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Iron deficiency anemia : 4A
Anemia associated with chronic diseases : 3A
Macrocytic (megaloblastic) anemia : 3A
Hemolytic anemia : 3A
Treatment of choice:
Orally administered iron supplements.
Iron is essential to normal human physiology.
Roles:
An essential component of proteins involved in oxygen transport.
Essential for the regulation of cell growth and differentiation.
Heme iron:
Derived from hemoglobin.
Found in animal foods that originally contained hemoglobin.
Absorbed better than nonheme iron.
Nonheme iron:
Found in plant foods.
Form of iron added to iron-enriched and iron-fortified foods.
Most dietary iron is nonheme iron.
Milligrams
Food % DV*
per serving
Chicken liver, pan-fried, 3 ounces 11.0 61
Oysters, canned, 3 ounces 5.7 32
Beef liver, pan-fried, 3 ounces 5.2 29
Beef, chuck, blade roast, lean only, braised, 3 ounces 3.1 17
Turkey, dark meat, roasted, 3 ounces 2.0 11
Beef, ground, 85% lean, patty, broiled, 3 ounces 2.2 12
Beef, top sirloin, steak, lean only, broiled, 3 ounces 1.6 9
Tuna, light, canned in water, 3 ounces 1.3 7
Turkey, light meat, roasted, 3 ounces 1.1 6
Chicken, dark meat, meat only, roasted, 3 ounces 1.1 6
Goals:
To supply sufficient iron to restore normal storage levels of iron, and
To replenish hemoglobin deficits.
Hemochromatosis
Genetic disease, affects 1 in 250 individuals of northern European.
Absorbs iron very efficiently excess iron organ damage such as liver
cirrhosis and heart failure.
Not diagnosed until excess iron stores have damaged an organ.
Individuals with blood disorders that require frequent blood transfusions are
also at risk of iron overload and are usually advised to avoid iron
supplements.
Very little iron is excreted from the body iron accumulate in body
tissues and organs when normal storage sites are full potential for iron
toxicity.
Indications:
Iron malabsorption, severe oral iron intolerance, and as a routine
supplement to total parenteral nutrition.
Drugs:
Desferrioxamine (DFO, Desferal)
Rapid renal excretion and poor absorption in the gut requires
continuous intravenous infusion or daily intramuscular injections.
Deferiprone (Ferriprox) and deferasirox (Exjade)
Longer half life than DFO Effective oral administration.
Mainly excreted in the urine but up to one-third is also
excreted in the stools.
It is usually given over 8–12 hours, 5–7 nights per week
using a battery operated pump.
Meta-analysis:
Treatment of mild and moderate anemia in chronic diseases
(cardiovascular diseases, renal failure, cancer) with transfusion of packed
RBC or administration of erythropoietin-stimulating agents harmful:
worsen clinical outcomes, higher mortality.
Darbapoetin alfa has been approved for use in patients with anemia
associated with chronic kidney disease.
Vit. B12 deficiency causes functional folate deficiency – the “Folate Trap”
Methionine synthase
Cause of deficiency:
Failure of the absorption of vit. B12 rather than dietary deficiency.
Result of failure of intrinsic factor secretion caused by autoimmune disease
(gastric atrophy destruction of parietal cells) or from production of anti-
intrinsic factor antibodies.
Clinical manifestation:
Megaloblastic anemia and neurological disorders (such as numbness and
tingling in the hands and feet).
Micrograms (mcg)
Food Percent DV*
per serving
Clams, cooked, 3 ounces 84.1 1,402
Liver, beef, cooked, 3 ounces 70.7 1,178
Breakfast cereals, fortified with 100% of the DV for
6.0 100
vitamin B12, 1 serving
Trout (fish), rainbow, wild, cooked, 3 ounces 5.4 90
Salmon, sockeye, cooked, 3 ounces 4.8 80
Trout (fish), rainbow, farmed, cooked, 3 ounces 3.5 58
Tuna fish, light, canned in water, 3 ounces 2.5 42
Cheeseburger, double patty and bun, 1 sandwich 2.1 35
Haddock (fish), cooked, 3 ounces 1.8 30
Breakfast cereals, fortified with 25% of the DV for
1.5 25
vitamin B12, 1 serving
Noted: Natural food sources of vitamin B12 are limited to animal foods
Age Male Female Pregnancy Lactation
0–6 months* 0.4 mcg 0.4 mcg
7–12
0.5 mcg 0.5 mcg
months*
1–3 years 0.9 mcg 0.9 mcg
4–8 years 1.2 mcg 1.2 mcg
9–13 years 1.8 mcg 1.8 mcg
14+ years 2.4 mcg 2.4 mcg 2.6 mcg 2.8 mcg
* Adequate Intake
Vitamin B12 is available for injection or oral administration.
Water soluble!
Excess vit. B12 will not result in greater retention of the vitamin,
and cleared rapidly from plasma into the urine.
No adverse effects have been associated with excess vit. B12
intake from food and supplements in healthy individuals.
The megaloblastic anemia that results from folate deficiency cannot be
distinguished from that caused by vitamin B12 deficiency, because of the
final common pathway of the major intracellular metabolic roles of the
two vitamins.
* Items marked with an asterisk (*) are fortified with folic acid as part of the Folate
Fortification Program.
Males and Females
Age Pregnancy (μg/day) Lactation (μg/day)
(μg/day)
1–3 years 150 N/A N/A
4–8 years 200 N/A N/A
9–13 years 300 N/A N/A
14–18 years 400 600 500
19+ years 400 600 500
*1 DFE (Dietary Folate Equivalent) = 1 μg food folate = 0.6 μg folic acid from
supplements and fortified foods
Form of marketed folic acid:
Oral tablets containing 0.4, 0.8, and 1 mg
pteroylglutamic acid.
Aqueous solution for injection (5 mg/ml).
In combination with other vitamins and minerals.
Oral folic acid usually is not toxic.
Even with doses as high as 15 mg/day, there have been no substantiated
reports of side effects.
Folic acid supplements can correct the anemia associated with vitamin B12
deficiency, but will not correct changes in the nervous system due to vit.
B12 deficiency.
A 12-year-old girl accompanied by her mother arrives at clinician’s office
with a chief complaint of pale. Patient also feels tired and sleepy easily at
school.
1 week ago, patient had heavy bleeding during her first menstrual period
(replace 3-4 pads/day) for 5 days.
Patient comes from poor family so that she does not eat regularly.