1. Drug treatment of iron deficiency
anemia

2. What is anaemia ?
• Definition:
• Erythropoeisis :
• Causes: Anemia occurs when balance between
production and destruction of RBC`S is disturbed
by
– Blood loss ( acute or chronic)
– Impaired red cell formation due to
• Deficiency of essential factors (iron, vitamin B12 )
• Bone marrow depression
• Erythropoietin deficiency
– Destruction of RBC`S ( hemolytic anemia)
• Types of Anemia

3. Iron deficiency anemia
– Hemoglobin = Haem + Globin
– Haem = Ferrous Iron (Fe2+) chelated between
porphyrin rings and globin chain
– When iron is inadequate small erythrocytes with
insufficient hemoglobin are formed giving rise to
microcytic hypochromic anemia
• Clinical features
Pallor, fatigue, dizziness, exertional dyspnoea
• Total body content of iron
3.5 to 4 gm in adult male , 2.5 gm female

4. • Daily requirement of iron
– Adult male 0.5 to 1 mg
– Menstruating female 1-2 mg/ day
– Pregnancy 3-5 mg/day
– Infant 60 µg/Kg
– Children 25 µg/Kg
• 5- 10 % of the dietary iron is absorbed
• 1 molecule of hemoglobin = 33% iron
• 1ml blood loss= 0.5 mg iron loss
• Dietary sources of iron

5. Dietary sources of iron
• Rich :liver,egg yolk,dry beans,dry
fruits,wheat germ,yeast
• Medium:meat,chicken,fish, spinach,
banana, apple
• Poor:milk and its products,root
vegetables

6. • Haeme iron is better absorbed, but
forms a smaller fraction of the
dietary iron(6%).
• Dietary iron :Haeme or non haeme
/Inorganic iron
• Non haeme iron and iron in inorganic
form is present as ferric iron must be
first reduced to ferrous iron .

7. • Pharmacokinetics
• Dietary iron mostly in the ferric form (Fe3+)
In the stomach Fe3+ Fe2+
In the mucosal cells Fe2+ Fe3+ Apoferritin
Ferritin ( Stored)
Iron slowly released
In the plasma Fe2+ Fe3+ + Transferrin
Iron bound transferrin
Transfers iron to
bone marrow , Liver , Spleen ( Stored)

8. • Iron excretion
– Tenaciously conserved in body 0.5 to 1 mg
excreted
– Intestine , Bile and sweat
– Menstrual blood loss 0.5 to 1 mg/ day
– Milk 1.5 mg appears in milk daily during lactation

9. Factors affecting iron absorption
– Facilitated by
• Acidic pH of stomach ,
• Ascorbic acid
• Cysteine by reducing ferric to ferrous form
– Inhibited by
• Excess phosphates, oxalates, Phytates
• Milk, antacids, tetracycline ↓ iron absorption
by forming insoluble complexes.

10. Iron preparations can be given in 2
routes
– Orally
– Parenterally

11. ORAL IRON THERAPY
 These preparation are mostly available as
ferrous(Fe+2) and some in ferric(Fe+3)form
 Ferrous salt are better absorbed than ferric
salts

12. – Oral
1. Ferrous sulphate: 200 mg tab contains 20 –
32% iron
2. Ferrous gluconate : 300 mg tab contains 12%
elemental iron
3. Ferrous fumarate: 200 mg tab ( 33%)
4. Colloidal ferric hydroxide: 200 mg tab (50%)
• Other oral preparations are ferrous choline
citrate , ferric ammonium citrate , iron
calcium complex, iron hydroxy polymatose.

13. Iron is poorly absorbed in the form of
carbonate, citrate and pyrophosphate, colloidal
iron and iron carbohydrate complex
FORMS
•Tablets, capsules
•Sugar coated & uncoated tablets
•Slow release tabs & chewable tabs
•Drops &syrups—used by children's

14. • Dosage :
– 200 mg of elemental iron in three
divided doses produces maximal
haemopoietic response
–Prophylactic dose is 30 mg daily
–Absorption better on empty stomach
but side effects more

15. • Important points to remember
oElemental iron content and not quantity
of iron compound per unit dose to be
considered
oSustained released preparations
expensive and irrational
oLiquid formulations should be put on
back of tongue and swallowed

16. • Indications for iron therapy
– Prophylactic
• Pregnancy: 100 mg elemental iron 4 month onward
• Infancy and rapidly growing children
• Professional blood donors: 300 mg FeSo4 daily 1 month
• Menstruating women and following partial gastrectomy
– Therapeutic
• Nutritional deficiency anemia (↓ Intake, ↓absorption)
• Anemia of infancy and pregnancy
• Anemia due to acute or chronic blood loss

17. • Response to oral therapy is considered as
satisfactory if Hb ↑ by 1 % per day (0.15 g %)
, with atleast 10 % (1.5 g % ) within 3 weeks
• Following oral iron normal Hb attained in 1- 3
months depending on initial Hb level but
therapy should be continued for 12 to 20
weeks after Hb levels return to normal in
order to replenish depleted stores

18. Causes of failure of oral iron therapy
• Incorrect Diagnosis
• Non compliance
• Continued blood loss
• Defective iron absorption
• Superimposed infection/Inflammation
• Underlying uremia or malignancy

19. Adverse reactions to oral iron
• Constipation is common than diarrhea
• Epigastric pain
• Vomiting
• Heart burn
• Metallic taste
• Nausea
• Staining of teeth.

20. Indications of parenteral therapy
• Oral iron is not tolerated
• Failure to absorb oral iron
• Non compliance to oral iron
• In presence of severe deficiency with
chronic bleeding
• Along with erythropoietin

21. Calculation for parenteral iron
• Parenteral iron therapy needs calculation of
total iron requirement of the patient
– Iron requirement (mg) =
4.4 X Body wt (Kg) X Hb deficit g/dL

22. Parenteral iron preparations
1. Iron dextran (Imferon): I.V/ I.M
2. Iron sorbitol citric acid complex: Only I.M
3. Iron carbohydrate complex : I.M
4. Sodium ferric gluconate: Recently approved
preparation for I.V use has much lower risk
of anaphylactic reaction than iron dextran

23. I.M therapy
• Iron dextran and iron sorbitol both contain 50
mg/mL recommended dose is 100 mg daily 2
mL on alternate days untill total required dose
is administered or maximum 2 g . To prevent
staining to skin given deep I.M in buttock
using z track technique

24. I.V Therapy
• Iron dextran after test dose 0.5 mL iron
dextran injected I.V over 5 to 10 min
• Total dose required diluted in 500 mL NS &
infused slowly over 6 to 8 hours under
supervision
• If required amount greater than 50 mL given
on two consecutive days

25. Comparative properties of iron dextran and iron sorbitol
Iron dextran Iron sorbitol
1. High molecular weight 1. Low molecular weight
2. I.M / I.V 2. I.M
3. I.M , 10 -30 % locally bound not 3. Not locally bound
available for immediate utilisation
4. Not excreted 4. 30 % excreted in urine
5. I.M absorbed through lymphatics 5. Absorbed directly in circulation
6. Not bound to transferrin 6. Bound to transferrin may saturate
it so very high free levels of iron in
blood will be attained so not suitable
for I.V administration
7. Taken up by macrophages and 7. Directly available
made slowly available to erythron

26. Adverse effects
• Intramuscular:
– Local pain at site , pigmentation of skin , sterile
abcess
– Systemic:
headache, fever, arthralgia, backache, tachycardia,
flushing hemolysis and collapse these effects are
probably due to excessive amount of free iron in
plasma
– Iron sorbitol may cause disorientation and
temporary loss of taste, urine turns black on
standing

27. Adverse effects
• Intravenous
– Systemic reaction of more severe form
– Anaphylactoid reaction can occur within minutes
– Severe chest pain , resp distress circulatory
collapse

28. Treatment of Acute iron poisoning
1. Stomach wash with 1% NaHCO3 to render it
insoluble and remove undissolved iron tablets
2. Desferrioxamine Mesylate 5 to 10 g in 100 mL
isotonic saline or calcium sodium edetate 35 to 40
mg/Kg to retard the absorption from GIT
3. Early replacement of fluids and electrolytes,
correction of metabolic acidosis and hypotension
by using RL and vasopressors
4. I.v desferrioxamine infusion
5. Diazepam and other anticonvulsants if epileptic

29. Desferrioxamine Mesylate
• Obtained from streptomyces pilosus
• Potent specific chelator of iron binds ferric iron to
form ferrioxamine a stable water soluble chelate
• Ferrioxamine is excreted 2/3 in urine and 1/3 in bile
colors urine reddish brown
• Removes iron from hemosiderin except that in bone
marrow
• Well tolerated rapid I.V may cause
hypotension, anaphylactic reactions and tachycardia
• Allergic reactions and cataract known with chronic
administration
• Contraindicated in renal disease anuria and pregnancy

30. • Uses of desferrioxamine
– Acute iron intoxication DOC
• I.M : 0.5 TO 1 g( 50 mg / kg repeat 4 to 12 hourly as
required
• I.V in shock: 10- 15 mg / Kg/ Hr Maximum 75 mg/ Kg in
a day till serum iron falls less than 300 µg/dL