2. Haematinics These are substances required in the formation of blood, and are used for treatment of anaemias. Anaemia occurs when the balance between production and destruction of RBCs is disturbed by:  Blood loss (acute or chronic)  Impaired red cell formation due to:  Deficiency of essential factors, i.e. iron, vitamin B12, folic acid.  Bone marrow depression (hypoplastic anaemia)  Erythropoietin deficiency  Increased destruction of RBCs (haemolytic anaemia)

3. IRON Distribution of iron in body Iron is an essential body constituent. It is distributed into:  Haemoglobin (Hb) : 66%  Iron stores as ferritin and haemosiderin : 25%  Myoglobin (in muscles) : 3%  Parenchymal iron (in enzymes, etc.) : 6% Iron is stored only in ferric form, in combination with a large protein apoferritin. aggregates Apoferritin + Fe3+ → Ferritin → Haemosiderin (not reutilized) Parenchymal iron occurs as prosthetic group in many cellular enzymes—cytochromes, peroxidases, catalases, xanthine oxidase and some mitochondrial enzymes. Though, the primary reflection of iron deficiency occurs in blood, severe deficiency affects practically every cell.

4. Oral iron The preferred route of iron administration is oral. 1. Ferrous sulfate: (hydrated salt 20% iron, dried salt 32% iron) is the cheapest. It often leaves a metallic taste in mouth 2. Ferrous gluconate (12% iron) 3. Ferrous fumarate (33% iron) 4. Colloidal ferric hydroxide (50% iron) 5. Other forms of oral iron are:  Ferrous succinate (35% iron)  Iron choline citrate  Iron calcium complex (5% iron)  Ferric ammonium citrate (20% iron)  Ferrous aminoate (10% iron)  Ferric glycerophosphate  Ferric hydroxy polymaltose Dissociable ferrous (Fe2+) salts are better absorbed than ferric (Fe3+) salts.  The most important side effects of oral iron:  Gastric irritation  Constipation  Staining of teeth  Metallic taste These are claimed to be better absorbed and produce less bowel upset, but lower iron content. They are generally more expensive.

5. Parenteral iron Iron therapy by injection is indicated only when: 1. Oral iron is not tolerated: bowel upset is too much. 2. Failure to absorb oral iron:  Malabsorption  Inflammatory bowel disease  Chronic inflammation 3. Non-compliance to oral iron. 4. Severe deficiency with chronic bleeding. Adverse effects Local  Pain at site of injection,  Pigmentation of skin,  sterile abscess—especially in old and debilitated patient. Systemic  Fever,  headache,  joint pains  palpitation,  chest pain  An anaphylactoid reaction

6. Indications 1. Iron deficiency anaemia It is the most important indication for medicinal iron. Iron deficiency is the commonest cause of anaemia, especially in developing countries. The RBC are microcytic and hypochromic due to deficient Hb synthesis. Apart from nutritional deficiency, chronic bleeding from g.i.tract (ulcers, inflammatory bowel disease) is a common cause. Iron deficiency also accompanies repeated attacks of malaria and chronic inflammatory diseases. 2. Prophylaxis Later half of pregnancy and infancy are periods when iron deficiency will develop unless medicinal iron is supplemented.

7. VITAMIN-B12 Deficiency of vit B12 and folic acid, which are B group vitamins, results in megaloblastic anaemia characterized by the presence of large red cell precursors in bone marrow and their large and shortlived progeny in peripheral blood. Vit B12 = Cyanocobalamin – are complex cobalt containing compounds present in the diet.

8. Vit B12 deficiency Deficiency Vit B12 deficiency occurs due to: Symptoms: 1) Addisonian pernicious anaemia: is an autoimmune disorder which results in destruction of gastric parietal cells → inability to absorb vit B12. 2) Other causes of gastric mucosal damage, e.g. chronic gastritis, gastric carcinoma, gastrectomy, etc. 3) Malabsorption (damaged intestinal mucosa), bowel resection, inflammatory bowel disease. 4) Consumption of vit B12 by abnormal flora in intestine (blind loop syndrome) or fish tape worm. 5) Nutritional deficiency: is a less common cause; may occur in strict vegetarians. 6) Increased demand: pregnancy, infancy. Megaloblastic anaemia Glossitis, g.i. disturbances: damage to epithelial structures. Peripheral neuritis Mental changes—poor memory, mood changes, hallucinations, etc.

9. Uses 1. Treatment of vit B12 deficiency 2. Prophylaxis 3. Mega doses of vit B12 have been used in neuropathies, psychiatric disorders. Adverse effects Allergic reactions

10. FOLIC ACID Dietary sources: Liver, green leafy vegetables (spinach), egg, meat, milk. It is synthesized by gut flora, but this is largely unavailable for absorption.

12. FOLIC ACID Folate deficiency occurs due to: Manifestations of deficiency are: 1) Inadequate dietary intake 2) Malabsorption: especially involving upper intestine— coeliac disease, tropical sprue, regional ileitis, etc. 3) Chronic alcoholism: intake of folate is generally poor. 4) Increased demand: pregnancy, lactation, rapid growth periods, haemolytic anaemia. 5) Drug induced: prolonged therapy with anticonvulsants (phenytoin, phenobarbitone, primidone) and oral contraceptives—interfere with absorption and storage of folate. Megaloblastic anaemia Epithelial damage: glossitis, enteritis, diarrhoea, steatorrhoea. Neural tube defects, including spina bifida due to maternal folate deficiency. General debility, weight loss, sterility.

13. Uses 1. Megaloblastic anaemias due to: Nutritional folate deficiency Increased demand: pregnancy, lactation, infancy, during treatment of severe iron deficiency anaemia, haemolytic anaemias. Pernicious anaemia Malabsorption syndromes: Tropical sprue, coeliac disease, idiopathic steatorrhoea, etc. Antiepileptic therapy 2. Prophylaxis of folate deficiency 3. Methotrexate toxicity 4. To enhance anticancer efficacy of 5-fluorouracil (5-FU) Folinic acid is now routinely infused i.v. along with 5-FU, because it is required for inhibition of thymidylate synthase by 5-FU. Adverse effects Nontoxic Injections rarely cause sensitivity reactions.

14. ERYTHROPOIETIN Erythropoietin (EPO) is a hormone produced by peritubular cells of the kidney that is essential for normal erythropoiesis. Erythropoietin actions:  Stimulates proliferation of colony forming cells of the erythroid series.  Induces haemoglobin formation and erythroblast maturation.  Releases reticulocytes in the circulation. The recombinant human erythropoietin (Epoetin α, β) is administered by i.v. or s.c. injection has a plasma t½ of 6–10 hrs

16. Uses The primary indication for epoetin is anaemia of chronic renal failure which is due to low levels of EPO. Anaemia in AIDS patients. Cancer chemotherapy induced anaemia. Preoperative increased blood production for autologous transfusion during surgery. Adverse effects Increased clot formation Hypertensive episodes, Serious thromboembolic events Flu like symptoms