ANAEMIA

Soumya Ranjan parida

Institute of Medical Sciences & SH

Bhubaneswar, India.

Anaemia

Anaemia is a condition in which the number of red blood cells or their oxygen-carrying capacity is insufficient to meet physiologic needs, which vary by age, sex, altitude, smoking, and pregnancy status. (WHO 2014)

Anaemia is a “Silent killer”. WHO criteria :

› Hb less than12 g/dL in females and less than 13g/dL in males

Anaemia

Globally, anaemia affects 1.62 billion people, which corresponds to 24.8% of the population.

In India, anaemia affects an estimated 50% of the population.

20%-40% of maternal deaths in India are due to anaemia

One in every two Indian women (56%) suffers from some form of anaemia.

!!!!

Anemia is rarely a disease by itself, It is mostly a manifestation or

consequence of an underlying (genetic or acquired) disease.

The finding of anemia has to start attempts to disclose an underlying disease . › What is the cause of anemia ?

Classification of Anaemia

Defective production of red cells:› Deficiency of iron, vitamin B12 or folate;

› Anaemia of chronic disorders; inflammatory, infectious, or malignant disease of a long-standing nature

› Reduced erythropoietin production—chronic kidney disease;

› Primary diseases of the bone marrow. Haemolytic anaemia

› Genetic—including membrane defects, haemoglobin disorders, and enzyme deficiencies;

› Acquired—including autoimmune and non-immune disorders.

Volume changes/acute bleeding and

anemia

normal

Hct (a/b

%):Normal

Dehydration Hct:Increased

Acute blood loss(early) Hct:unchanged

Chronic anemia Hct: Low

1 2 3 4 5

Increased plasma volume Hct: Low

b

a

Anemia is a laboratory diagnosis

Men WomenHemoglobin (g/dL) 14-17.4 12.3-15.3

Hematocrit (%) 42-50% 36-44%

RBC Count (106/mm3) 4.5-5.9 4.1-5.1

Reticulocytes 1.6 ± 0.5% 1.4 ± 0.5%

WBC (cells/mm3) ~4,000-11,000

MCV (fL) 80-96

MCH (pg/RBC) 30.4 ± 2.8

MCHC (g/dL of RBC) 34.4 ± 1.1

RDW (%) 11.7-14.5%

CBC Report:

COMMON CAUSE OF ANAEMIA IN INDIA

Nutritional Anaemia (commonest)› Decreased iron intake : low dietary

intake, poor iron (less than 20 mg /day) and folic acid intake (less than 70 micrograms/day)

› Decreased absorption: poor bio-availability of iron (3-4 percent only) in phytate fibre-rich Indian diet

› Increased requirement: Pregnancy; Lactating Mothers; Children – 1 to 11 years

› Increased iron loss: PPH, Menstrual abnormalities, Malaria, Hookworm

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IRON

Sources: Liver, Fish, Dry fruits, Jaggery, Spinach, Banana, Meat.

PHARMACOKINETICS› Haemoglobin, Myoglobin, Respiratory

Enzymes, Cytochrome› Dietary Iron is in Ferric Form› HCl in stomach reduces Ferric to Ferrous

iron› Absorption of Iron takes place in

Duodenum and upper jejunum.

Factors Affecting Iron Absorption

Acidic pH, Ascorbic Acid(Vit-C), Cysteine Reduces Ferric[Fe3+] to Ferrous[Fe2+]

Phosphates, Oxalates, Phytates Milk, Antacid, Tetracyclines (Forms

Insoluble complexes)

Sites of absorption of iron and vitamin B12.

Dietary iron is in Ferric Form.

Reduced to Ferrous form to be absorbed.

IF secretion

Tiredness Fatigability Headache Body ache Failure to thrive in

infants Perverted appetite

Smooth tongue Angular stomatitis Koilonychia Splenomegaly Plummer-Vinson or

 Paterson-Kelly syndrome

Symptoms

Signs

Clinical Presentation Of Iron Deficiency Anaemia

HAEMATINICS

IRON B12

Folic Acid

Therapeutic uses of Iron

During Pregnancy Due to blood loss Due to nutritional iron deficiency Due to poor absorption of iron from the

gut.

PHARMACOTHERAPY OF IDA ORAL

› Ferrous sulfate (20%)› Ferrous

Gluconate(12%)› Ferrous Fumerate

(33%)› Colloidal Ferric

Hydroxide (50%)› Carbonyl iron› Ferrous succinate› Ferric ammonium

citrate

PARENTERAL› Iron dextran› Iron sorbitol citric

acid› Ferrous sucrose› Ferric carboxy

maltose

Oral iron preparations The most common iron salt used for oral

administration is ferrous sulfate, Ferrous fumarate and gluconate have less

gastrointestinal side effects and are readily absorbed than ferrous sulfate.

Ferrous succinate is more completely absorbed, but is more expensive and has no advantage over ferrous fumarate and ferrous sulfate

Ferrous calcium citrate has very low iron content and does not supply adequate elemental iron unless several tablets are taken which is inconvenient for the patient.

Colloidal ferric hydroxide has high elemental iron(52.26%).Better absorption and less gastric irritation

DRAWBACKS OF ORAL IRON PREPARATIONS

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Epigastric pain Heart burn Nausea Staining of teeth Bloating

Metallic taste Intestinal colic Constipation Vomiting

The total dose of Parenteral iron is calculated by the formula:

IRON Required(mg)=

4.4 x Body weight(kg) x [Target Hb-Patient’s Hb deficit](g/dl)

Intramuscular Therapy

Dose- 100mg daily or alternative day up to 2gm.

Deep IM into the buttock using ‘Z-track’ technique.

To prevent staining of skin.

Intravenous therapy

Iron dextran complex- diluted in 500ml of NS and infused over 1-2hrs after administering a test dose.

Sodium ferric gluconate Iron sucrose

Adverse effects- painful, discolouration, nausea, vomitting, athralgia, rashes, anaphylactic reactions.

ERYTHROPOEITIN MW- 34,000 Sialoglycoprotein Erythropoietins are called epoetins (EPO). There are four different types of epoetin:

Epoetin alfa Epoetin beta Epoetin zeta Epoetin theta

Darbepoetin alfa is hyperglcosylated modified epoetin.

Indicated in CKD patients with anaemia.

Maturation Factors

Vitamin B12

Folic Acid

Essential for DNA synthesis Deficiency causes megaloblastic

anaemia.

Vitamin B12

Synthesized by colonic bacteria Present in meat, liver, egg, fish. Required for Haemopoiesis and for

maintenance of myelin.

PHARMACOKINETICS:STOMACH

• Vitamin B12 Complexes with Intrinsic Factor (IF)

ILEUM • Binds to specific receptors• Vit B12 gets absorbed into blood

BLOOD •Transported to various cells of body

• Excess B12 gets stored in Liver.

• Excreted in Bile & undergoes entero-hepatic circulation.

Preparations, Indications and Uses:

Cyanocobalamin, Hydroxycobalamin, Methylcobalamin.

B12 Deficiency states: Megaloblastic anaemia, Degenerative changes in spinal cord, Peripheral Neuropathy.

Pernicious anaemia ( Parietal cells destruction)

I.M or S.C Dose- 1000mcg Once a week x6 then

every month

FOLIC ACID

Abundant in Fresh green leafy vegetables, liver, fruits.

Requirement increases in Pregnancy and Lactation.

FOLATE DEFICIENCY:› Dietary def; Decreased absorption;

Diminished hepatic storage; Increased demand; Drug Induced(Methotrexate).

Pharmacokinetics of F.A

Folic acid Tetrahydrofolate

Manifestations of F.A deficiency and uses of F.A preparations.

THANK YOU