ANEMIA DRUGS DSN KEVIN DOBI, MS, APRN Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Chapter 54

Formation of new blood cells  Red blood cells (RBCs)  White blood cells (WBCs)  Platelets Hematopoiesis Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 2

RBCs  Manufactured in bone marrow  Immature RBCs are reticulocytes  Lifespan is 120 days More than one third of an RBC is made of hemoglobin  Heme: red pigment, contains iron  Globin: protein chain Hematopoiesis (cont’d) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 3

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Maturation defects  Cytoplasmic  Nuclear Excessive destruction of RBCs (hemolytic anemias)  Intrinsic RBC abnormalities  Extrinsic mechanisms Anemias Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 5

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epoetin alfa (Epogen)  Biosynthetic form of the natural hormone erythropoietin  Used for treatment of anemia associated with end-stage renal disease, chemotherapy-induced anemia, and for anemia associated with zidovudine therapy Erythropoiesis Stimulating Agents Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 10

Erythropoiesis Stimulating Agents (cont’d) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 11 epoetin alfa (Epogen)  Longer acting form of epoetin called darbepoetin (Aranesp)  Contraindications: drug allergy, uncontrolled hypertension, head and neck cancers, risk of thrombosis

Classroom Response Question Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 12 Before administering epoetin alfa to a patient in renal failure, it is most important for the nurse to assess which laboratory result? A.BUN B.White blood cell count C.Hemoglobin level D.Urine specific gravity

Essential mineral in the body Oxygen carrier in hemoglobin and myoglobin Stored in the liver, spleen, and bone marrow Iron deficiency results in anemia Iron Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 13

Dietary sources: meats, certain vegetables and grains Dietary iron must be converted by gastric juices before it can be absorbed Iron (cont’d) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 14

Classroom Response Question Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 15 Which food will the nurse teach the patient to avoid when ingesting an iron supplement? A.Eggs B.Veal C.Orange juice D.Fish

Some foods enhance iron absorption  Orange juice  Veal  Fish  Ascorbic acid Some foods impair iron absorption  Eggs*  Corn  Beans*  Cereal products containing phytates * Also common dietary sources of iron Iron (cont’d) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 16

Supplemental iron may be given as a single drug or as part of a multivitamin preparation Oral iron preparations are available as ferrous salts  ferrous fumarate (Femiron), ferrous gluconate, ferrous sulfate(FeSO 4 ) Parenteral  iron dextran (INFeD, Dexferrum)  iron sucrose (Venofer)  ferric gluconate (Ferrlecit)  ferumoxytol (Feraheme) Iron (cont’d) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 17

Prevention and treatment of iron-deficiency syndromes Administration of iron alleviates the symptoms of iron-deficiency anemia, but the underlying cause of the anemia should be corrected Iron: Indications Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 18

Most common cause of pediatric poisoning deaths Causes nausea, vomiting, diarrhea, constipation, and stomach cramps and pain Causes black, tarry stools Liquid oral preparations may stain teeth Injectable forms cause pain upon injection Iron: Adverse Effects Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 19

Symptomatic and supportive measures  Suction and maintenance of the airway, correction of acidosis, control of shock and dehydration with intravenous fluids or blood, oxygen, and vasopressors In patients with severe symptoms of iron intoxication, such as coma, shock, or seizures, chelation therapy with deferoxamine is initiated Deferiprone is used in iron overload Iron Toxicity Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 20

Iron dextran (INFeD, Dexferrum)  May cause anaphylactic reactions, including major orthostatic hypotension and fatal anaphylaxis  Test dose of 25 mg of iron dextran is administered before injection of the full dose, and then remainder of dose is given after 1 hour  Used less frequently now; replaced by newer products ferric gluconate and iron sucrose Parenteral Iron Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 21

Ferric gluconate (Ferrlecit)  Indicated for repletion of total body iron content in patients with iron-deficiency anemia who are undergoing hemodialysis  Risk of anaphylaxis is much less than with iron dextran, and a test dose is not required  Doses higher than 125 mg are associated with increased adverse events, including abdominal pain, dyspnea, cramps, and itching Parenteral Iron Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 22

Classroom Response Question Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 23 The nurse has administered iron intravenously to a patient. To prevent orthostatic hypotension, it is recommended that the nurse have the patient remain in the recumbent position for how long? A.10 minutes B.30 minutes C.60 minutes D.90 minutes

Water-soluble, B-complex vitamin Essential for erythropoiesis Primary uses  Folic acid deficiency  During pregnancy to prevent neural tube defects Malabsorption syndromes are the most common cause of deficiency Folic Acid Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 24

Should not be used until actual cause of anemia is determined May mask symptoms of pernicious anemia, which requires treatment other than folic acid Untreated pernicious anemia progresses to neurologic damage Folic Acid (cont’d) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 25

Classroom Response Question Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 26 The use of folic acid to prevent fetal neural tube defects should be started: A.during a woman’s adolescence. B.at least 1 month before pregnancy. C.when a pregnancy is first discovered. D.at the beginning of the last trimester of pregnancy.

Cyanocobalamin (Vitamin B 12 ) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 27 Used to treat pernicious anemia and other megaloblastic anemias Administered orally or intranasally to treat vitamin B 12 deficiency Usually administered by deep intramuscular injection

Assess patient history and medication history, including drug allergies Assess for potential contraindications Assess baseline laboratory values, especially Hgb, Hct, reticulocytes, others Obtain nutritional assessment Nursing Implications Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 28

Ferrous salts are contraindicated in patients with ulcerative colitis, PUD, liver disease, and other GI disorders Keep away from children because oral forms may look like candy Iron dextran is contraindicated in all anemias except for iron-deficiency anemia Nursing Implications (cont’d) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 29

For liquid iron preparations, follow manufacturer’s guidelines on dilution and administration Instruct patient to take liquid iron preparations through a straw to avoid staining tooth enamel Nursing Implications (cont’d) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 30

Oral forms of iron should be taken between meals for maximum absorption, but may be taken with meals if GI distress occurs Oral forms should be given with juice, but not with milk or antacids Nursing Implications (cont’d) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 31

Patients should remain upright for 15 to 30 minutes after oral iron doses to avoid esophageal corrosion Patients should be encouraged to eat foods high in iron/folic acid Nursing Implications (cont’d) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 32

For iron dextran, a small test dose should be given  After 1 hour, if no reaction, the remainder of the dose can be given  Administer deeply into a large muscle mass using the Z-track method Nursing Implications (cont’d) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 33

For IV doses of iron dextran, give carefully according to manufacturer’s instructions Have resuscitative equipment available in case of anaphylactic reaction Nursing Implications (cont’d) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 34

Determine cause of anemia before administering folic acid Administer oral folic acid with food Folic acid may also be given IV and added to total parenteral nutrition solutions Nursing Implications (cont’d) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 35

Monitor for therapeutic responses  Improved nutritional status  Increased weight, activity tolerance, well-being  Absence of fatigue Monitor for adverse effects Nursing Implications (cont’d) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 36

Classroom Response Question Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 37 Which action does the nurse perform when administering iron intravenously? A.Premedicate the patient with an antihistamine to prevent anaphylaxis B.Administer the iron with a running dextrose solution C.Flush the intravenous line with 10 mL of normal saline D.Have available Regitine to reverse vasoconstriction at the site should infiltration occur