anaemia nidhi
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Pharmacotherapy of Anaemia
By Nidhi MaheshwariDepartment of PharmacologyMIMER Medical CollegeTalegaon-Dabhade
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Sideroblastic
anaemia of chronic disease
Sickle cell
Megaloblastic
Iron Deficiency
Hemolytic
Thalasemia
Aplastic
IRON DEFICIENCY ANAEMIA
Preparations: ORAL (Preferred) / PARENTERAL
Ferrous sulphate (Fersolate): (200 mg tab = 60 mg elemental iron)• Most commonly used• LESS EXPENSIVE• Metallic taste
Ferric Hydroxy Polymaltose (100% iron content)• Better absorbed• Less bowel upset• EXPENSIVE
Ferrous gluconate, Ferrous fumarate, Ferrous succinate, carbonyl iron, Iron polysaccharide complex
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Commonly available oral combinations:
Autrin: Ferrous fumarate +B12 +Folic Acid Dumasules: Ferrous fumarate+ Vit B12+Folic acid+Vit B1+Niacinamide+Vit C+Vit B6 Polyron, Biofer, Polyfer: Ferric hydroxy polymaltose + Folic Acid Hbfast: Carbonyl iron + Folic Acid
TYPE DOSE
(mg)
Elemental Iron Content (mg)
SULPHATE(desiccated)
200 TDS 195
GLUCONATE 300 TDS 108
FUMARATE 200 TDS 198
SUCCINATE 300 OD 105
POINTS TO REMEMBER…
Do not use irrational hematinic combinations (shotgun preparations)
Consider ELEMENTAL iron content
Sustained release preparation: Irrational
Liquid preparations: Put on the back of the tongue and swallow
Empty stomach: better absorption but more side effects
Escalate the dose
Treatment continued: 3-5 months after attaining normal Hb: (Stores)
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METALLIC taste Teeth discoloration GI disturbances: Epigastric pain, nausea, vomiting, Black stools
Constipation (astringent action), diarrhea (reflect irritant action)
↑ Absorption: Vit C, meat, acidic pH (Fe+++ Fe ++)
↓ Absorption: Alkalies, antacids, phytates (maize, wheat), phosphates (egg yolk), tetracyclines, captopril, milk, calcium
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ADRs - Oral Iron
Factors affecting absorption
Indications for Parenteral Iron : Oral iron intolerance Severe malabsorption syndrome: Sprue, IBD Colostomy Severe deficiency with chronic bleeding With erythropoetin: in advanced kidney disease
Dose requirement: Iron req.(mg)=4.4 x body weight (kg) x Hb deficit (g/dl)
Response to oral or parental route is similar (about 0.7-1 gm% rise in Hb/wk)
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Available preparations for IM use:
IRON DEXTRAN (imferon, dexferrum) Old , HMW complex Can be given iv 25% added in calculated dose 100mg in 2 ml vial IM: Z-technique – deeply in gluteal region to avoid staining Sensitivity test is done before iv/im
Others Iron sorbitol-citric acid complex : not favoured now Iron sucrose and sodium ferric gluconate.
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Available preparations for IV use
FERROUS SUCROSE(uniferon, microfer)
New HMW complex Not im / sc as alkaline Do not give oral iron concurrently or till 5 days 100mg iv in 5 min max: 200 mg Once a day/week Low hypersensitivity reactions Preferred in pregnants
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FERRIC CARBOXY MALTOSE (ENCICARB)
New, Safest Never IM 100 mg/ml iv or
1000mg/100ml saline for infusion( not with glucose) for 15 min Mildest side effects Not used in children(<14 yrs): no safety data available Causes rapid ↑ in Hb
Others: HMW iron dextran (imferon) LMW iron dextran (casmofer) Iron saccharate, Ferric gluconate
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Adverse Drug Effects
IM Route:
Local toxicity pain permanent discoloration local inflammation and regional lymphadenopathy
Systemic toxicity Fever, headache, joint pains, flushing, tachycardia, chest pain, lymph node
enlargement
I V Route Same as IM but v rare
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IRON TOXICITY
ACUTE IRON POISONING
Common in children: (≥1 gm: Toxic)
Abdominal pain, vomiting, haematemesis, diarrhea,
acidosis, dehydration, cyanosis, convulsions, shock,
cardiovascular collapse
Death within 12-48 hrs (Metabolic acidosis: damage liver and/or brain)
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Treatment
Desferrioxamine: Iron chelator, a specific antidote, reduces mortality significantly
0.5-1 gm (50mg/kg) IM: repeat 4-12 hrly
10-15mg/kg/hr (max:75mg/kg) IV: if shock present
DTPA / Calcium Edetate
Vomiting, Gastric lavage with Sodium Bicarbonate
Diazepam in case of convulsions
Milk and egg yolk orally
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THALASSEMIA
Multiple blood transfusions can result in iron overload (CHRONIC IRON OVERLOAD) Desferrioxamine High affinity for Fe 3+
1 gm chelates 85 mg elemental iron
0.5-1mg/kg or 500 mg BD IM daily injection
With blood transfusion in thalassemia: 2gm desferrioxamine at 15mg/kg/hr by separate iv line slowly
Inexpensive and safer in long term
s/e: diarrhoea, hypotension, skin rashes, hearing loss, flushing,
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Desferasirox: not in use Deferiprone Oral Preferred in thalassemia: compliance is good Less affinity for Zn and Cu Better tolerated: Only GI upset
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MEGALOBLASTIC ANAEMIA
VIT B12
Hydroxocobalamine: 500,1000 µg/ml (im)
Cyanocobalamine: 100 µg/ml (im/sc): usually IM
Oral formulations: given for maintenance.
Hydroxocobalamine Slow absorption highly protein bound Slow excretion Long acting
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Dose : 500-1000µg IM daily on alternate day for 2 WEEKS followed by ONCE a month
Add folic acid and iron: reinstitution of brisk haemopoiesis unmask deficiency of
these factors
In neurological deficits
Maintenanace dose: every 1-2 weeks for 6 months before switching to monthly injections
Methylcobalamine : 1000-1500/µg/day orally
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FOLIC ACID
2-5mg/day (folvite) : orally with vitamin B12
Absorption: jejunum
For DNA synthesis, folic acid and Vit B12 both are required
Don’t give folate alone in megaloblastic anameia as only folic acid improves anaemia but worsens neurological deficit (Succinyl Co A from methyl malonyl CoA requires Vit B12)
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PROPHYLAXIS
3-10 µg/day Vit B12 orally in those at risk of developing deficiency
100 mg IRON and 500 μg FOLIC ACID is given for 100 days in pregnancy
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ANAEMIA OF CHRONIC DISEASE
Recombinant DNA erythropoietin
Available in 2000,4000,10000 IU in 1 ml prefilled syringes
Epoetin alpha T1/2 :4-13 hrs in renal failure patients, not cleared by dialysis Given IV thrice a week
Darbepoetin alpha Once a week, longer T1/2
Epoetin beta once in 2-4 weeks, iv or sc
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In patients treated with an Erythropoietin
Increase in reticulocyte count is seen in 10 days
Increase in hematocrit and Hb level is seen in 2-6 weeks
ADR: Allergic reactions, Pure red cell aplasia, hypertension, headache, nausea
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SICKLE CELL ANAEMIA
Antibiotics: Penicillin (initial 5 yrs): to prevent childhood illness
Malaria Chemoprophylaxis
Pneumococcal vaccination
Analgesics: NSAIDs and OPIOIDS
Blood transfusion
Hydroxyurea: Increases Hb F level, which interferes with the polymerization of HbS
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SICKLE CELL ANAEMIA
Drugs precipitating hemolysis:
Sulphonamaide, Dapsone Nitrofurantoin, Nalidixic acid, Flouroquinlones Primaquine, Quinine, Proguanil Salicylates, Methylene blue, Chloramphenicol
For prophylaxis: Folic acid may be given
G6PD patients are more prone.
In SIDEROBLASTIC ANAEMIA : Pyridoxine ( Vit B6) may be given
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REFERENCES
Sharma and Sharma Tripathi Katzung Harrison book of Medicine Internet
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THANK YOUJul 23, 2017
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