Scott, Govan, Lancet -1949 Jan ,253(6540)14-7 </li></ul>
  17. 17. Iron Sucrose ( Orofer-s ) <ul><li>Polynuclear ferric hydroxide </li></ul><ul><li>MW 34,000-60,000 daltons </li></ul><ul><li>Each ml contains 20 mg of Fe </li></ul><ul><li>After iv administration it dissociates into iron & sucrose </li></ul><ul><li>t/2 is 6hrs </li></ul>
  18. 18. Peak levels reached in 10 min by 24 hours all the iron sucrose is used (pre & post serum iron was same)
  19. 19. Less oxidative cell injury <ul><li>All iron preparations except iron sucrose were capable of causing tissue peroxidation iron sucrose is sequestered much more by the RES and lesser in the parenchyma. Less risk of tissue parenchymal injury by free iron. </li></ul><ul><li> Zager et al Am J of Kidney disease 2002,40;90-103 </li></ul><ul><li>Iron sucrose do not over saturate the transferrin </li></ul><ul><li>Am J soc Nephrology 2004 Jun vol 6 </li></ul>
  20. 20. Total dose infusion not recommended <ul><li>200mg max dose per sitting </li></ul><ul><li>Administered thrice weekly </li></ul><ul><li>Can be given by either iv bolus undiluted push or iv infusion </li></ul><ul><li>50 mg to be injected slowly over 2 minutes, wait for 2-3 min ,then give another 50 mg over 2 min </li></ul><ul><li>100mg-200 mg to be diluted with 100ml NS ,infuse at least 15 min </li></ul><ul><li>LD 50 in mice is > 200mg/kg </li></ul>
  21. 21. Pregnant women with anemia
  22. 22. Post partum anemia
  23. 23. <ul><li>High EPO state in postpartum anemia </li></ul><ul><li>Iv iron supplementation in such period increases the erythropoiesis 5 times </li></ul><ul><li>The Hb rise will be evident in as early as 5 days! Harrisons principles of medicine </li></ul>
  24. 24. Iv bolus v/s iv infusion <ul><li>Iv bolus push is less costly, more compliance </li></ul><ul><li>hema divakar ,myanyonda on a study of 152 pts </li></ul><ul><li>Presently working on large multicentric trial </li></ul>
  25. 25. Take home message <ul><li>Iv iron sucrose is safe & effective </li></ul><ul><li>Faster & certain resolution of IDA </li></ul><ul><li>200mg iron sucrose can be given per sitting </li></ul><ul><li>Can be given thrice weekly </li></ul><ul><li>Iron sucrose is given both bolus push & infusion </li></ul>
  26. 26. Conclusions contd… <ul><li>Other parenteral iron becoming obsolete </li></ul><ul><li>Highly suitable for pregnancy with anemia </li></ul><ul><li>Post partum anemia quicker response </li></ul><ul><li>Pre – post operative anemia can also be cured </li></ul><ul><li>Less need for blood transfusion </li></ul>
  27. 27. <ul><li>Thank you </li></ul>

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