Hematinics

Pharmacology for nurses

1. Hematinics Dr. Binu Babu Ph.D , M.Sc. (N), MBA Mrs. Jincy Ealias M.Sc. (N)

2. Hematinics Hematinics are the compounds or nutrients required in the formation of blood (hematopoiesis) and are used for the treatment of anemia. Major Hematinics are; Iron Vitamin B 12 Folic acid

3. Iron

4. Iron Iron is essential for the production of hemoglobin. Daily Requirement of Iron Adult male 0.5-1 mg Adult female 1-2 mg Pregnancy and lactation 3-5 mg Dietary sources of iron Fish, chicken, spinach, liver , egg yolk, meat, dry fruits, wheat, jaggery , apple, banana.

5. Pharmacokinetics The average Indian diet provides about 10-20 mg of iron. Only 10% of dietary iron is absorbed. Inorganic ferrous iron (from non vegetarian sources) is better absorbed than ferric iron (from vegetarian sources ). Maximum absorption taken place in the duodenum and upper jejunum.

6. Iron is transported with the help of a glycoprotein transferrin and stored as ferritin and hemosiderin, in the liver, spleen and bone marrow. Excretion : Daily 0.5-1 mg of iron is excreted. In females , iron is also lost in menstruation.

7. Factors influence iron absorption Increase absorption Ascorbic acid Amino acids Meat Increased gastric acidity Decrease absorption Antacids Phosphates Phytates Tetracyclines Presence of food in the stomach

8. IRON PREPARATIONS Iron is available both in oral and parenteral forms . Indications For treatment Iron deficiency anemia Pregnancy Blood loss Poor iron absorption from gut For prophylaxis Iron deficiency anemia Pregnancy Lactation Chronic illness

9. Oral Iron Preparations Used for long term therapy. Ferrous sulphate-200 mg tab Most economical form of iron. Available commercially and in government supplies. Ferrous fumarate-200 mg tab Ferrous gluconate-300 mg tab Ferrous succinate-100 mg Iron calcium complex-5% iron Ferric ammonium citrate-45 mg

10. Adverse Effects of Oral Iron Epigastric pain Nausea Vomiting Gastritis Metallic taste Constipation ( due to astringent effect) or diarrhea (irritant effect) Liquid preparations cause staining of teeth .

11. Parenteral iron preparations Indications When oral iron is not tolerated Failure of absorption-as in malabsorption , chronic bowel disease Noncompliance to oral iron Severe deficiency with bleeding . Post gastrectomy patients

12. Preparations Iron dextran Given IV/IM Iron-sorbitol-citric acid complex Given only IM Ferrous sucrose Given only IM Ferric carboxymaltose

13. Administration Given deep IM in the gluteal region using 'Z technique to avoid staining of the skin . Intravenous iron is given slowly over 5-10 minutes or as infusion (diluted in 500 ml of NS or glucose and infused over 6-8 hrs ) after a test dose. Oral iron should be stopped 24 hours before starting parenteral iron therapy and not restarted until five days after the last injection.

14. Adverse effects of parenteral preparation Local : Pain at the site of injection Pigmentation of the skin Abscess at the site of injection Systemic : Fever Headache Nausea, vomiting Joints pain Enlargement of lymph node Palpitation Difficulty in breathing Anaphylaxis (rarely)

15. Iron poisoning   Common in infants and children Due to accidental ingestion of about 10 iron tablets, can be lethal. Manifestations   Vomiting Abdominal pain Hematemesis, Bloody diarrhea Shock Drowsiness Cyanosis Acidosis, Dehydration Cardiovascular collapse Coma

16. Treatment Treatment should be initiated immediately as death may occur in 6-12 hours . Gastric lavage with sodium bicarbonate solution Desferrioxamine is the antidote. It is instilled into the stomach after lavage, to prevent iron absorption; also injected IV/IM. Correction of acidosis and shock.

17. Vitamin B12

18. Vitamin B12 Cyanocobalamin Essential for DNA synthesis and RBC maturation. Dietary sources  Liver, fish, egg yolk, meat, cheese and pulses Daily requirement Adults 1-3 μ g Pregnancy and lactation 3-5 μg

19. Pharmacokinetics Vitamin B12 is absorbed with the help of intrinsic factor, a protein secreted by the stomach . It is carried in the plasma by B12-binding proteins called transcobalamin and is stored in the liver.

20. Preparations Cyanocobalamin 100 μ g /ml injection may be given IM or deep SC Hypersensitivity reactions can occur Hydroxocobalamin 100, 500 , 1000 μg /ml injection Has long lasting effect but can result in the formation of antibodies. Multivitamin preparations – oral form

21. Administration Vitamin B12 replacement therapy is given by intramuscular injection . Hydroxocobalamin is preferred, given as an initial loading dose followed by three monthly maintenance treatment for life.

22. Uses Prophylaxis and treatment Megaloblastic anemia  Pernicious anemia Needs life long treatment with vitamin B12 Prophylactic dose of vitamin B12 is 3-10 mcg daily. Intestinal malabsorption B12 neuropathies like subacute combined degeneration respond to vitamin B12

23. Folic Acid

24. Folic Acid Essential for DNA synthesis and RBC maturation . Dietary source: Egg, Green vegetables, liver, yeast , milk Daily requirement Adults 50-100 μg Pregnancy and lactation 200-400 μg  

25. Pharmacokinetics Absorption takes place in the jejunum and is transported in the blood by active and passive transport, and is stored in the liver .

26. Uses Megaloblastic anemia Folic acid 2-5 mg/day is given orally along with vitamin B12. Malabsorption syndrome Folic acid is given IM . Prophylactically in pregnancy , lactation, infancy 500 mg daily orally.

27. Haematopoietic growth factors

28. Hematopoietic growth factors Hematopoietic growth factors are hormones that regulate erythropoiesis . Hemotapoietic Growth Factors Include: Erythropoietin Myeloid growth factors GM-CSF G-CSF M-CSF Megakaryocyte growth factors Thrombopoietin Interleukin-II

29. Erythropoietin   Stimulates RBC production. Uses Treatment of anemia in chronic renal failure, bone marrow disorders, malignancies , chronic inflammation & anemia associated with AIDS . Mechanism of action Erythropoietin  binds to erythropoietin receptors on red cell progenitors and stimulates RBC production .

30. Preparations Epoetin Given thrice weekly in a dose of 25-100 units/kg by IV/SC route. Darbepoetin Given once weekly or once every 2-4 wks. Given in a dose of 0.45 mcg/kg by IV/SC route once weekly. Adverse effects Hypertension Allergic reaction Thrombosis 

31. Myeloid growth factors Myeloid growth factors include Granulocyte - macrophage colony stimulating factor ( GM-CSF) Granulocyte colony stimulating factor ( G-CSF) Monocyte colony stimulating factor (M-CSF )

32. Mechanism of action Myeloid growth factors bind to specific receptors on the myeloid progenitor cells Stimulates proliferation and differentiation of neutrophils and monocytes Adverse effects Bone pain Fever Arthralgia Myalgia Dyspnea

33. Uses Bone marrow transplantation Following cancer chemo-therapy Aplastic anemia Congenital neutropenia Myelodysplasia AIDS patients with neutropenia

34. Megakaryocyte Growth Factors Thrombopoietin Increases the production of platelets. Uses Thrombocytopenia following cancer chemotherapy. Drug-induced thrombocytopenia Bone marrow transplantation

35. Interleukin-II Enhances megakaryocyte maturation . Given daily via subcutaneous injection until the platelet count >10000/ μl . Side effects Fluid retention and associated cardiac symptoms Injection site reactions Paraesthesias Blurred vision Uses Thrombocytopenia

36. Nursing implications Assess for contraindications or cautions and any known allergies to the drug to be administered to avoid hypersensitivity reactions . Ensure that iron deficiency anemia is confirmed before administering drugs to ensure proper use of the drug . Administer the oral form of iron with meals that do not include eggs, milk, coffee, and tea to prevent Gl irritation.

37. Nurse should educate the patient, to take iron with citrus juices to enhance its absorption . Patient should be  educated regarding good dietary  habits and importance of taking balanced diet. Take measures to alleviate constipation. IV infusion of iron should be given slowly to prevent hypersensitivity . Monitor for adverse effects.

38. Thank you