Anemia

Luciana
Kasus
 Tn MS usia 64 tahun, dengan BB : 48 kg dan TB : 165 cm, masuk RS dengan keluhan
demam, low intake, lemas dan mual-muntah. Riwayat penyakit dahulu post operasi
craniotomy ai stroke hemoragik, konvulsi, hipertensi dan diare sejak 3 hari sebelum
masuk RS. Tekanan darah saat masuk 85/47 mmHg; nadi : 110x/menit; RR ;
23x/menit; SatO2 : 97% dengan O2 nasal 3 liter/menit.
 Riwayat penggunaan obat : fluconazole 150 mg 1x sehari, phenytoin 100 mg 3x sehari
ac, candesartan 8 mg 1x sehari.
 Hasil pemeriksaan laboratorium : Hb : 8,6 g/dL ( 13- 16 ); Leukosit : 11.400 (
5.000-10.000 ); Neutrofil : 78% ( 50-70% ); Trombosit : 237.000 ( 150.000-500.000 );
Ureum : 47,11 ( 21,3-44 ); creatinine : 1,35 ( 0,72-1,25 ); albumin : 2,5 g/dL ( 3,5-
5,2 ); GDS : 168 ( 70-180 ). Dokter meminta Apoteker untuk melalukan evaluasi
penggunaan obat pasien sebelum mulai memberikan terapi. Lakukan evaluasi
penggunaan obat dan rekomendasi apa yang dapat ada sampaikan kepada dokter ?
Introduction
 Anemia ( WHO criteria ) defined as hemoglobin ( Hb < 13 g/dL in
men or 12 g/dL in women )
 The highest prevalence is seen in women, African American, the
elderly, and low income persons
 Anemia influences morbidity as shown in patients with end-stage
renal disease, CKD, and heart failure
 During pregnancy, anemia has been associated with increased risk
for low birth weight, preterm delivery, and perinatal mortality
 Anemias can result from :
• Inadequate RBC production
• Increased RBC destruction
• Blood loss
• Chronic renal disease
• Infection
• Malignancy
 Anemias are classified by RBC size :
 Macrocytic : vit B12 and folic acid deficiency
 Normocytic : blood loss or chronic disease
 Microcytic : iron deficiency
 Macrocytic anemias are divided into :
 Megaloblastic anemias : vit B12 and folic acid deficiency (
hemolytic anemias )
 Non megaloblastic anemias
 Macrocytic anemias may be due to etiologies such as : liver
disease, hypothyroidism, and alcoholism
Normal Hematologic Values
Specific Anemias
 Iron-Deficiency Anemia ( IDA )
• Iron is vital to the function of all cell. Without iron, cells
lose their capacity for electron transport and energy
metabolism
 High risk for IDA :
 Children younger than 2 years
 Adolescent girls
 Pregnant females and lactation
 Elderly older than 65 years
 Medication history : aspirin, alcohol, corticosteroid,
warfarin, NSAID, anticoagulants,
Recommended Daily Allowance

 Adult males and post menopausal females : 8 mg

 Menstruating females : 18 mg
 Children require more iron because of growth-related
increases in blood volume
 Pregnant women have an increased iron because of fetal
development
Treatment Iron-Deficiency Anemia

 Dietary supplementation and therapeutic iron preparations :

vegetables, grain products, dairy product and eggs
 Supplemental of iron 200 mg daily
 ADR of iron : gastrointestinal upset, a dark discoloration of feces,
constipation or diarrhea, nausea and vomiting
Oral Iron Products
 Adverse reactions to therapeutic doses of iron are :
 Consist of dark discoloration of feces
 Constipation or diarrhea
 Nausea
 Vomiting

 Note :
 GI side effects usually are dose related
 administration with meals may minimize this adverse effects
Iron-Salt-drug Interactions
Parenteral Iron Therapy

 Indications for parenteral iron therapy :

• Intolerance to oral
• Malabsorption
• Patient with CKD, especially undergoing haemodialysis
• Cancer patients receiving chemotherapy
Parenteral Iron Preparations
Adverse effect of Parenteral Iron Therapy
 Iron dextran :
• Staining of the skin
• Pain at the injection site
• Allergic reaction
• Rarely anaphylaxis

 Ferric gluconate
• Cramps, nausea, vomiting, upper gastric pain
• Flushing
• Hypotension
• Rash and pruritus
Adverse effect of Parenteral Iron Therapy

 Iron sucrose :
• Leg cramps and hypotension
• Iron sucrose injection should not be administered
concomitantly with oral iron preparation, because
it will reduce the absorption of oral iron.
Megaloblastic anemias

 Caused by abnormal DNA metabolism resulting from vit B12 or folate

deficiency
 It can be caused by administration of various drugs : hydroxyurea,
zidovudine, cytosine arabinoside, methotrexate, azathioprine, 6
Mercaptopurine,
Drug-induced Megaloblastic Anemia

 Chloramphenicol
 Cotrimoxazole
 5- Fluorouracil
 Hydroxyurea
 Oral contraceptives
 6-Mercaptopurine
 Phenytoin
 Phenobarbital
 Pyrimethamine
Vitamin B12 Deficiency Anemia

 The causes of Vit B12 are :

• The use of gastric acid-suppressing agents
• Malabsorption syndromes
• Patients who are strict vegans and their breast-fed infants, chronic
alcoholics, elderly patients with financial limitation
 Low levels of Vit B12 result in : venous thromboembolic disease,
peripheral vascular, coronary,
Drug induced Vit B12 deficiency

 Metformin- its effect on the intestinal mucosa

in the ileum
 H2 receptor antagonists and proton pump
inhibitors - inhibit gastric acid , acidic
environment is needed for vit B12 to be absorbed
in GIT from food
Recommended Daily Allowance

 Adults : 2 mcg
 Pregnant or breast feeding woman : 2,6 mcg

 Vit B12 deficiency can cause :

• Neurologic and hematologic complication
Treatment Vit B12 Deficiency Anemia
 For initial parenteral vit B12 regimen consists of 1000 mcg of
cyanocobalamin for 1 week to saturate Vit B12 stores in the body.
 Administration 1 mg of oral Vit B12 daily
 Intake types of foods high in vit B12
 Contraindication to oral replacement therapy are :
o Inability to take medications orally
o Diarrhea
o Vomiting
Folic Acid Deficiency Anemia
 Folic acid deficiency is associated with : poor eating habits (
junk food ), the poverty stricken, alcoholism, chronic illness
 Increased folate requirements as seen in : pregnant women,
patients with hemolytic anemia, malignancy, dialysis, burn
patients
 Several drugs are reported to cause folic acid deficiency :
• Inhibit DNA synthesis : azathriopine, 6-mercaptopurine, 5-FU,
hydroxyurea, and zidovudine
• Folate antagonist : methotrexate, TMP, phenytoin,
phenobarbital, and primidone

• Alcohol can interfere with folic acid and Vit B12 absorption on
the intestinal mucosa
Recommended daily allowance for folate

 Minimum daily requirement is 50 to 100 mcg

 For non pregnant females is 400 mcg
 For pregnant females is 600 mcg
 For lactating female is 500 mcg

 The body stores about 5-10 mg folate, primarily in the

liver
Treatment of Folic Acid Deficiency

 1 mg daily of folic acid is sufficient to replace stores

 1 mg to 5 mg daily is necessary due to malabsorption
 Patients with a folic acid deficiency should be placed on
diets containing foods high in folate ( chicken liver,
asparagus, kidney beans, orange, tomato juice )
 Women with a family history of neural tube defect should
comsumpt 4 mg daily of folic acid
Anemia of Inflammation

 To describe both ACD and anemia of critical illness

 The most common develop among elderly
Diseases Causing AI
Treatment of AI

 Supplementation of folic acid, iron ( parenteral iron ) and Vit

B12
 Erytropoietin –stimulating agent ( not approved by FDA ). ESA
treatment is effective when the marrow has an adequate supply
of iron, cobalamin and folic acid
 Dosage : 50-100 units/kg ( 3 times a week )
 Toxicities of ESA :
 Increased blood pressure, nausea, headache, fatigue, fever
Anemia of Chronic Disease

 ACD is one of the most common form of anemia,

particularly in the elderly
 ACD has been associated with infectious or inflammatory
processes, tissue injury
Hemolytic Anemia

 Hemolytic anemia results from decreased survival time of

RBCs secondary to destruction in the spleen or circulation

 Laboratory findings : urine analysis ( hemoglobinuria ),

increase indirect bilirubin
Drug Associated with hemolytic Anemia

• Phenobarbital
• Phenytoin
• Ketoconazole
• NSAIDs
• Omeprazole
• Rifampicin
Treatment of Hemolytic Anemia

 No specific therapy but steroids and other

immunosuppressive agents have been used for
management of autoimmune hemolytic anemias
Anemia in pediatric

 Newborn period can lead to IDA include prematurity and

insufficient dietary intake
 Prematire infants are at increased risk for IDA  poor GI
absorption and increased blood loss
 Dietary deficiency of iron in the first 6 to 12 months of
life is less common today because of the increased use of
iron supplementation during breast feeding
Treatment

 For infants aged 9 to 12 months with a mild microcytic

anemia, the most cost effective treatment is Ferrous
sulfat at dose 3-6 mg/kg /day of elemental iron divided 1-
2 times daily.

 For macrocytic anemia in children- folate 1 mg daily

Kasus
 Ny DS usia 37 tahun dengan BB : 51 kg dan TB : 155 cm, didiagnosis HIV,
pneumonia dengan PCP dan TB paru.
 Saat ini pasien dalam terapi Efavirenz 600 mg 1x sehari; , tenofovir 300 mg
1x sehari; dan ; cotrimoksazole DS 3x sehari 2 tablet; lamivudine 300 mg 1x
sehari; ranitidine injeksi 50 mg tiap 12 jam, rifampicin 450 1x sehari; ac
pagi; isoniazid 300 mg 1x sehari; ethambutol 1000 mg 1x sehari dan
pyrazinamide 1000 mg 1x sehari
 Hasil pemeriksaan laboratorium :
 Hb : 9,6 g/dL ( 12-14 ); Leukosit : 4900 ( 5000-10.000 ); Trombosit :
108.000 ( 150.000-500.000 ); Ureum : 51,4 ( 21-43 ); creatinine : 1,5 (
0,57-1,11 ); albumin : 2,9 ( 3,5-5,2 ); SGOT: 87; SGPT : 91.
Lakukan analisis terhadap terapi Ny DS dan rekomendasi apa yang dapat anda
berikan.
TERIMA KASIH