Treatment of Iron Deficiency Anemia

PO is recommended route (if tolerated)

Response begins in 7-10 days

Hgb will rise about 1 g/dL per week

Re-evaluate if Hgb does NOT ↑ by 2 g/dL in 3 weeks

Dosage of Elemental Iron for Treatment

of Iron Deficiency Anemia

200 mg daily (2 - 3 doses/day)

Take on empty stomach for max absorption

(↑ absorption with vitamin C)

GI AE may prevent patient from taking on empty stomach

Types of PO Fe Supplements

Ferrous Sulfate (Feosol®)

Ferrous Gluconate (Fergon®)

Ferrous Fumarate (Feostat®)

Polysaccharide-iron Complex (Niferex®)

Adverse effects of PO Fe Supplementation

Abdominal pain

Nausea

Dyspepsia/heartburn

Constipation

Dark stools

Drug Interactions with PO Fe Supplementation

Forms bonds (↓ absorption of other meds)

FQs, Tetracyclines, Phenytoin

Separate the interacting drug by 2-4 hours

Black Box for PO Fe Supplementation

Iron toxicity - severe toxicity may occur in overdose, particularly when ingested by children; iron is a leading cause of fatal poisoning in children; store out of children's reach and in child-resistant containers

Use of Parenteral Fe Supplementation

Iron deficiency anemia & unable to tolerate PO Fe or have failed PO Fe therapy (malabsorption)

Use of Iron Dextran (InFED) 50 mg/mL

Given as IV infusion or IM injection

IM injections: Z-track & staining of skin

Black box warning: test dosing for allergic reaction

Newer formulations of parenteral Fe supplements

Approved for anemia associated with CKD

Less adverse effects (allergenicity) but very expensive

Iron sucrose (Venofer)

Sodium ferric gluconate (Ferrlecit)

Treatment of vitamin B12 Deficiency

Vitamin B12 (Cyanocobalmin)

Route: PO, parenteral

PO: Poor absorption

Parenteral: complete absorption (works without intrinsic factor)

- Deep SQ injection, IM injection

- Dosing daily x 1 week, weekly, then monthly for life

Intranasal treatment of Vitamin B12 deficiency

Nascobal - vitamin B12 nasal spray 500 mcg/spray

Dosing & administration - Initial dose is one spray 500 mcg in ONE nostril once weekly

Response to treatment of vitamin B12 deficiency

Neurologic symptoms & megaloblastic cells

begin resolving within a few days & Hgb

levels begin to ↑ after 1 week of therapy

Adverse effects to treatment of vitamin B12 deficiency

Injection: injection site reaction, rash, pruritis

Nasal: rhinitis; nasal irritation

Use of PO Treatment of Folic Acid Deficiency

• Initial dose of 1 mg/day (malabsorption requires ↑ dosages)
• Response - Rapid resolution of symptoms & reticulocytosis
• Hgb begins to rise after about 2 weeks of therapy, do treatment for 2-4 months

Adverse effects and drug interactions of PO Folic Acid

for Folic Acid Deficiency

AEs: Allergic reactions, flushing, rash

DIs: Phenytoin (↓ phenytoin levels)

Drug-disease interaction: may obscure dx in

pernicious anemia (vitamin B12)

Parenteral Treatment of Folic Acid Deficiency

IM, IV, SubQ

Dosing of Erythropoietin Products

• Titrating schedule based labs & type/severity of anemia
• Hgb at least every 2 weeks with adjustment of dosing
• Patients should also be assessed for Fe deficiency anemia (adequate Fe stores are required)
• Discontinue: Hgb > 12 g/dL & restart if Hgb < 12 g/dL

Use of erythropoietin products for patients with CKD

Recommended to start CKD patients on treatment in the earlier stages of CKD

Slowed disease progression with initiation of earlier treatment