Drugs Used in The Treatment of Anemia: Prepared By: Dr. Ghazi Bamagous
Drugs Used in The Treatment of Anemia: Prepared By: Dr. Ghazi Bamagous
Hematopoiesis
Also called: hemopoiesis or hematogenesis or hemogenesis. It originated from: hemato which means blood + genesis which means development or generation. It is defined as the production of blood cells (RBCs, WBCs and platelets) from the undifferentiated stem cells.
The main components of the hemopoietic system are the blood, bone marrow, lymph nodes and thymus, with the spleen, liver and kidneys as important accessory organs.
Hemopoiesis produces over 200 billion new blood cells every day. It takes place mainly in the bone marrow.
It requires 3 essential nutrients: iron, vitamin B12 and folic acid with hematopoietic growth factors (i.e. proteins that regulate the differentiation of hematopoitic cells).
Inadequate supply of any of these agents leads to deficiency of functional blood cells e.g. anemia (deficiency of oxygen carrying erythrocytes), thrombocytopenia, and neutropenia.
Anemia
RBCs have the principal function of carrying oxygen. Their oxygen-carrying power depends on their hemoglobin content.
The most important site of formation of red blood cells in adults is the bone marrow, whereas the spleen acts as their graveyard.
Red cell loss in healthy adults is precisely balanced by production of new cells.
Types of Anemia
Classification depends on RBC size, hemoglobin content and microscopic examination of blood smear. Two famous types of anemia include: Hypochromic, microcytic anemia (small red cells with low hemoglobin; caused by iron deficiency).
Macrocytic anemia (large red cells, few in number; caused by vitamin B12 or folic acid deficiency).
Causes of anemia
1.
2.
Deficiency of nutrients necessary for hemopoiesis, most importantly: iron, folic acid, vitamin B12.
Depression of the bone marrow, caused by: toxins (e.g. drugs used in chemotherapy), radiation therapy, bone marrow diseases (e.g. leukaemias), reduced production of erythropoietin (e.g. chronic renal failure, rheumatoid arthritis). Excessive destruction of red blood cells (i.e. hemolytic anemia); this has many causes, including hemoglobinopathies (such as sickle cell anemia), adverse reactions to drugs, and inappropriate immune reactions.
3.
It is important to note that Anemia alone is not a diagnosis but needs further investigations to find out its underlying cause. Therefore, treatment of anemia consists of 2 parts:
1. Treatment the underlying cause (if possible) e.g. bleeding. 2. Providing the hematinic agents e.g. iron.
There is an estimated 500 million people with iron deficiency in the world. It takes the form of hypochromic microcytic anemia.
When heme binds with globin, forms hemoglobin that binds oxygen reversibly providing the way to deliver oxygen from the lungs to other tissues.
Therefore, iron deficiency leads to small erythrocytes with insufficient hemoglobin that results in hypochromic microcytic anemia.
Iron metabolism
The normal daily requirement for iron is approximately 5 mg for men, and 15 mg for growing children and for menstruating women. A pregnant woman needs between 2 and 10 times this amount because of the demands of the fetus and increased requirements of the mother. The average diet provides 15-20 mg of iron daily, mostly in meat. Iron in meat is generally present as heme. Nonheme iron in foods (is mainly in the ferric state) must be reduced to ferrous iron (Fe2+) before it can be absorbed by intestinal mucosal cells.
Regulation of iron absorption is a function of the intestinal mucosa, influenced by the body's iron stores. Iron absorption increases in response to low iron stores or increased iron requirements.
Indications of iron
The only indication of iron salts is the treatment of iron deficiency anemia (i.e. hypochromic microcytic anemia) that might take place as a result of:
1. Chronic blood loss: the common cause of iron deficiency anemia (e.g. with menorrhagia, hookworm, colon cancer). 2. Increased demand: (e.g. in pregnancy, lactation, growing children and during hemodialysis in patients with kidney disease).
Only trace amounts of vitamin B12 are normally lost in urine and stool. Because the normal daily requirements of vitamin B12 are only about 2 mcg, it would take about 5 years for all of the stored vitamin B12 to be exhausted and for megaloblastic anemia to develop if B12 absorption were stopped.
Once absorbed, vitamin B12 is transported to the various cells of the body.
Nutritional deficiency is rare but may be seen in strict vegetarians after many years without meat, eggs, or dairy products. Vitamin B12 deficiency leads to megaloblastic* macrocytic normochromic anemia, GI symptoms and neurological abnormalities.
The neurological syndrome associated with vitamin B12 deficiency usually begins with paraesthesias in peripheral nerves and weakness and progresses to spasticity, ataxia, and other central nervous system dysfunctions. Correction of vitamin B12 deficiency arrests the progression of neurological disease.
As there are large stores in the liver, the results of the deficiency can take a long time to become manifest.
Pernicious anemia
It is caused by gastric mucosal atrophy that leads to failure of intrinsic factor production and vitamin B12 deficiency. It is an autoimmune disease in which there is antibodies destruction of gastric parietal cells secreting intrinsic factor. Treatment: initial intramuscular injection of vitamin B12 is given daily for 2 weeks then once monthly for life. However, oral route can be used.
Unwanted effects do not occur with the treatment using vitamin B12.
Spina bifida
It is a developmental congenital disorder. Caused by failure of the fusion of the embryonic neural tube, usually in the lumbo - sacral region.
Treatment with folic acid is given to correct the anemia, restore normal serum levels and replenish body stores.
Treatment need to be continued until the cause of deficiency is removed or may continue life long in certain groups of patients. Usually there are no side effects of treatment associated with properly diagnosed folic acid deficiency.
Clinical note
Once a diagnosis of megaloblastic anemia is made, it must be determined whether vitamin B12 or folic acid deficiency is the cause. (Other causes of megaloblastic anemia are very rare.) This can usually be accomplished by measuring serum levels of the vitamins.