Business Use

Business Use

Definisi Anemia

Penurunan jumlah massa eritrosit (red cell

mass) sehingga tidak dapat memenuhi
fungsinya untuk membawa oksigen dalam
jumlah yang cukup ke jaringan perifer
(penurunan oxygen carrying capacity).
Bervariasi tergantung umur, etnis,
ketinggian dan keadaan fisiologis.
 Business Use

Klasifikasi Anemia
Berdasarkan patofisiologi: Berdasarkan Morfologi Sel Darah
Merah:
Perdarahan yang akut ataupun kronis yang berlebihan sehingga terjadi MCV < 80 fl, MCH <27 pg
pengeluaran eritrosit yang berlebihan, maka jumlah eritrosit yang - Anemia defisiensi besi - Anemia akibat penyakit kronis
beredar dalam sirkulasi pun menjadi berkurang, sehingga terjadi anemia. - Thalasemia mayor - Anemia sideroblastik

anemia hemolitik autoimun dan non imun ( malaria), Penyebabnya bisa MCV 80-95 fl, MCH 27-34 pg
- Anemia pasca perdarahan akut - Sindrom mielodisplastik
berasal dari ekstrakorpuskuler dan intrakorpuskuler. - Anemia aplastic - Keganasan hematologik
- Anemia hemolitik didapat
- Anemia akibat penyakit kronis
- Anemia pada CKD

Insufisien : Defisiensi EPO; nutrient ( B12, asam folat, besi),

Myelosupresi (chemo/radioterapi); marrow fibrosis/infiltration ( Multiple MCV > 95 fl
MEGALOBLASTIK NON-MEGALOBLASTIK
myeloma, leukemia, Myelofibrosis). - Defisiensi asam folat - Penyakit hati kronik
- Defisiensi B12 - Hipotiroid
Inefectif eritropoesis : MDS, Anemia sideroblastic, Thalasemia, - Sindrom mielodisplastik
Defisiensi asam folat, B12
 Business Use

Klasifikasi anemia berdasarkan morfologi sel darah merah

 Business Use

Defisiensi besi
• Secara global, 50% anemia disebabkan oleh defisiensi besi
• Penyebab:
Meningkatnya • Pertumbuhan cepat masa bayi
kebutuhan besi dan remaja
• Kehamilan
• Terapi erythropoietin
Meningkatnya • Hilang darah kronis, infeksi
kehilangan darah cacing
• Menstruasi
• Hilang darah akut
• Donasi darah
• Flebotomi (Terapi polisitemia
vera)
Menurunnya • Diet yang tidak mencukupi
intake / absorbs • Malabsorbsi dari penyakit
besi (Crohn’s disease)
• Malabsorbsi dari operasi
Business Use
 Business Use

Klasifikasi anemia
Business Use
 Business Use

Klasifikasi anemia
 Business Use

Tatalaksana Anemia
• Terapi kegawatan (perdarahan, anemia gravisanemia heart disease)
o Hb <7 g/dL untuk pasien dengan hemodinamik stabil, asimtomatik
o Hb <8 g/dL untuk pasien menjalani operasi ortopedik, operasi jantung,
atau dengan penyakit kardiovaskular sebelumnya
o Hb <9-10 g/dL untuk pasien dengan penyakit coroner akut
• Terapi penyebab
• Terapi penyakit dasar
 Business Use

MANAGEMENT BESI
DEFISIENSI BESI FUNGSIONAL DEFISIENSI BESI ABSOLUT

↓ Saturasi Transferin
& Feritin Serum Adekuat ↓ Saturasi Transferin
& ↓ Feritin Serum

satT < 20% feritin serum > 100 ug/L satT < feritin serum < 100 ug/L (pasien non-
(pasien non-dialysis, CAPD) dialysis, CAPD) dan < 200 ug/L
dan > 200 ug/L (pasien dialisis) 20% (pasien dialisis)

• Terapi besi ada dalam 2 fase yaitu fase koreksi dan

fase pemeliharaan. Terapi besi fase koreksi bertujuan
untuk koreksi anemia defisiensi besi absolut.
• Dosis terapi besi fase koreksi 100 mg 2x per minggu,
saat HD, dengan perkiraan keperluan dosis total 1000
mg (10x pemberian).
 Business Use

Preparat besi oral

• Terapi pengganti besi: 200mg besi elemental perhari (3-
4 tablet besi) diberikan sepanjang hari
• Idealnya diminum saat perut kosong  beberapa makanan
menghambat penyerapan besi
• Tujuan: tidak hanya memperbaiki anemia, tapi membuat
simpanan besi setidaknya 0.5 – 1gr besi.
• Respon baik bila retikulosit:
1. Meningkat dalam 4-7 hari setelah mulai terapi
2. Mencapai puncaknya 1 – 1.5 minggu (hari ke-10)
3. Normal kembali setelah hari ke-14
4. Diikuti kenaikan Hb 0,15g/hari atau 2g/dl setelah
3-4 minggu
5. Hb menjadi normal setelah 4 – 10 minggu
 Business Use

Terapi besi parenteral

Indikasi:
1. Intoleransi terhadap pemberian besi oral
2. Kepatuhan obat yang rendah
3. Gangguan pencernaan (colitis ulseratif yang dapat
kambuh bila diberi besi)
4. Penyerapan besi tergangu (gastrektomi)
5. Kehilangan darah banyak, tidak cukup dikompensasi oleh
besi oral
6. Kebutuhan besi besar dalam waktu pendek (sebelum
operasi atau kehamilan trimester tiga)
7. Defisiensi besi fungsional relative akibat pemberian
eritropoietin (anemia gagal ginjal kronik atau anemia
penyakit kronik)
 Business Use

Terapi besi parenteral

Tujuan pemberian:
1. Mengembalikan kadar hemoglobin dan mengisi besi sebesar 500-
1000mg
2. Memberi besi parenteral dosis kecil berulang selama periode
yang berkepanjangan (pada pasien dialysis)
Jumlah zat besi yang dibutuhkan seorang pasien:
Berat badan (kg) x 2.3 x (15 – Hb pasien g/dL) + 500
atau 1000mg (untuk penyimpanan)
Nama Kandungan
Iron sucrose 200 mg
besi/infus
Ferumoxytol (Feraheme) 510 mg
besi/infus
Sodiun ferric gluconate 125 mg
(Ferrlecit) besi/infus
Low molecular weight (LMW) 1500 mg
iron dextran (InFed) besi/infus
Ferric carboxymaltose 750 mg
 Business Use

MANAGEMENT BESI
• Sebelum terapi ESA dilakukan maka harus dilakukan pemeriksaan status besi.
• Status besi dikatakan cukup sebagai syarat memulai terapi ESA bila saturasi transferin (satT)> 20 %
dan feritin serum > 100 ug/L (pasien pre-dialisis) dan > 200 ug/L (pasien dialisis). Bila ditemukan
defisiensi besi maka defisiensi besi haruslah dikoreksi terlebih dahulu.
• KDIGO 2012 merekomendasikan pada pasien anemia yang belum mendapat terapi besi maupun terapi
ESA, disarankan untuk diberikan terapi besi (trial therapy), secara IV pada pasien HD dan oral pada
PGK-ND dan PGK-PD selama 1-3 bulan, bila satT < 30% dan feritin < 500ng/mL. Terapi besi
percobaan tersebut juga disarankan pada pasien yang sudah mendapat ESA namun belum mendapat
terapi besi.
• Rute suplementasi besi bisa melalui parenteral maupun oral
• Indikasi Terapi besi oral : pada pasien PGK non-D dan PGK-PD dengan defisiensi besi.
• Indikasi Terapi besi parenteral : Pasien PGK yang sudah melakukan hemodialisis, jika setelah 3 bulan
saturasi transferin tidak dapat dipertahankan ≥ 20% dan/atau Feritin Serum ≥ 100 ng/ml.
 Business Use

TERAPI ESA pada ANEMIA PENYAKIT

• Terapi ESA dimulai
KRONIS
setelah identifikasi faktor lain yang memperberat anemia dan lakukan koreksi terlebih
dahulu. Selain ltu pastikan bahwa status besi cukup untuk memulai terapi ESA.
• Indikasi terapi ESA : bila Hb < 10 g/dl dan penyebab lain anemia sudah disingkirkan dan harus memenuhi syarat
yaitu tidak ada defisiensi besi absolute dan tidak ada infeksi yang berat.
• Cara kerja: melawan efek antiproliferasi dari sitokin pro-inflamasi yakni menekan
produksi TNF-α dan interferon-γ
• Efek samping: tekanan darah naik, konvulsi serebral/ensefalopati hipertensi,
komplikasi trombo-embolik, defisiensi besi, influenza-like syndrome
Darbepoetin

ESA alfa dan beta • 0.45 mcg/Kg/mgg

• 50 – 100 unit/Kg
• 2-3 mingu • 0.75 mcg/Kg/ 2 mgg

Target kenaikan Hb 1-1.5 g/dL per bulan

(PERNEFRI).

KDIGO 2012 merekomendasikan 1-2 g/dL/ bulan

pada koreksi anemia fase inisiasi/awal, dengan
HINDARI kenaikan Hb yang cepat > 2g/dL.
Business Use
 Business Use

Tatalaksana
Defisiensi kobalamin (B12)
• Enam suntikan vit. B12 (hydroxocobalamin atau
cyanocobalamin) 1.000 µg IM dengan interval 3 – 7 hari.
• Maintenance: 1.000 µg IM satu kali setiap 3 bulan
• Pada pasien pernicious anemia diberikan dosis oral
harian 1.000 – 2.000 µg sebagai terapi pengganti dan
maintenance
• Terapi anjuran: Perenteral sebagai terapi inisial
(terutama pada anemia berat atau adanya neuropati),
dilanjutkan vit. B12 oral dengan dosis rendah 50 µg
perhari sebagai maintenance
 Business Use

Tatalaksana
Defisiensi asam folat (B9)
• Pastikan tidak ada defisiensi kobalamin sebelum
pemberian asam folat
• Dosis oral 5 – 15mg asam folat setiap hari
• Terapi dilakukan selama 4 bulan, ketika semua sel darah
merah yang kekurangan folat sudah dieliminasi dan
digantikan dengan sel cukup folat
• Terapi asam folat jangka panjang ketika:
o Penyebab mendasar defisiensi tidak dapat diperbaiki
o Defisiensi mudah terulang (pada dialysis kronik atau
anemia hemolitik)
• Folinic Acid  bentuk stabil folat. Dapat diberikan IV
dan parenteral untuk
o Diberikan PO dan parenteral
o Untuk mengatasi efek toxic methotrexate atau
Case study Business Use

Clinical presentation and history

Mrs D, 34 years old Official employee
• Presents with fatigue, shortness of breath (particularly after activity),
intermittent headaches, and constipation.
• No fever, palpitations, weight loss, leg cramps, or rectal bleeding.
• Diagnosed with moderate IDA 1 week earlier and was prescribed an oral iron
supplement (ferrous sulfate 325 mg once daily). Experienced constipation
since starting therapy, affecting adherence to treatment.
• Lacto-vegetarian.
• Abnormal menstrual cycle, menometroragi +
• Experienced nose bleeds since her teenage years.
• No other known medical problems or history of allergies.
• Her mother had anemia during pregnancy.

IDA, iron deficiency anaemia.

 Business Use

Case study
Clinical assessment
• A complete blood count was done to reveal that she still had moderate
anaemia.

Laboratory results
 Haemoglobin: 7.6 g/dL
 Haematocrit: 29.4%
 Red cell distribution width: 18%
 Reticulocyte count: 3.36%
 Mean corpuscular volume: 78 fL
 Ferritin: 28 μg/L
 Leucocyte 9400 /mmk
 Platelet 210.000/mmk

IDA, iron deficiency anaemia.

 Business Use

Case study
Management recommendations
• Patient was provided nutritional advice.
o As she was a lacto-vegetarian, she was advised to include grains
and legumes in her diet.

• Due to patient’s intolerance to ferrous sulfate (gastrointestinal adverse

events), treatment was switched to a different oral iron supplement.
o Ferrous gluconate 324 twice daily.

IDA, iron deficiency anaemia.

 Business Use

Penyebab terbesar dari anemia adalah

kekurangan zat besi*1
Anemia karena kekurangan zat besi
(Iron Deficiency Anemia atau IDA)
menyumbangkan

62.6%

Dari seluruh kasus anemia di

1 dari 6 orang
17% Mungkin menderita
2013 secara global1
IDA.†1,2
*In 2013; †Statistic estimated by using number of IDA prevalent cases reported in Kassebaum et al. 2016 (1,208,360,100) divided by the global population in 2013 (7,210,581,976).
ID, iron deficiency; IDA, iron deficiency anaemia.
1. Kassebaum NJ et al. Hematol Oncol Clin North Am 2016;30:247–308; 2. Worldometer. World population by year. Available at: worldometers.info/world-population/world-population-by-year/
(accessed 25 October 2021).
 Business Use

Diagnosis ADB biasanya sulit karena banyak pasien tidak memiliki gejala yang
terlihat1

~40%
Penderita ADB tidak memiliki
gejala yang mengacu kepada
ADB1

For Health Care Professional Only

 Business Use

Gejala dan tanda ADB biasanya kurang jelas dan tidak spesifik1,2

Tanda yang terlihat: Gejala yang dapat dirasakan:

Pucat1 Kuku rapuh2 Cheilosis, Bibir Rambut Kelelahan1 Sakit kepala1 Nafas Susah
pecah pecah rontok2 pendek1 konsentrasi3
dan sariawan2

Pusing3 Tangan dan kaki Kelelahan3 Sulit tidur4 Rentan terkena

terasa dingin3 infeksi5

For Health Care Professional Only

 Business Use

WHO merekomendasikan suplemen besi oral untuk mencegah ADB pada

kelumpok orang yang memiliki risiko tinggi1–8
Kelompok masyarakat berikut direkomendasikan
diberikan suplemen besi oral harian atau intermiten
untuk mencegah ADB :

Remaja Ibu hamil Bayi

32% 49% 39%

Wanita usia
Anak-anak Ibu pasca produktif
27% melahirkan 18%
For Health Care Professional Only
 Business Use

ID / IDA is underdiagnosed and

underappreciated in women1
According to a recent survey about IDA conducted with
over 1,000 women between the age of 18–65:*1

51%
have experienced a
potential IDA symptom
in the last 12 months.1
31%
Women with IDA
had not discussed their
experienced a diagnosis
potential IDA symptoms with
delay of 3.9 years since
their healthcare provider.1
symptom onset.1

For Health Care Professional Only

 Business Use

Untreated ID / IDA can have serious medical

and societal consequences1–3

• Reduced growth • Adverse outcomes • Diminished physical • Increased frailty and

during childhood.1 of pregnancy for and work productivity decreased cognitive
both mothers and in adults.2 function in the elderly.3
• Impaired immune
newborns.2
function.1 • Increased risk of
morbidity and mortality.3
• Decline in cognitive
performance in
young children.2

For Health Care Professional Only

 Business Use

ID / IDA has detrimental consequences on the

function of several biological systems and organs1–
3

Biological systems and organs affected by ID / IDA

CNS Immune Cardiorespiratory Skin / hair Genitourinary GI tract

system

For Health Care Professional Only

 Micronutrients lain yang penting untuk
pembentukan darah yang sehat
Membantu dalam proses Folic Vitamin Membantu produksi
pematangan sel darah
merah2
acid B6 hemoglobin5

Antioksidan dan kofaktor untuk

enzim yang terlibat dalam Vitamin Micronutrient adaah Mendukung metabolisme
Copper
metabolisme dan imunitas3
C vitamin dan mineral
yang dibutuhkan
besi6

untuk memastikan
pembentukan dan
pengembangan sel
Memfasilitasi pembentukan Vitamin darah merah yang Menjaga proses sel yang
Manganese
sel darah merah yang sehat4
B12 sehat1
terlibat pada homeostasis
darah7

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 Dokter dan Apoteker dapat membantu manajemen efek
samping dari pemberian suplemen besi1

Meningkatkan Modifikasi makan2 Mengganti ke Mengganti sediaan Menggunakan

interval pemberian suplemen yang besi dari oral ke pelunak tinja*2
suplemen menjadi mengandung cairan2
2 hari sekali jumlah besi
(selang satu hari)2 elemental yang
lebih rendah2

For Health Care Professional Only

 Business Use

Management of ID / IDA
Algorithm

For Health Care Professional Only

 Business Use

A quick algorithm for the management of

patients with IDA1
IDA diagnosis

Determine cause
Diet, gastrointestinal symptoms, surgical history, or family
history of gastrointestinal malignancy

Treat for IDA

Initiate IV iron therapy
If patients cannot tolerate
oral iron therapy.
Initiate oral iron therapy

Improvement Monitor for improvement No improvement

Continue (oral) iron therapy Monthly monitoring of haemoglobin concentration Consider IV iron/transfusion
If blood count normalises, and red blood cell indices Re-evaluate underlying cause
continue for another 3 months

For Health Care Professional Only

 Business Use

Clinical management algorithm for IDA in adult populations

Microcytic anemia

RBC count>5.0 x 106/μL β-thalassemia carrier

SF>100 ng/mL SF>100 ng/mL SF<30 ng/mL

TSAT 20–50% TSAT<20% TSAT<20%

CRP First-observation IDA Recurrent IDA

Identify Fragile pts Non-fragile pts Explained IDA Unexplained IDA

inflammation
disease
CKD
CHF Evaluate: Chronic infection by Autoimmune IRIDA
Elderly • Patient adherence to H.pylori and Giardia gastritis
sTfR IBD lambia
Hamp Identify and Fe suppl.
GI-OB
treat cause • Duration of Fe suppl. Hamp
IDA • AEs related to Fe Treat infection;
suppl. oral Fe suppl.
Functional ID
Hb>10–11 g/dL Hb<10 g/dL IV Fe suppl. IV Fe suppl.
Failure of oral Fe
Follow-up IV Fe suppl. if oral Fe suppl.; GI symptoms
Oral Fe suppl. IV Fe suppl. Oral Fe suppl. suppl. inadequate Consider IV suppl.

Follow-up Follow-up Follow-up Follow-up Follow-up Follow-up Follow-up

Figure adapted from De Franceschi L, et al.1

For Health Care Professional Only

 Business Use

Clinical management algorithm for ID/IDA in patients with CHF

CHF

If NYHA II–IV

Measure SF and TSAT, plus Hb

ID with or without anaemia

Normal Anaemia*
(SF<100 μg/L or TSAT<20%)

Anaemia after 1 year

or if signs of disease IV iron Assess and treat
progression

Figure adapted from Cappellini MD, et al.1

 Business Use

Clinical management algorithm for ID/IDA for patients with CKD

with non-dialysis or dialysis
Non-dialysis CKD Dialysis CKD

Measure SF and TSAT, Measure SF and TSAT,

plus Hb plus Hb

ID with or without anemia ID

Normal (SF<100 μg/L or IDA/anemia* Normal (SF<100 μg/L or IDA/anemia*
TSAT<20%) TSAT<20%)

Anemia after If IDA:

If IDA: IV iron first,
3 months or if signs of Oral or IV iron Oral or IV iron first, Assess monthly IV iron
then ESA therapy†
disease progression then ESA therapy†

Figure adapted from Cappellini MD, et al.1

For Health Care Professional Only

 Business Use

Clinical management algorithm for ID/IDA in

patients with IBD IBD

Measure SF and TSAT,

plus Hb and CRP or stool calprotectin

ID with or without anemia

Normal Anemia*
(SF<100 μg/L or TSAT<20%)

Anemia after 1 year or Symptoms Assess and treat

dependent on disease activity

Hb≤10 g/dL or Hb>10 g/dL and

active/advanced no active disease/
disease comorbidities

IV iron Oral iron

Figure adapted from Cappellini MD, et al.1

For Health Care Professional Only

 Business Use

Elderly with anaemia should be started on

low dose oral iron therapy1 Elderly

In the absence of any history of hemorrhage, IDA in older people is

sometimes related to diet but is usually a result of occult GI bleeding.
Common causes in this population include malnutrition, chronic NSAID
use or aspirin therapy, malignant conditions (colonic cancer or polyp,
gastric cancer), and IBD .

Start a smaller than the recommended amount of

elemental iron for adults to minimise side effects and
improve compliance.1

If the patient had reticulocytosis but no improvement

in anaemia after oral iron was started,*
IV iron therapy can be considered.1
*May be due to continued blood loss or insufficient iron
absorption.
IV, intravenous.
1. Smith DL et al. Am Fam Physician 2000;62:1565–72.
 Business Use

Clinical management of ID / IDA across

guidelines*:
Salient practice points

Diagnosis1 Treatment1 Treatment targets1

SF is diagnostic for ID Oral iron is the Hb 10–12 g/dL

first-line treatment for ID
TSAT is considered as an SF >100 or 200 μg/L
alternative or complementary IV iron is particularly SF <500 or 800 μg/L (CKD)
diagnostic test to SF considered in patients with
CKD and CIA TSAT 20–50%

*Based on guidelines issued by 29 professional associations from the United States (n=8), Europe (n=6), Britain (n=4), Canada (n=3), international
organizations (n=2), France (n=2), Poland (n=1), Australia (n=1), Mexico (n=1), and Japan (n=1).
CIA, chemotherapy-induced anaemia; CKD, chronic kidney disease; Hb, haemoglobin; ID, iron deficiency; IDA, iron deficiency anaemia; IV, intravenous; SF, serum
ferritin; TSAT, transferrin saturation.
1. Peyrin-Biroulet L,et al. Am J Clin Nutr 2015;102:1585–94.
 Business Use

Treatment of ID / IDA

For Health Care Professional Only

 Business Use

Oral and intravenous iron formulations are used

for IDA treatment

Oral iron
• First-line therapy for ID.1

Intravenous iron
• For patients with intolerance or inadequate response to oral iron.2
• First-line therapy for patients who need rapid increase in iron stores.2
• First-line therapy for patients with IBD or CHF.2

For Health Care Professional Only

 Business Use

Various oral and intravenous iron preparations

are currently available1–3

Iron Ferric
Ferrous Ferrous Ferrous
polymaltose sodium
fumarate gluconate sulfate
complex EDTA

Ferric Ferrous Iron Iron Ferric

Ferumoxytol
carboxymaltose gluconate sucrose isomaltoside saccharate

For Health Care Professional Only

 Business Use

Oral iron is taken up by enterocytes whereas

intravenous iron is taken up by circulating
monocytes1
Oral iron preparation
Absorption in duodenum and upper jejunum.1
• Fe2+ formulations: Absorbed directly by enterocytes.1
• Fe3+ formulations: Fe3+ is first reduced to Fe2+.1

Intravenous iron preparation

• Administered as high doses of iron directly in the bloodstream in
its trivalent Fe3+ form.1
• Fe3+ transported via bloodstream to target cells.1

For Health Care Professional Only

 Business Use

Characteristics of oral versus intravenous

iron1
Parameters Oral iron Intravenous iron

Absorption and • Comparatively lower • Not affected by inflammation

bioavailability iron absorption
• Affected by inflammation

Administration • Easy • Needs expertise

• Needs facility for cardiopulmonary
resuscitation
• May cause administration site reactions
• May cause fatal hypersensitivity reactions
• Recurrent dosing

Dosing • 3 times a day • Single high-dose or multiple

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 Business Use

Oral iron therapy can rapidly restore

haemoglobin levels1
Haemoglobin response rate in response
to oral iron therapy over time1

100%
90.0% 88.6%
90% 85.5% Oral iron improved haemoglobin levels,
80% 72.8% 75.1%
72.2% with near-maximal response rates
65.4%
70%
by Day 28.1
Percentage of patients

60%

50%
46.1% 45.7% 43.2%
40%
36.2%

30%
17.6%
20% Inadequate response to oral iron
10% supplementation can be determined
0% within 2 weeks of starting treatment.1
Day 14 Day 28 Day 42/56 Final assessment

Haemoglobin ≥1 g/dL Haemoglobin ≥2 g/dL Haemoglobin ≥ 3 g/dL

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 Business Use

Haemoglobin response to oral iron therapy

depends on the causes of anaemia and patient
characteristics1 Percentage of patients receiving oral iron supplementation who achieved
≥1.0 g/dL increases in haemoglobin at Day 141
100%

90% 95.5%
80%
Percentage of patients

70%

60%

50% 56.3% 53.5%

40%
42.9%
30%

20%

10%

0%
Postpartum anaemia Heavy uterine bleeding Gastrointestinal-related Other causes
causes
Cause of iron deficiency anaemia

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 Business Use

Compliance with oral iron therapy are

influenced by several factors1

Higher education level* Not experiencing side effects

This could be attributed to a
greater awareness on maternal
and foetal health, ANC utilisation Not worried of having a
and ability in decision making. large size of baby
Factors
associated with
Pregnant women with higher odds of Previously anaemic
spouses of older age
compliance

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 INACG / WHO merekomendasikan suplemen
besi untuk bayi dan anak kecil 1,2
Suggested scheme for iron supplementation in infants and young children aged 6–23 months1,2
Anaemia prevalence Amount Supplement form Duration

High
(≥40%)
10–12.5 mg
elemental iron* Syrup / drops
Daily
3 months
consecutively
Low
(>20%)
1 year
10–12.5 mg
elemental iron* Syrup / drops

Bayi memiliki kebutuhan suplemen besi yang tinggi karena pertumbuhannya yang
cepat.2 Bayi biasanya terlahir dengan cadangan besi yang cukup, namun di atas usia
6 bulan, cadangan besi biasanya tidak cukup untuk memenuhi kebutuhan bayi.
Sedangkan, makanan yang dikonsumsi biasanya memiliki kadar besi yang rendah.2

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 WHO merekomendasikan suplemen besi untuk
anak usia pra-sekolah dan usia sekolah1,2
Suggested scheme for iron supplementation in pre-school (24–59 months) and school age children (5–12 years)1,2
Anaemia prevalence Age Amount Supplement form Duration

High 24–59 mo 30 mg
(≥40%) Daily
Pre-school-age elemental iron Syrup / drops / tablets 3 months
consecutively

5–12 yr 30–60 mg 1 year

School-age elemental iron Tablets / capsules

Low Weekly Restart weekly

(<40%) 24–59 mo 25 mg For 3 months* For 3 months*
Pre-school-age elemental iron Syrup / drops

5–12 yr 45 mg
School-age elemental iron Tablets / capsules 3 mo no supplementation

For Health Care Professional Only

 INACG / WHO merekomendasikan suplemen
besi untuk remaja dan anak-anak1–3
Suggested scheme for iron supplementation for adolescents and adults 1–3
Anaemia prevalence Age Amount Supplement form Duration

High
(≥40%) Daily
Adolescent 3 months
girls and 30–60 mg consecutively
adult women elemental iron* Tablets / capsules
1 year

Weekly Restart weekly

Low For 3 months* For 3 months*
(>20%) Adolescent
60 mg
girls and elemental iron
adult women 2.8 mg folic acid Tablets / capsules

3 mo no supplementation

For Health Care Professional Only

 WHO merekomendasikan suplemen besi
untuk wanita hamil dan menyusui1,3
Suggested scheme for iron supplementation in pregnant and postpartum women 1,2
Amount Duration Amount Duration

Pregnant 30–60 mg Daily Postpartum

women elemental iron*†
At 12 weeks or women
first antenatal care visit
0.4 mg folic acid
Daily / weekly
Duration of pregnancy
30–60 mg 6–12 weeks
elemental iron‡ after delivery

Weekly Once menses

At 12 weeks or first antenatal care visit has returned
Intolerant to
oral iron therapy or 120 mg
low prevalence of elemental iron*†
anaemia (<20%) 2.8 mg folic acid

Duration of pregnancy

Iron and folic acid is recommended for pregnant women to prevent

maternal anaemia, puerperal sepsis, low birth weight, and preterm birth.

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Jenis preparat zat besi

FERRAZONE/ IRON
FERROUS FERROUS FERROUS
SIFAT SODIUM POLYMALTOSE
SULFAT GLUKONA FUMARAT
FEREDETAT COMPLEX
T
Unsur Zat Besi
20% 12% 33% 14% 18%
(mg)

Garam Garam Garam Bentuk yang Senyawa zat

Jenis Zat Besi
Anorganik Organik Organik tidak menyatu besi non-ion

Penyerapan + ++ ++ +++ ++

Kemanjuran + + + + +

Tolerabilitas + + + ++ ++

Efek Terjadi lebih Lebih sedikit Lebih sedikit Lebih sedikit Lebih sedikit terjadi efek
Samping banyak iritasi terjadi iritasi dan terjadi iritasi dan terjadi iritasi dan samping yang merugikan
yang lambung dan sembelit sembelit sembelit secara signifikan
merugikan sembelit

+ : sama dengan ferrous sulfat; ++, +++ : lebih dari ferrous sulfat For Healthcare Professional Only
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Ferrous fumarate

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Ferrous fumarate in patients with peripartum anemia1

Ferrous fumarate had substantial improvements in hemoglobin and ferritin levels (P <
0.0001)1

Hemoglobin levels1 Serum ferritin levels1

110 106.5 g/dl 35 30.6 ng/ml
105 30
Hemoglobin (g/dl)

Ferritin (ng/ml)

P < 0.0001 25
100 P < 0.0001
91.4 g/dl 20
95
15 9.1 ng/ml
90 10
85 5
80 0
Baseline After 4 weeks of treatment Baseline After 4 weeks of treatment

1. Bhavi SB, et al. Intravenous iron sucrose v/s oral ferrous fumarate for treatment of anemia in pregnancy. A randomized controlled trial. BMC Pregnancy
Childbirth. 2017;17(1):137
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Ferrous fumarate in female adolescents with IDA1

Hemoglobin levels
12.6
12.4 g/dl
12.4
 Improvements in hemoglobin
Hemoglobin (g/dl)

12.2
levels within 3 months of 12.0 g/dl
12
treatment.1 11.8
11.5 g/dl
11.6
 Sustained improvements in
11.4
hemoglobin levels (3 months
11.2
after stopping treatment).1
11
Baseline 3 months of 3 months after
treatment stopping treatment

1. Jalambo M, et al. Effects of iron supplementation and nutrition education on haemoglobin, ferritin and oxidative stress in iron-deficient female
adolescents in Palestine: Randomized control trial. East Mediterr Health J 2018;24(6):560-568. For Healthcare Professional Only
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Ferrous fumarate is effective for patients who failed to

respond to iron polymaltose complex1-3

27 patients with iron deficiency 75 patients with iron deficiency

anemia failed to respond anemia failed to respond
to IPC for 4-52 weeks1,2 to IPC for 4-14 months1,3

Switched to ferrous fumarate Switched to ferrous fumarate

and responded within 4-13 and responded within 1-14
weeks1,2 months1,3

1. Santiago P. Ferrous versus ferric oral iron formulations for the treatment of iron deficiency: A clinical overview. Scientific World Journal
2012;2012:846824; 2. Mehta BC. Ineffectiveness of iron polymaltose treatment of iron deficiency anaemia. J Assoc Physicians India 2003;51:419-421; 3. IPC, iron polymaltose
Ruiz-Arguelles GJ, et al. Ineffectiveness of oral iron hydroxide polymaltose in iron-deficiency anemia. Hematology 2007;12(3):255-256. complex
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Ferrous fumarate is more tolerable than ferrous sulfate1

Incidence of gastrointestinal adverse events1

100% Ferrous fumarate Ferrous sulfate

80%
Incidence rate

60%
45%
39%
40% 30%
25%
20% 10% 13% 13%
0%
0%
Constipation Diarrhea Nausea Epigastric pain

Ferrous fumarate had lower rates of gastrointestinal adverse events than ferrous sulfate.1

1. Panicker NK, et al. Comparison of efficacy and safety profile of oral iron formulations in patients with iron deficiency anemia. Int J Pharm Sci Rev Res For Healthcare Professional Only
2016;41(2),Article No 46:248-252.
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Ferrous Gluconate

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Ferrous gluconate in premenopausal women with

severe iron deficiency anemia1
Significant improvements in hemoglobin and ferritin levels from baseline (P < 0.0001)1

Hemoglobin levels1 Serum ferritin levels1

12 11 g/dl 30 27.1 ng/ml
Hemoglobin (g/dl)

10 25
P < 0.0001 P < 0.0001
Ferritin (ng/ml)

7.6 g/dl
8 20
6 15 10.1 ng/ml
4 10
2 5
0 0
Baseline End of treatment Baseline After 3 months of
therapy

1. Tazeen FM, et al. The efficacy and safety of oral ferrous gluconate in premenopausal women with severe iron deficiency anaemia. Annals of Abbasi
Shaheed Hospital and Karachi Medical & Dental College 2017;22(1):5-11. For Healthcare Professional Only
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Ferrous gluconate was more efficacious than ferrous sulfate

in patients with secondary anemia1
Ferrous gluconate had higher daily
Iron utilization in ferrous gluconate was increases in hemoglobin levels than
1.5 times better than ferrous sulfate1 ferrous sulfate1
Iron utilization Mean daily hemoglobin increases
28.3
Iron utilization co-efficient

30
Rate of hemoglobin increase

10%
9%
25 8%
20 18.1 7%
6%
15 5%
4%
10 3%
5 2% 1.49% 1.02%
1%
0 0%
Ferrous gluconate Ferrous sulfate Ferrous gluconate Ferrous sulfate

1. Haler D. The therapeutic response of secondary anaemias to organic and inorganic iron salts. Br Med J1952;2(4796):1241-1243.
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Take home messages

• Jenis anemia yang paling umum ditemui adalah anemia defisiensi besi (ADB)
• Kekurangan zat besi pada ADB dapat diakibatkan oleh berbagai macam hal, seperti
kurang nutrisi, mens berlebihan, kehamilan, gangguan GIT, dan lainnya
• Suplementasi besi merupakan terapi simptomatik dari anemia kekurangan zat besi
• Pemberian suplementasi besi dapat diberikan setelah diagnosis ADB telah ditegakkan
• Berdasarkan anjuran WHO, suplementasi besi dapat diberikan sebagai pencegahan ADB
pada daerah yang prevalensinya > 40% (Indonesia merupakan salah satunya), yaitu 30-60
mg besi elemental selama 3 bulan berturut turut untuk remaja dan dewasa
• Ferrous fumarate dan ferro gluconate memiliki efikasi yang lebih baik serta efek samping
yang lebih dapat ditoleransi dibandingkan ferro sulfat
• Ferro fumarate efektif pada pasien yang gagal merespon terapi dengan Iron Polymaltose
Complex (IPC)
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