Pharmacological Treatment Options for Anemia, Iron Deficiency

Nicholas Tsourounis, PharmD Candidate 2007

Oral Iron Replacemement Parenteral Iron Replacement Therapy Erythropoesis Stimulating Androgens used in
Therapy Factors used in conjunction with Iron
conjunction with Iron Replacement therapy
Replacement therapy
Product • Iron-polysaccharide • Ferric Gluconate (Ferrlecit®) • Epoetin Alfa • Nandrolone
Availability Complex (Fe-Tinic • Iron sucrose (Venofer®) (Epogen®, Procrit®) (Durabolin®,
Deca-
Generic (Brand)
150® [OTC], Ferrex • Iron dextran (Dexferrum®, INFeD®) • Darbepoetin alfa Durabolin®)
150® [OTC], Hytinic® (Aranesp®) • Oxymetholone
[OTC], Niferex 150® (Anadrol®)
[OTC], Niferex®
[OTC], Nu-Iron 150®
[OTC])
• Ferrous Fumarate
(Femiron® [OTC],
Feostat® [OTC],
Ferretts® [OTC],
Ferro-Sequels®
[OTC], Hemocyte®
[OTC], Ircon® [OTC],
Nephro-Fer® [OTC])
• Ferrous gluconate
(Fergon® [OTC])
• Ferrous sulfate
(Feosol® [OTC], Fer-
Gen-Sol® [OTC], Fer-
In-Sol® [OTC], Fer-
Iron® [OTC],
Feratab® [OTC], Slow
Fe® [OTC])
Ferrous sulfate/ascorbate
(Fero-Grad 500® [OTC],
Vitelle®, Irospan®
[OTC])

Student Name, PharmD Candidate 2007 Pharmacotherapy Presentation – Pharmaceutical Care Rotation
University of Maryland School of Pharmacy Happy Harry’s Pharmacy Patient Care Center, Perryville, MD
Mechanism All aforementioned products are All aforementioned products are iron salts, which get Both Epoetin-alfa and Both Nandrolone and
of Action iron salts, which get incorporated into hemoglobin and increase the Darbepoetin-alfa cause Oxymetholone promote
incorporated into hemoglobin oxygen-carrying capacity of the blood. erythropoesis by stimulating anabolism, and promote the
and increase the oxygen- the division and differentiation production of erythropoetin and
carrying capacity of the blood. of erythroid progenitor cells IGF1. The end result is an
increase in hemoglobin and
RBC volume.
EFFICACY Both Epoetin-alfa and Both Nandrolone and
These products are indicated for All these products are inidcated for use in Darbepoetin-alfa are indicated Oxymetholone are indicated for
(Indication/Use, use in the prevention and for use in the treatment of use in the treatment of anemia
treatment of iron-deficiency
the treatment of microcytic, hypochromic anemia in patients with CRF, in of renal insufficiency, with or
Clinical Data
Support) anemias. anemia due to iron deficiency or blood loss, with or without dialysis. These without dialysis. These drugs
when oral therapy for these conditions drugs are being included since are being included since there
proves ineffective, or in dialysis patients. there drugs are usually given in drugs are usually given in
conjunction with iron conjunction with iron
replacement therapy if serum replacement therapy.
ferritin is <100mcg/mL and
transferrin saturation <20%
SAFETY Interactions: Interactions: Interactions: Interactions:
• False positive on fecal • Chloramphenicol may delay response to iron • EtOH consumption • may increase the effects of
(Major Drug occult blood test therapy decreases the effect of oral anticoagulants
Interactions, • Increased these drugs • may increase the effects of
Pre-cautions, absorption/effect when Precautions: insulin and oral
Contra- co-administered with • Use with caution in asthmatics, people with Precautions: antidiabetics
indications, >200mg vitamin C per hepatic impairment, or rheumatoid arthritis • Use with caution in • may increase the effects of
Adverse Effects, 30 mg elemental iron • Not recommended for children <4months old patients with a history ACTH and other adrenal
Pregnancy Risk • Co-administration of • Anaphylaxis can occur following of seizures, HTN, steroids
Category) iron and tetracyclines administration, possibly resulting in death angina, or CHF • increased hepatotoxicity of
decreases absorption of • A test dose is needed to determine whether • Use with caution in cyclosporine
both drugs anaphylaxis will occur patients with
• Iron decreases the porphyria Precautions:
absorption of Contraindications: • Discontinue use • monitor DM patients
fluoroquinolones, • Hypersensitivity to any component of the within 2 weeks of a closely
levodopa, methyldopa, formulation successful renal • may cause peliosis
and penecillamine • Hemochromatosis allograft hepatitis,
• Concurrent • Hemolytic anemia • Use with caution in hepatocellular
administration of • Anemias that are not due to iron deficiency patients at risk for carcinoma, changes in
antacids, dairy thrombosis blood lipids, and
products, H2 blockers, Adverse Effects: • Iron stores must be increase the risk of
and PPI’s may • Flushing monitored during atherosclerosis
decrease iron • Dizziness therapy • use in caution in
absorption • Fever elderly patients, they
• Chloramphenicol may Contraindications: may be at a greater risk
• N/V
• Hypersensitivity to of prostatic hyperplasia
Student Name, PharmD Candidate 2007 Pharmacotherapy Presentation – Pharmaceutical Care Rotation
University of Maryland School of Pharmacy Happy Harry’s Pharmacy Patient Care Center, Perryville, MD
 delay response to iron • Metallic taste human albumin, • use with caution in
therapy • HA mammalian cell- patients with epilepsy
• Staining of skin at site of injection derived products, or or cardiac, renal, or
Precautions: • chills polysorbate 80 hepatic disease
• Avoid in patients with • Diaphoresis (Darbepoetin) • may accelerate bone
peptic ulcer disease, • Athralgia • Uncontrolled HTN maturation, decreasing
ulcerative colitis, or • Urticaria height potential
enteritis Adverse Effects:
-these last 6 effects may be delayed up to 48 hours
• Avoid administering after IV administration, or 3-4 days after IM • HTN Contraindications:
continuously for >6 administration • HA • Those who have a
months unless patient • Anaphylaxis • Fever hypersensitivity to the
is continuously • Fatigue drug or any component
bleeding • Nausea of the formulation
• Avoid using in patients Pregnancy Risk category: C • Athralgia • Pregnant women
receiving frequent • Chest pain • Infants
blood transfusions • Asthenia • Those with carcinoma
• Avoid use in • Injection site pain of the breast or
premature infants until • MI prostate
vitamin E stores are
• CVA • Patients with nephrosis
repleted to avoid
• TIA
increase hemolysis Adverse Effects:
Contraindications • Epoetin-alfa - seizure
• Acne
• Hypersensitivity to any • Darbepoetin –
• Gynocomastia
active or inactive preipheral edema,
fluid overload, • Priapism
ingredient in the • Nausea
formualtion • Diarrhea
Pregnancy Risk category: C
• Hemochromatosis • Virilism
• Hemolytic anemia • Prostatic hyperplasia
• Peliosis hepatitis
Adverse Effects:
• Hepatic necrosis
• Stomach cramps
• Hepatocellular
• Nausea/vomiting
carcinoma
• Dark stools
• Suppression of clotting
• Constipation factors
• Heartburn • CAD
• Discolored urine • Peripheral edema
• Stained teeth • Electrolyte
abnormalities
Pregnancy Risk category: A
• Impotence
• Testicular
atrophy/dysfunction
• Clitoromegaly

Student Name, PharmD Candidate 2007 Pharmacotherapy Presentation – Pharmaceutical Care Rotation
University of Maryland School of Pharmacy Happy Harry’s Pharmacy Patient Care Center, Perryville, MD
 • Dyslipidemia
• Menstrual irregularity
• jaundice

Pregnancy Risk category: X

Therapeutic Class/Agents Therapeutic Class/Agents Therapeutic Class/Agents Therapeutic Class/Agents

Dosage & • Iron-polysaccharide Ferric Gluconate Epoetin-alfa – IV or SQ Nandrolone

Administration 1. tablets or elixir – 1. Adults – Test dose of 2mL diluted in 1. Pedicatrics – 50 1. Women, 50-100mg
Units/kg 3x/week Qweek
50 to 100mg BID NS 50mL over 60 minutes, 125mg 2. Men, 100-200mg
(Include renal 2. Adults – 50 to 100
and/or hepatic
2. capsules – 150 to elemental iron/10mL by IV infusion Units/kg 3x/week Qweek
adjustments) 300 mg QD or slow injection 3. Adjustments – 3. Pediatrics, 25-50mg
• Ferrous Fumarate 2. Pediatrics – 1.5mg/kg (max 125mg) Increase dose 25% if Qweek
1. prophylaxis - 60 to diluted in 25mL NS infused over 60 Hgb does not increase
by 2g/dL within 8 Oxymetholone – 1 to 5
100mg QDay minutes
weeks. Decrease dose mg/kg/day in one dose, max
2. In elderly – up to Iron sucrose 25% if Hgb increases dose 100mg/Day
200mg 3-4x/Day 1. during dialysis – 100mg 1-3x/week 1g/dL within a 2 week
3. Pediatrics – 4 to 6 2. PD patients – two 300mg infusions period.
mg/kg/day in 3 over 1.5 hours 14 days apart with one Darbepoetin-alfa – IV or SQ
divided doses 400mg infusion 14days later 0.45mcg/kg Qweek or
0.75mcg/kg QOweek, titrate to
• Ferrous gluconate 3. non-dialysis – 200mg slow infusion response.
1. prophylaxis – on 5 different days during a 2 week
60mg QDay period
2. Treatment - adults Iron dextran - administered IV bolus of
- 60mg BID to <1mL/min or diluted in 250-1000mL NS
QID infused over 1-6 hours
3. Treatment – 1. 0.5mL test dose should be given in adults,
pediatrics, severe – 0.25mL test dose in pediatrics
2. Fe Deficiency –
4 to 6 mg/kg/day in Dose=0.0476*LBW(kg)*(normal Hgb –
3 divided doses observed Hgb)+(1mL/5kgLBW up to 14mL)
4. Treatment – 3. Blood loss – Replacement Iron (mg) = blood
pediatrics, mild to loss mL’s * Hct
moderate – 3 4. Max dose – Pediatrics <10kg,
1mL.Pediatrics 10-50kg, 2mL. Adults
mg/kg/day QDay >50kg, 2mL.
or in 2 divided
doses
• Ferrous sulfate
Student Name, PharmD Candidate 2007 Pharmacotherapy Presentation – Pharmaceutical Care Rotation
University of Maryland School of Pharmacy Happy Harry’s Pharmacy Patient Care Center, Perryville, MD
 1. Prophylaxis –
300mg QDay
2. Treatment –
300mg BID to
QID, or 250mg ER
Qday to BID
• Ferrous
sulfate/ascorbate - One
525mg FeS/500mg Vit
C tablet QDay
Monitoring o Efficacy –
Monitor Hct, Hgb,
(Efficacy and
serum Fe, TIBC,
Toxicity
Parameters) reticulocyte count,
transferrin saturation,
serum ferritin, and
patient specific signs
and symptoms of
anemia
o Toxicity -
Gi irritation, stomach
ulcers, hematemesis,
lethargy, acidosis,
hepatic or renal
impairment, and
coma
Patient • Do not take within 2
Education hours before or 4 hours
after taking an antacid
• Do not take with
cereals, fiber-
containing foods, tea,
coffee, eggs, or milk
• Take with water or
juice on an empty
stomach
• To enhance absorption,
Student Name, PharmD Candidate 2007
University of Maryland School of Pharmacy
o Efficacy – Monitor Hct, Hgb, o Efficacy –
serum Fe, TIBC, reticulocyte count, Monitor Hct, Hgb,
transferrin saturation, serum ferritin, CBC with
and patient specific signs and differential,
symptoms of anemia reticulocyte count,
o Toxicity – anaphylaxis, transferrin
pulmonary edema, convulsions, saturation, serum
tachycardia, hematemesis, hepatic and ferritin, and patient
renal impairment, acidosis, lethargy, specific signs and
coma symptoms of anemia
(2x weekly, then 2-
4x monthly)
o Toxicity –
BP, polycythemia,
MI, CVA, TIA, seizures,
peripheral edema, fluid
overload
• You will need frequent blood tests while on • Do not take any new
this medication medications without
• If you have RA, you may have an increase in consulting prescriber
swelling or pain in your joints • If self-administering,
• Exercise caution while driving after follow exact
treatment because of some side effects directions for use
• Small meals, proper oral hygeine, and • You will require
lozenges or chewing gum may help with frequent blood tests to
nausea or metallic taste determine appropriate
• With any respiratory difficulty, acute GI dosage
problems, rapid heartbeat, yellowing of the • Do not change intake
Pharmacotherapy Presentation – Pharmaceutical Care Rotation
Happy Harry’s Pharmacy Patient Care Center, Perryville, MD
o Efficacy –
Hgb, Hct,
reticulocyte count
Q3months
o Toxicity –
LFT’s, BG, jaundice,
and blood lipids
Q6months, prostate
exam Qyear
• Do not take any new
medications unless
approved by prescriber
• Do not donate blood
for at least 1 month
following use
• Take as directed
• May cause nausea,
vomiting, and diarrhea
• May cause a myriad of
side effects (see above)
 try to take with a glass skin, or swelling of hands and feet, consult of dietary iron without
of orange juice physician consulting physician
• This medication will • Report
cause a false positive signs/symptoms of
on a fecal occult blood edema, swollen
test, which is a test extremities,
used to screen for respiratory difficulty,
colon cancer. Before or rapid weight gain
taking an FOBT, • If you experience
inform your physician severe HA, acute back
that you are on an iron pain, chest pain,
supplement. tremors, or seizure,
contact 911
Cost • Iron-polysaccharide – Ferric Gluconate - $688.00 Epoetin-alfa - $2,123.88 Oxymetholone - $1,178.45
(1-month) Darbepoetin - $3,584.36 Nandrolone - $83.96
Capsules - $8.93 - $17.86 Iron sucrose - $688.00
Elixir – $21.91 Iron dextran - $452.40
• Ferrous Fumarate –
$24.99
• Ferrous gluconate -
$5.99
• Ferrous sulfate -
$18.99
• Ferrous
sulfate/ascorbate - all
brands DC’ed
References Lexicomp Lexicomp Lexicomp Lexicomp
(Guidelines, Walgreens.com http://uuhsc.utah.edu/pharmacy/bulletins/venofer.html Walgreens.com Walgreens.com
Drug Info
Sources)

Student Name, PharmD Candidate 2007 Pharmacotherapy Presentation – Pharmaceutical Care Rotation
University of Maryland School of Pharmacy Happy Harry’s Pharmacy Patient Care Center, Perryville, MD