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Chapter 54
Anemia Drugs
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Hematopoiesis
Formation of new blood cells
Red blood cells (RBCs)
White blood cells (WBCs)
Platelets
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3. Hematopoiesis (cont’d)
RBCs
Manufactured in bone marrow
Immature RBCs are reticulocytes
Lifespan is 120 days
More than one third of an RBC is made of hemoglobin
Heme: red pigment, contains iron
Globin: protein chain
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Anemias
Maturation defects
Cytoplasmic
Nuclear
Excessive destruction of RBCs (hemolytic anemias)
Intrinsic RBC abnormalities
Extrinsic mechanisms
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10. Erythropoiesis Stimulating Agents
epoetin alfa (Epogen)
Biosynthetic form of the natural hormone erythropoietin
Used for treatment of anemia associated with end-stage renal disease, chemotherapy-induced anemia, and for anemia associated with zidovudine therapy
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11. Erythropoiesis Stimulating Agents (cont’d)
epoetin alfa (Epogen)
Longer acting form of epoetin called darbepoetin (Aranesp)
Contraindications: drug allergy, uncontrolled hypertension, head and neck cancers, risk of thrombosis
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12. Classroom Response Question
Before administering epoetin alfa to a patient in renal failure, it is most important for the nurse to assess which laboratory result?
BUN
White blood cell count
Hemoglobin level
Urine specific gravity
Correct answer: C
Rationale: Use of epoetin and darbepoetin is contraindicated in cases of uncontrolled hypertension and when hemoglobin levels are above 10 g/dL for cancer patients and 12 g/dL for renal patients. Use in patients with head or neck cancers or patients at risk for thrombosis is controversial as these medications increase tumor growth and risk for thrombosis.
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Iron
Essential mineral in the body
Oxygen carrier in hemoglobin and myoglobin
Stored in the liver, spleen, and bone marrow
Iron deficiency results in anemia
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Iron (cont’d)
Dietary sources: meats, certain vegetables and grains
Dietary iron must be converted by gastric juices before it can be absorbed
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15. Classroom Response Question
Which food will the nurse teach the patient to avoid when ingesting an iron supplement?
Eggs
Veal
Orange juice
Fish
Correct answer: A
Rationale: Although eggs are a common dietary source of iron, they should be avoided when ingesting oral iron preparations. The other foods enhance iron absorption.
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Iron (cont’d)
Some foods enhance iron absorption
Orange juice
Veal
Fish
Ascorbic acid
Some foods impair iron absorption
Eggs*
Corn
Beans*
Cereal products containing phytates
* Also common dietary sources of iron
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Iron (cont’d)
Supplemental iron may be given as a single drug or as part of a multivitamin preparation
Oral iron preparations are available as ferrous salts
ferrous fumarate (Femiron), ferrous gluconate, ferrous sulfate (FeSO4)
Parenteral
iron dextran (INFeD, Dexferrum)
iron sucrose (Venofer)
ferric gluconate (Ferrlecit)
ferumoxytol (Feraheme)
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Iron: Indications
Prevention and treatment of iron-deficiency syndromes
Administration of iron alleviates the symptoms of iron-deficiency anemia, but the underlying cause of the anemia should be corrected
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Iron: Adverse Effects
Most common cause of pediatric poisoning deaths
Causes nausea, vomiting, diarrhea, constipation, and stomach cramps and pain
Causes black, tarry stools
Liquid oral preparations may stain teeth
Injectable forms cause pain upon injection
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Iron Toxicity
Symptomatic and supportive measures
Suction and maintenance of the airway, correction of acidosis, control of shock and dehydration with intravenous fluids or blood, oxygen, and vasopressors
In patients with severe symptoms of iron intoxication, such as coma, shock, or seizures, chelation therapy with deferoxamine is initiated
Deferiprone is used in iron overload
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Parenteral Iron
Iron dextran (INFeD, Dexferrum)
May cause anaphylactic reactions, including major orthostatic hypotension and fatal anaphylaxis
Test dose of 25 mg of iron dextran is administered before injection of the full dose, and then remainder of dose is given after 1 hour
Used less frequently now; replaced by newer products ferric gluconate and iron sucrose
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Parenteral Iron
Ferric gluconate (Ferrlecit)
Indicated for repletion of total body iron content in patients with iron-deficiency anemia who are undergoing hemodialysis
Risk of anaphylaxis is much less than with iron dextran, and a test dose is not required
Doses higher than 125 mg are associated with increased adverse events, including abdominal pain, dyspnea, cramps, and itching
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23. Classroom Response Question
The nurse has administered iron intravenously to a patient. To prevent orthostatic hypotension, it is recommended that the nurse have the patient remain in the recumbent position for how long?
10 minutes
30 minutes
60 minutes
90 minutes
Correct answer: B
Rationale: It is recommended that the patient remain recumbent for 30 minutes after an intravenous injection of iron to prevent drug-induced orthostatic hypotension.
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Folic Acid
Water-soluble, B-complex vitamin
Essential for erythropoiesis
Primary uses
Folic acid deficiency
During pregnancy to prevent neural tube defects
Malabsorption syndromes are the most common cause of deficiency
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Folic Acid (cont’d)
Should not be used until actual cause of anemia is determined
May mask symptoms of pernicious anemia, which requires treatment other than folic acid
Untreated pernicious anemia progresses to neurologic damage
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26. Classroom Response Question
The use of folic acid to prevent fetal neural tube defects should be started:
during a woman’s adolescence.
at least 1 month before pregnancy.
when a pregnancy is first discovered.
at the beginning of the last trimester of pregnancy.
Correct answer: B
Rationale: It is recommended that administration of folic acid begin at least 1 month before pregnancy and continue throughout early pregnancy to reduce the risk for fetal neural tube defects.
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27. Cyanocobalamin (Vitamin B12)
Used to treat pernicious anemia and other megaloblastic anemias
Administered orally or intranasally to treat vitamin B12 deficiency
Usually administered by deep intramuscular injection
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Nursing Implications
Assess patient history and medication history, including drug allergies
Assess for potential contraindications
Assess baseline laboratory values, especially Hgb, Hct, reticulocytes, others
Obtain nutritional assessment
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29. Nursing Implications (cont’d)
Ferrous salts are contraindicated in patients with ulcerative colitis, PUD, liver disease, and other GI disorders
Keep away from children because oral forms may look like candy
Iron dextran is contraindicated in all anemias except for iron-deficiency anemia
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30. Nursing Implications (cont’d)
For liquid iron preparations, follow manufacturer’s guidelines on dilution and administration
Instruct patient to take liquid iron preparations through a straw to avoid staining tooth enamel
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31. Nursing Implications (cont’d)
Oral forms of iron should be taken between meals for maximum absorption, but may be taken with meals if GI distress occurs
Oral forms should be given with juice, but not with milk or antacids
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32. Nursing Implications (cont’d)
Patients should remain upright for 15 to 30 minutes after oral iron doses to avoid esophageal corrosion
Patients should be encouraged to eat foods high in iron/folic acid
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33. Nursing Implications (cont’d)
For iron dextran, a small test dose should be given
After 1 hour, if no reaction, the remainder of the dose can be given
Administer deeply into a large muscle mass using the Z-track method
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34. Nursing Implications (cont’d)
For IV doses of iron dextran, give carefully according to manufacturer’s instructions
Have resuscitative equipment available in case of anaphylactic reaction
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35. Nursing Implications (cont’d)
Determine cause of anemia before administering folic acid
Administer oral folic acid with food
Folic acid may also be given IV and added to total parenteral nutrition solutions
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36. Nursing Implications (cont’d)
Monitor for therapeutic responses
Improved nutritional status
Increased weight, activity tolerance, well-being
Absence of fatigue
Monitor for adverse effects
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37. Classroom Response Question
Which action does the nurse perform when administering iron intravenously?
Premedicate the patient with an antihistamine to prevent anaphylaxis
Administer the iron with a running dextrose solution
Flush the intravenous line with 10 mL of normal saline
Have available Regitine to reverse vasoconstriction at the site should infiltration occur
Correct answer: C
Rationale: The appropriate nursing action when administering iron intravenously is to flush the intravenous line with 10 mL of normal saline prior to administering the iron.
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