Iron therapy what options do we have

The most common causes of anemia are poor nutrition, iron deficiencies, micronutrients deficiencies including folic acid, vitamin A and vitamin B12, diseases like malaria, hookworm infestation and schistosomiasis.

1. IRON THERAPY- WHAT OPTIONS DO WE HAVE? DR. NIRANJAN CHAVAN

2. IRON DEFICIENCY ANAEMIA Most common micronutrient deficiency in the world affecting ~ 24% of the world population. Iron deficiency can range from sub-clinical state to severe iron deficiency anemia.

3. Dietary Factors that affects absorption

4. Iron Requirements 2.5 mg/day in early pregnancy 5.5 mg/day from 20-32 weeks 6 to 8 mg/day from 32 weeks onwards Average : 4mg/day Ideally women should enter pregnancy with adequate iron stores As a public health approach, prolonged oral iron supplementation even before pregnancy is a better strategy ( PRECONCEPTION COUNSELING)

5. WHO recommends 60 mg elemental iron with 250 mg folic acid for 6 months in pregnancy and additional 3 months postpartum

6. GOI & MOH recommendation 100 mg elemental iron with 500 mg of folic acid for 100 days in second half of pregnancy

7. Routes of iron therapy Oral route 2. Parenteral route

8. ORAL IRON Iron is best absorbed in ferrous form within the body. Preparations available are Ferrous gluconate Ferrous fumarate Ferrous succinate

9. Treatment should be continued till the blood picture becomes normal. There after a maintenance dose of 1 tab./day is to be continued for atleast 100 days following delivery to replenish the iron stores.

10. Drawbacks of oral iron therapy : Intolerance : It is evidenced by – Pain Nausea Vomiting Diarrhea Constipation To avoid intolerance, therapy should be started with a smaller dose (1 tab./day) and then to increase the dose to a maximum of 3 tab./day

11. With the therapeutic dose, the serum iron may be restored but there is difficulty in replenishing the iron stores. Response : It is evidenced by – Sense of well being Increased appetite Improved outlook of the patient Rise in Hb levels about 0.7 gm/100 ml/week. Contraindications : - Intolerance to oral iron Severe anaemia in advance pregnancy

12. PARENTERAL IRON THERAPY Indications : - Intolerance to oral iron Cases seen for the first time during the last 8-10 weeks with severe anemia. Routes 1. Intravenous route - a. Total dose infusion (TDI) b. Repeated injections 2. Intramuscular route

13. Intravenous route: Total dose infusion (TDI) : - Iron dextran or Iron sucrose are used to correct the deficit in a single sitting. – Estimation of dose : • For Iron sucrose : 2.3 x W x D + 500 (W= weight in kg before pregnancy) D= Hb ( target-actual )

14. Pre-requisites: - Correct diagnosis of iron deficiency anaemia Adequate supervision Facilities for management of anaphylactic reaction Advantages : - It eliminates repeated and painful I.M inj. Early discharge of the patients Less costly as compared to I.M therapy

15. INTRAMUSCULAR ROUTE Compounds are used: Iron dextran ( Imferon ) . Iron sorbitol complex – ( Jectofer ) Both preparation contains 50 mg of elemental iron in 1 ml. Precautions : - Oral iron should be suspended atleast 24 hrs prior to therapy to avoid reaction. Drawbacks : - Painful procedure Chance of abscess formation at the site of infection Discoloration of the skin over the injection site

16. Newer Iron Preparations Ferric carboxy maltose Structure: Macromolecular ferric hydroxide carbohydrate complex, with ferric hydroxide core stabilized by a carbohydrate shell (controlled delivery of iron, leading to decreased oxidative stress) Around 60 – 100% of iron is used for RBC production, within 16 – 24 days. Peak of Serum ferritin levels occur within 48 – 120hrs after administration Increases transferrin saturation rapidly, but didn’t change s. transferrin levels or transferrin receptor levels Reticulocyte count increases at around 8 days

17. Dose : maximum single dose of 1000mg of iron, not exceeding 15mg/kg or calculated cumulative dose, over a minimum infusion time of up to 15 min. Infusions shouldn’t be administered more than once per week

18. Side effects & tolerability: Most adverse events noticed with FCM are mild to moderate in intensity Rash (pruritis & urticaria are uncommon) & local skin reactions (generally after first dose, not recur) Transient & asymptomatic decrease in serum phosphorous levels Tolerance is very good Mild adverse effects No multiple doses No long infusion times as with other IV iron preparations No gastrointestinal side effects as with oral iron No serious hypersensitivity reactions as with Iron dextran

19. THANK YOU