Dr.

Mika L Tobing, SpPD-KHOM,FINASIM

Sub Bag Hematologi-Onkologi Medik
Bagian Ilmu Penyakit Dalam
FK UNDIP RS Dr. Kariadi

 Gangguan kronik yg sering dijumpai

1/3 s/d wanita sehat di USA cadangan besi
nol
10% dari jml ini menderita Anemia defisiensi
Fe

Tahapan Defisiensi Fe
Iron depletion (cadangan besi / - )
Iron deficiency (SI saturasi transferrin
rendah)
Iron deficiency Anemia

Intake yg non adekwat

Malabsorbsi
Perdarahan kronik (Chronic Blood Loss)
Hamil & menyusui
Hemolisis intravaskular & Hemoglobinuria
Kombinasi

Causes of true iron deficiency

Increased loss of iron
Bleeding
Menorrhagia
Gastrointestinal
Surgery
Trauma
Childbirth
Excessive phlebotomy
Blood donations
Factitious
Chronic hemoglobinuria
Mechanical heart valve hemolysis
Paroxysmal nocturnal hemoglobinuria

Decreased intake of iron

Dietary deficiency
Limited meat
Malabsorbtion
Sprue
Achlorhydria :
Gastric atrophy
Partial gastrectomy
Proton pump inhibitors
Inflammatory bowel disease
Increased utilization of iron
Pregnancy
Rapid growth

 Fe sintesis Hb eritropoesis
aktifitas sitokrom
Disfungsi neurologik
sekresi asam lambung
Atrofi mukosa mulut & lambung

 Gejala umum Anemia

Korelasi nilai Hb dgn gejala tidak jelas
Irritabilitas, nyeri kepala
Perlambatan respons neurologik
Pica

 Pucat, lidah licin & merah

Stomatitis, cheilitis angularis
Koilonychia
Perdarahan retina
Splenomegalia

Laboratorium
Anisositosis, ovalositosis ringan, sel target
Elongasi Elliptositosis Hipokromik (sel pensil)
Hipokromia progresif (MCH rendah)
Mikrositosis (MCV rendah)
Retikulosit rendah /

Laboratorium
Jumlah E, Hb, Ht
Trombositosis (50-75% penderita)
BMA :
- Selularitas & ratio ME bervariasi
- Sideroblast / nol
- Eritroblast kecil
SI : / normal
TIBC :
Serum Ferritin : < 10 mg/L

Laboratorium
Anamnesis & laboratorium
Bila dijumpai Chronic Blood Loss diperlukan
pemeriksaan endoskopik saluran cerna
Cause of Hypochromic Anemia

SI

TIBC

%Sat

BMSI

Iron Deficiency

-N

-N

-N

-N

-N

Thalassemias
Sideroblastic Anemias
Chronic disease

SI = Serum Iron, TIBC = Total Iron binding Capacity, Sat = Saturation

BMSI = Bone Marrow Storage Iron
* SI and TIBC occasionally normal in iron deficiency

Pengobatan
Oral Iron Therapy
Diet rendah tdk cukup
Aman & murah
Hindari hematinic ganda
Jgn diberikan bersama makanan, antasida, H2
antagonis
Diteruskan selama 12 bln sesudah Hb normal
Dosis total 150-200 mg besi elemental (1 tablet
sulfas ferron (325 mg) mengandung 65 mg
besi elemental)
Dosis 3 4 kali/hari 1 jam sebelum makan
Efek samping : Intoleransi gastrointestinal

Pengobatan
Parenteral Iron Therapy
Keadaan malabsorbsi
tidak kooperatif
Intoleransi thd preparat oral
Iron Dextran : berisi 50 mg besi elemental im / iv
Diteruskan selama 12 bln sesudah Hb normal
Hati-hati reaksi Anaphylaxis

Medications and foods that reduce iron absorption

Antacids (alkaline liquids, H2-blockers, proton pump
inhibitors)
Tetracyclines (especially doxycycline)
Pancreatic enzyme supplements
Biphosphonates
Cholestyramine
Calcium supplements
Tea
Dairy products
Phosphonates (vegetables)

Medications malabsorbed because of the

coadministration of iron

Quinolone antibiotics
Biphosphonates
Cefdinir
Levodopa, carbidopa, methyldopa
Thyroxine
Penicillamine
Mycohenolate mofetil
Zinc or copper salts

Intravenous iron supplements

FDA-approved dosing

AWP perdose*

Ferric gluconate complex in

sucrose (Ferrlecit; 12.5
mg/mL iron)

125 mg iron in 10 mL over

at least 10 minutes
or
Some dose plus 90 mL 0.9%
sodium chloride over 1 hour

$ 86

Iron sucrose (Venofer : 20

mg/mL iron)

100 mg iron in 5 mL into

dialysis line at 1 mL/min
or
Same dose plus 95 mL 0.9%
sodium chloride over at
least 15 minutes

$ 69

Average wholesale price (2003 Drug Topics Redbook)