FARMAKOTERAPI

ANEMIA

SYIFA AYUDIA FINUZI

31116194
By James Sager – Oct 26, 2017
3D fARMASI
 OUTLINE

EPIDEMIOLOGI PATOFISIOLOGI ETIOLOGI DIAGNOSIS MANIFESTASI PENATALAKSANAAN

KLINIK TERAPI
Konsep Klinis
Definisi
01 Anemia didefinisikan sebagai berjurangnya produksi sel
darah merah karena rendahnya konsentrasi zat besi dalam
tubuh.

Penyebab
02 Asupan zat besi yang rendah, penyerapan zat besi yang
rendah, peningkatan kebutuhan zat besi, dan peningkatan
kehilangan zat besi

Diagnosis
03 Konsentrasi Hb adalah indikator utama dalam diagnosis
anemia

Terapi
04 Menurut American Family Physician, 2013
Toward Optiimize Practize, 2018
International Nutritional Anemia Consultative Group
(INACG), 1998
 EPIDEMIOLOGI
Asia Tenggara
Eropa
preSac: 85,1 PW: 85,6
preSac: 26,5 PW: 8,3 NPW: 85,4 SAC: 13,6
NPW:28 SAC: 9,3 Men: 4,1 E: 5,2
Men: 14,1 E: 8 All: 14,9
All: 22,9

Afrika
preSac: 76,7 PW: 53.8
NPW: 56,2 SAC: 47,1
Men: 34,3 E: 47,6
All: 58%

Afrika Western Pacifif

preSac: 74.6 PW: 65.8 preSac: 90,4 PW: 90,2
NPW: 61.4 SAC: 13.2 NPW: 96,9 SAC: 83.1
Men: 21.9 E: 0.0 Men: 96,2 E: 93,3
All: 40.7 All: 13,8

a P opulation groups: PreSAC , preschool-age children (0.00–4.99 yrs); PW , pregnant women (no age range defined); NPW , non-pregnant women (15.00–49.99
yrs), SAC , school-age children (5.00–14.99 yrs), Men (15.00–59.99 yrs), Elderly (≥60.00 yrs). (WHO, 2008)
Klasifikasi Anemia
 FATOFISIOLOGI

Anemia akibat kekurangan zat besi akan membatasi proses terjadinya eritropoiesis yaitu murni
karena kekurangan zat besi atau cadangan zat besi yang habis karena ketidakseimbangan antara penyerapan
dan pemanfaatan zat besi. Kekurangan zat besi saja sering dikaitkan dengan kelelahan dan RLS (restless legss
syndrom), sehingga pasien dapat bergejala tapi tanpa anemia. Ketidakseimbangan antara penyerapan dan
pemanfaatan zat besi menyebabkan anemia mikrositik dan hipokromik.
Kekurangan zat besi yang fungsional disebabkan oleh gangguan pelepasan zat besi ke sirkulasi
darah dari eritrosit, makrofag, atau hepatosit. Eritropoiesis yang dibatasi oleh zat besi akan menyebabkan
anemia berkembang dan eritrosit menjadi normositik atau mikrositik. Hal inilah yang menjadi dasar terjadinya
penyakit anemia kronis, dimana peradangan mengarah ke ekspresi hepsidin yanng berlebihan.
ETIOLOGI
CAUSE
Overt blood loss
gastrointestinal (GI)
Confirmed IDA but no overt
blood loss or history of GI
Frequent blood donor
No overt blood loss
ACTION
Refer for upper and lower GI investigations.
a. Refer for upper and lower GI investigations: all premenopausal women and/or women
with hysterectomy <50 years of age with GI symptoms; all postmenopausal females and all
males with/without GI symptoms.
b. Screen for celiac disease in all patients.
c. DO NOT use fecal blood testing (i.e., FIT) – it is of no benefit in the investigation of IDA.
NOTE: Contrast X-rays alone are not adequate investigations given many relevant GI
conditions could be missed.
a. Stop donation until iron stores return to normal.
b. Encourage donation at reduced frequency.
c. Recheck to ensure iron deficiency is corrected or if not corrected investigate further.
a. Those with signs or symptoms specific to a system e.g., bleeding from gastroenterological,
gynecological, urological source should be referred to the appropriate specialty.
b. Consider screening for von Willebrand’s in women and adolescents with menorrhagia.
c. Investigate for hematuria. If present, consistently or intermittently, additional
investigation should follow for:
- RBC in the urine indicative of GU bleeding
- Hemoglobinura (positive dipstick without RBC on micro) could be indicative of hemolysis
(Toward Optimize Practice, 2018)
MANIFESTASI KLINIK
(Toward Optimize Practice, 2018)
 Pasien yang menderita anemia defisiensi besi sering memiliki tanda dan gejala yang
tidak jelas dan biasanya asimptomatik sehingga sering tidak terdiagnosis.
Gejala defisiensi besi yang tidak spesifik tetapi umum yaitu:
1. kelelahan
2. Kelemahan
3. kesulitan berkonsentrasi
4. produktivitas kerja rendah akibat rendahnya pengiriman oksigen.
DIAGNOSIS
(Toward Optimize Practice, 2018)
TEST AND CUT-OFF VALUES
Hemoglobin (Hb)
<120 g/L females (>11 years old)
<135 g/L males (>14 years of age)
<125 g/L females (12-14 years old)
<115 g/L males (<12 years old)
PLUS ONE OR BOTH OF: IMPORTANT CONSIDERATIONS/CAVEATS OF THESE ADDITIONAL TEST RESULTS
Mean Corpuscular Volume
(MCV) <75 fl a. A decrease reflects advanced stage of iron deficiency.
b. Patients with iron deficiency anemia may present with a normal MCV therefore correlation with serum
ferritin is required.
c. Other common causes of low MCV include:
• Thalassemia trait: Hb is typically lower limit of normal and profound anemia is not present
• Anemia of inflammation: MCV is rarely <75
Ferritin
<30 μg/L male a. Gold standard test for diagnosing iron deficiency
<13 μg/L female b. Provides an indication of total body iron stores, but has limitations as it is an acute phase reactant and may
<10 μg/L male and female (<12 years old) be unreliable in patients with chronic disease or cancer.
c. In the setting of an inflammatory process, serum ferritin <100 suggestive of iron deficiency. However, an
upper limit, beyond which patients will not respond to iron replacement therapy, has not been established.

†Lab cut-offs are specific to detecting IDA only. These values should not be used to diagnose patients with iron depletion or other conditions. These reference
levels vary slightly depending on source. Use actual reference ranges, cut-off values, critical results as indicated by your local lab service provider.
Variasi Terkait Usia dalam Level Hemoglobin dan MCV
PENATALAKSANAAN TERAPI
Form Formulation Elemental Iron Adult dosage
Intravenous
Sodium Ferric gluconate Solution for Injection 12,5 mg per mL Berdasarkan berat dan
(ferlecit) jumlah perubahan
hemoglobin yang diinginkan
Iron Dextran Solution for Injection 50 mg per mL
Iron sucrose Solution for Injection 20 mg per mL
Ferumoxytol Solution for Injection 30 mg per mL
Oral
Fe Fumarat 324 mg tablet 106 mg Satu tablet dua kali sehari
Fe gluconate 300 mg tablet 38 mg 1-3 tablet 2 atau 3 kali
sehari
Fe sulfat 325 mg tablet 65 mg Satu tablet tiga kali sehari
* Elemental iron (mg) = 50 x [0,442 (tingkat hemoglobin yang diinginkan dalam g/L – kadar hemoglobin yang diamati
dalam g/L) X BB ideal + 0,26 (x BB ideal) ]2

Dosis fe pada orang dewasa 120 mg per hari untuk tiga bulan; dosis untuk anak-anak adalah 3-60 mg/kg per hari.

(American Family Physician, 2013)

Peningkatan hemoglobin 1 g per dL setelah satu bulan pengobatan menunjukkan respons yang memadai
terhadap pengobatan. Pada orang dewasa, terapi harus dilanjutkan selama tiga bulan setelah anemia diobati
untuk memungkinkan penyimpanan zat besi menjadi dapat terpenuhi kembali. Ketaatan terhadap terapi zat
besi oral dapat menjadi penghalang untuk pengobatan karena efek samping GI seperti epigastrik
ketidaknyamanan, mual, diare, dan sembelit. Efek-efek ini dapat dikurangi ketika zat besi dikonsumsi
bersamaan saat makan, tetapi penyerapannya dapat berkurang hingga 40 persen. Obat-obatan seperti
inhibitor pompa proton dan faktor-faktor yang menyebabkan hiposekresi asam lambung (mis., Gastritis
atrofi kronis, gastrektomi atau vagotomi baru-baru ini) berhubungan dengan berkurangnya penyerapan zat
besi dan tablet zat besi
Toward Optimize Practice, 2018
 Guidelines for Iron Suplement to Pregnant Women

International Nutritional Anemia Consultative Group (INACG), 1998

Guidelines for Iron Suplement to Children 6-24 months age

International Nutritional Anemia Consultative Group (INACG), 1998

Guidelines for Iron Suplement to Other Population Grup

International Nutritional Anemia Consultative Group (INACG), 1998

Guidelines for Iron and Folat Therapy to Treat Severe Anemia

International Nutritional Anemia Consultative Group (INACG), 1998

Monitoring
(Toward Optimize Practice, 2018)
IF PATIENT IS RESPONDING TO THERAPY IF PATIENT IS NOT RESPONDING TO THERAPY:
• Continue to monitor hemoglobin and Ferritin Reassess iron dosage, and ensure underlying cause has been
monthly/bimonthly to ensure levels remain within the normal addressed
range
• For school-aged children, treat for 3-4 months then stop as long
as all parameters have normalized (CBC, ferritin and iron
studies).

• Continue with iron supplementation for an additional 4-6 • If prescribed oral iron, rule out cause of poor response. If the
months (all patients) until Hgb/MCV and Ferritin normalize and cause is non-adherence and hemoglobin is not lower than 90g/L,
to replenish iron stores. try another oral formulation that may be better tolerated
Note: Non-adherence is the

• Once IDA has resolved and iron stores normalize, a low dose of
oral iron may be necessary for maintenance if there is an
ongoing need for additional iron (e.g., growth spurt,
menstruation, dietary habits).
Note: women with menses and ongoing IDA should be evaluated
for a bleeding disorder.
• If iron supplementation is discontinued consider repeating CBC,
iron studies and ferritin in 4-6 months.
• If there is not an adequate response to an appropriate oral
treatment dose for a three-month period, OR
• If the patient has not tolerated a trial of two different oral agents,
OR
• If hemoglobin continues to decline (e.g., <90 g/L)
- Adults: Initiate IV iron therapy (as per Appendix A algorithm).
- Pediatrics (<18 years old): refer to Pediatric Hematology

• Consider referral for dietary advice if IDA is primarily diet Refer to hematology if no response to IV iron and another cause for
related. the anemia is suspected.