1. 1 ANTI - ANEMIC DRUGS BY: Dr.Abdul latif Mahesar

2. 2 ANaEMIA Decrease Hemoglobinconcentration Decreased number of RBCs

3. 3 CAUSES 1. Blood loss (commonest cause) related to menstruation. 2. Increased demand as in growing children, child bearing,lactating women, succesive prgnacies 3.Deficiency of nutrients; malnutrition such as Iron, vitB12, folic acid, vitamin C, pyridoxine and others

4. 4 4. Reduced production or decreased response to erythropoietin (CRF, R. Arthritis, AIDS) 5. Haemolysis ( sickle cell disease) 6. Diseases of the bone marrow (aplastic anemia)

5. 5 A 70 kg man caontains 4 gm of iron. 65% of this is in heamoglobin Half of remaining is strored in liver,spleen and bone marrow as ferritin. Normal daily requirment is 5mg for men and 15 mg for woman and growing children.

6. 6 TYPES OF ANEMIA Examples: Iron deficiency anemia ---- microcytic, hypochromic Megaloblastic anemia ---- macrocytic, normochromic due to Vit. B 12 or Folic Acid deficiency Anemia due to decreased Erythropoietin as in chronic renal failure

7. 7 Treatment of Anemia Remove the cause Treat the cause Replacement of deficient agents

8. 8 ANTI-ANEMIC DRUGS Drugs effective in iron deficiency and other hypochromic anemias: Iron Pyridoxine, Riboflavin, Copper and others Drugs effective in megaloblastic anemia: Vitamin B 12 Folic Acid Hematopoietic growth factors: Erythropoietin

9. 9 IRON Preparations: Oral: Ferrous sulphate Ferrous gluconate Ferrous fumarate, etc. Parenteral: Iron dextran ---- i.m or i.v Iron Sorbitol ----- i.m only.

10. 10 Pharmacokinetics Absorption ---- depends on requirements iron stores Ferrous (Fe ++ ) / ferric (Fe +++ ) form pH (it has poor absorption in neutral PH) in stomach it binds to mucoproteins in presence of Vitamin C to get absorbed. Chelators or complexing agents Malabsorption syndrome

11. 11 Non haem iron is mainly in the form of ferric and this needs to be converted to ferrous to get absrobed. in cell the ferrous iron is changed to ferric iron Absorption of iron has main role to balance the body iron

12. 12 Pharmacokinetics (Contd.) Distribution: Transferrin A beta-globulin, transport iron in plasma, specifically bind ferric iron. Storage: Apoferritin + ferric hydroxide Ferritin, the storage form of iron in intestinal mucosal cells & cells of reticuloendothelial systems

13. 13 Pharmacokinetics (Contd.) Excretion: No mechanism for excretion of iron Small amounts --- lost by exfoliation of intestinal mucosal cells into stool. Trace amounts --- excreted in bile, urine, & sweat.

14. 14 Uses Prevention and treatment of iron deficiency anemia, as in: Pregnant, lactating, or menstruating women Growing children & adolescence Infants, especially premature infants Malabsorption ---- gastrectomy, severe small bowel disease Occult G.I. bleeding ----- G.I. Cancer Dietary deficiency

15. 15 Administration It is usually given orally but may be given parenterally in special circumstances

16. 16 Adverse effects of Oral iron therapy These are dose dependant Nausea, abdominal pain, & either constipation or diarrhea.

17. 17 Acute Oral toxicity (overdose ; poisoning) Usually occurs in children Necrotizing gastroenteritis with ---- vomiting, abdominal pain, bloody diarrhea ► Shock, lethargy & dyspnea ► Severe metabolic acidosis ► Coma ► Death

18. 18 Acute Oral toxicity (overdose ; poisoning): (Contd.) Treatment: ► Whole bowel irrigation ► Desferrioxamine (Deferoxamine) ► orally --- for Unabsorbed iron ► Parenteral ( i.m., i.v. ) --- for iron absorbed Desferrioxamine + ferric iron Ferrioxamine --- excreted in urine and bile.

19. 19 Acute Oral toxicity (overdose ; poisoning): (Contd.) These adverse effects should be treated as per requirment ► gastrointestinal bleeding ► metabolic acidosis ► shock

20. 20 Chronic iron toxicity (iron overload ) e.g., in: ► Hemochromatosis ► Hemolytic anemias ► Thalassaemia with tranfusional overload

21. 21 Chronic iron toxicity (iron overload): (Contd.) Hemosiderosis: a focal or general increase in tissue iron stores without associated tissue damage Hemochromatosis: associated with tissue damage

22. 22 Chronic iron toxicity (iron overload) (Contd.) Treatment: ► Intermittent Venesection (Phlebotomy)---- when there is no anemia ► Chelation (Desferrioxamine) ---- for transfusional overload

23. 23 Adverse effects of Parenteral iron therapy ► Local pain & tissue staining – (brown discoloration of tissue overlying the injection site). ► Headache, light-headedness, fever, arthralgias, ► nausea, vomiting, back pain, flushing, urticaria, bronchospasm, &, ► Rarely anaphylaxis & death

24. 24 FEATURES OF VITAMIN B12 DEFECIENCY Impairment of DNA synthesis affects all cells but most apparently RBCs. ► Megaloblastic Anemia ► GI symptoms ► neurologic abnormalities

25. 25 Vitamin B12 deficiency Neurological abnormalities : Degeneration of brain and spinal cord (Subacute combined degeneration ) and peripheral nerves. Symptoms may be psychiatric & physical. Paresthesia & weakness in peripheral nerves spasticity, ataxia, & other CNS dysfunction

26. 26 B12 deficiency is usually due decreased absorption either due to lack of intrinsic factor or condition that interfere with absorption in the terminal ileum such as chron’s disease or surgical removal

27. 27 VITAMIN B 12 Chemistry ► Porphyrin-like ring with a central cobalt atom & nucleotide. ► Cobalamins = various organic groups covalently bound to cobalt atom

28. 28 ► Vitamin B 12 available for therapeutic uses: Cyanocobalmin Hydroxycobalamin Hydroxycobalamin --- is preferred because it is highly protein-bound & therefore remains longer in the circulation.

29. 29 Cyanocobalamin, hydroxycobalamin & other cobalamin (found in food sources) are converted to active forms Deoxyadenosylcobalamin & methylcobalamin

30. 30 Pharmacokinetics ► Absorption: Intrinsic factor (IF) --- a glycoprotein, secreted by parietal cells of gastric mucosa IF-Vit.B 12 Complex --- absorbed by active transport in the distal ileum ► Transported in plasma bound to the glycoprotein transcobalamin II & is taken up by tissues where required & stored in hepatocytes

31. 31 Pharmacokinetics (Contd.) Route of administration ► Mostly ------ Parenteral ---- i.m. ► Oral ► Aerosol

32. 32 Pharmacokinetics (Contd.) Elimination: ► not significantly metabolized ► pass into bile ► Enterohepatic circulation ► Excreted via kidney

33. 33 Uses ► Pernicious (addisonian) anemia ► After partial or total gastrectomy ► Malabsorption syndromes ► Insufficient dietary intake

34. 34 Adverse effects Allergic hypersensitivity reactions Antibodies to hydroxycobalamin-transcobalamin II complex Arrhythmias secondary to hypokalemia

35. 35 FOLIC ACID (PTEROYLGLUTAMIC ACID; VITAMIN B 9 ) Is inactive Active form is ---- tetrahydrofolic acid

36. 36 Functions ► Is required for synthesis of Amino acids, purines, pyrimidines, & DNA ; & therefore in the cell division

37. 37

38. 38 Features of folic acid deficiency ► Mitotically active tissues such as erythroid tissues are markedly affected. ► Anemia ► Congenital malformations --- neural tube defects ( e.g., spina bifida) ► Vascular disease

39. 39 Pharmacokinetics ► Route of administration ----- usually oral ► In diet ---- Polyglutamate form ► For absorption ---- must be converted to --- Mono-glutamyl form and again converted to polyglyamuyl ► Absorbed mostly --- in proximal jejunum

40. 40 Pharmacokinetics (Contd.) ► Transported to tissues ---- bound to a --- plasma-binding protein ► Excreted --- in urine & stool ► Also destroyed by catabolism ► Hepatic reserves sufficient for only 1-6 months

41. 41 Uses Prevention & treatment of folic acid deficiency ► Dietary insufficiency (e.g. in elderly) ► Pregnancy & lactation ► to prevent --- Congenital malformations --- neural tube defects ( e.g., spina bifida) ► High red cell turn over --- e.g. in hemolytic anemias --- ►Premature infants ► Malabsorption syndromes

42. 42 Uses (contd.) ► Myelofibrosis ► Exfoliative dermatitis ► Rheumatoid arthritis ► Malignant disease, e.g., lymphoma ► Chronic hemodialysis

43. 43 Adverse effects ► Generally well tolerated ► Rarely --- ► G.I. Disturbances ► hypersensitivity reactions ► Status epilepticus may be precipitated

44. 44 Precautions / contraindications ► Undiagnosed Folic acid deficiency / megaloblastic anemia

45. 45 ERYTHROPOIETIN (EPOTEIN) ► a glycoprotein hormone ► produced : 90% --- by peritubular cells in kidney remainder --- by liver and other tissues ► is essential for normal reticulocyte production ► synthesis is stimulated by hypoxia ► synthesized for clinical use ---- by --- recombinant DNA technology

46. 46 Pharmacokinetics ►Route of administration --- S.C. or I.V. ►Plasma t 1/2 ---- 4 - 13 hrs in patients with chronic renal failure. ►Not cleared by dialysis

47. 47 Mechanism of action ►increases rate of stem cell differentiation ►increases rate of mitosis in red cell precursors, blast-forming units, colony forming cells. ►increases release of reticulocyte from marrow ►increases Hb synthesis ►its action requires adequate stores of iron

48. 48 Uses ►Anemia associated with chronic renal failure ►premature infants ►Anemia during chemotherapy of cancer ►Anemia of AIDS (which is exacerbated by zidovudine treatment) ►to increase the yield of autologous blood before donation ►Anemia of chronic inflammatory conditions such as rheumatoid arthritis ►MISUSED --- by sports people

49. 49 Adverse effects ► Usually due to excessive increase in hematocrit ►increase blood pressure ►thrombosis ►seizures ►headache ►hypertensive crises with encephalopathy-like symptoms ►clotting in dialyser

50. 50 Adverse effects ►Transient influenza-like symptoms ------ chills & myalgias ► iron deficiency ►transient increases in platelet count ►hyperkalemia ►skin rashes ►pure red cell aplasia --- discontinue the drug ►antibodies to epoetins

51. 51 Precautions / contraindications ►hypertension should be well controlled ► seizures ►thrombocytosis ►ischemic vascular disease ►iron, folic acid, vit. B 12 supplements may be needed ►heparin during dialysis

52. 52 Monitor ►hematocrit ►blood pressure ►platelet count ►serum potassium