Drugs used in hypoplastic, haemolytic, and renal anaemias 509

9.1.3 Drugs used in hypoplastic, haemolytic, and renal anaemias 509

9.1.4 Drugs used in platelet disorders 515

9.1 Anaemias and some other

9.1.5 G6PD deficiency

blood disorders

9.1.6 Drugs used in neutropenia

9.2 Fluids and electrolytes

9.1.1 Iron-deficiency anaemias

9.2.1 Oral preparations for fluid and

9.1.2 Drugs used in megaloblastic

electrolyte imbalance

anaemias

9.2.1.1 Oral potassium

9.1.3 Drugs used in hypoplastic,

9.2.1.2 haemolytic, and renal anaemias

Oral sodium and water

9.1.5 G6PD deficiency bl

Oral bicarbonate

ood 9.2.1.3 521

9.1.4 Drugs used in platelet disorders

9.2.2 Parenteral preparations for fluid

9.1.6 Drugs used in neutropenia

and electrolyte imbalance

and

n 9.2.2.1 Electrolytes and water

Before initiating treatment for anaemia it is essential to

9.2.2.2 Plasma and plasma substitutes

determine which type is present. Iron salts may be

9.3 harmful and result in iron overload if given alone to Intravenous nutrition 526

Nutritio patients with anaemias other than those due to iron

9.4 Oral nutrition

532 deficiency.

9 9.4.1 Foods for special diets

9.4.2 Enteral nutrition

9.1.1 Iron-deficiency anaemias

9.5 Minerals

9.5.1 Calcium and magnesium

9.1.1.1 Oral iron

9.5.1.1 Calcium supplements

9.1.1.2 Parenteral iron

9.5.1.2 Hypercalcaemia and hypercal- Treatment with an iron preparation is justified only in the ciuria

presence of a demonstrable iron-deficiency state. Before

9.5.1.3 Magnesium

starting treatment, it is important to exclude any serious

9.5.2 underlying cause of the anaemia (e.g. gastric erosion, Phosphorus 535 gastro-intestinal cancer).

9.5.2.1 Phosphate supplements

Prophylaxis with an iron preparation may be appropriate

9.5.2.2 Phosphate-binding agents

in malabsorption, menorrhagia, pregnancy, after subto-

9.5.3 Fluoride

tal or total gastrectomy, in haemodialysis patients, and

9.5.4 in the management of low birth-weight infants such as Zinc

preterm neonates.

9.5.5 Selenium

9.6 Vitamins

9.1.1.1 Oral iron

9.6.1 Vitamin A

9.6.2 Vitamin B group

Iron salts should be given by mouth unless there are

9.6.3 good reasons for using another route.

Vitamin C

Ferrous salts show only marginal differences between

9.6.4 Vitamin D

one another in efficiency of absorption of iron. Haemo-

9.6.5 Vitamin E

globin regeneration rate is little affected by the type of

9.6.6 Vitamin K

salt used provided sufficient iron is given, and in most

9.6.7 patients the speed of response is not critical. Choice of

Multivitamin preparations

preparation is thus usually decided by the incidence of side-effects and cost.

BNF 57

9.1.1 Iron-deficiency anaemias 505

The oral dose of elemental iron for iron-deficiency There is no justification for the inclusion of other ingre- anaemia should be 100 to 200 mg daily. It is customary

dients, such as the B group of vitamins (except folic to give this as dried ferrous sulphate, 200 mg (: 65 mg

acid for pregnant women, see notes above and on elemental iron) three times daily; for prophylaxis of iron-

p. 508).

deficiency anaemia, a dose of ferrous sulphate 200 mg once or twice daily may be effective. For treatment of

Modified-release preparations Modified-release iron-deficiency anaemia in children and for prophylaxis

preparations of iron are licensed for once-daily dosage, of iron-deficiency anaemia in babies of low birth weight,

but have no therapeutic advantage and should not be see BNF for Children.

used. These preparations are formulated to release iron gradually; the low incidence of side-effects may reflect

Iron content of different iron salts

the small amounts of iron available for absorption as the iron is carried past the first part of the duodenum into an

area of the gut where absorption may be poor. Ferrous fumarate

Amount

Content of

Iron salt

ferrous iron

200 mg

65 mg

Ferrous gluconate 300 mg

35 mg

FERROUS SULPHATE

Ferrous sulphate, dried Indications 200 mg 65 mg iron-deficiency anaemia Cautions interactions: Appendix 1 (iron) Therapeutic response The haemoglobin concentra- Side-effects see notes above tion should rise by about 100–200 mg/100 mL (1–2 g/

Ferrous sulphate 300 mg

60 mg

Dose

litre) per day or 2 g/100 mL (20 g/litre) over 3–4 weeks. . See under preparations below and notes above When the haemoglobin is in the reference range, treat-

ment should be continued for a further 3 months to Ferrous Sulphate (Non-proprietary)

replenish the iron stores. Epithelial tissue changes such Tablets , coated, dried ferrous sulphate 200 mg (65 mg as atrophic glossitis and koilonychia are usually

iron), net price 28-tab pack = £1.44 Dose improved, but the response is often slow. prophylactic, 1 tablet daily; therapeutic, 1 tablet 2–3 times daily; CHILD , see BNF for Children

Side-effects c Gastro-intestinal irritation can occur with Ironorm Drops (Wallace Mfg) iron salts. Nausea and epigastric pain are dose-related

Oral drops , ferrous sulphate 125 mg (25 mg iron)/mL. but the relationship between dose and altered bowel

Net price 15-mL = £3.35 habit (constipation or diarrhoea) is less clear. Oral iron,

Dose ADULT and CHILD over 6 years, prophylactic, 0.6 mL daily; CHILD under 6 years, see BNF for Children

particularly modified-release preparations, can exacer- bate diarrhoea in patients with inflammatory bowel

Modified-release preparations disease; care is also needed in patients with intestinal

DU (= capsules m/r), clear/red, enclosing Iron preparations taken orally can be constipating, par-

strictures and diverticular disease. Feospan c (Intrapharm)

Spansule c

green and brown pellets, dried ferrous sulphate ticularly in older patients and occasionally lead to faecal

150 mg (47 mg iron). Net price 30-cap pack = £1.65. impaction.

Label: 25

If side-effects occur, the dose may be reduced; alterna- Dose 1–2 capsules daily; CHILD over 1 year, 1 capsule daily; can be opened and sprinkled on food

Nutrition

tively, another iron salt may be used but an improve- ment in tolerance may simply be a result of a lower

Ferrograd c (Teofarma) U content of elemental iron. The incidence of side-effects

Tablets , f/c, m/r, red, dried ferrous sulphate 325 mg due to ferrous sulphate is no greater than with other iron

(105 mg iron). Net price 30-tab pack = £1.18. Label: 25 salts when compared on the basis of equivalent amounts

and

Dose ADULT and CHILD over 12 years, prophylactic and thera-

of elemental iron. peutic, 1 tablet daily before food

blood

Iron preparations are a common cause of accidental overdose in children. For the treatment of iron over-

With folic acid c

dose, see Emergency Treatment of Poisoning, p. 32.

Fefol (Intrapharm)

DU (= capsules m/r), clear/green, enclosing

Spansule c

Counselling Although iron preparations are best brown, yellow, and white pellets, dried ferrous sul- absorbed on an empty stomach they may be taken

phate 150 mg (47 mg iron), folic acid 500 micrograms. Net price 30-cap pack = £1.69. Label: 25

after food to reduce gastro-intestinal side-effects; they

may discolour stools 1 capsule daily Ferrograd Folic c (Teofarma) U

Dose

Compound preparations Preparations containing Tablets , f/c, red/yellow, dried ferrous sulphate iron and folic acid are used during pregnancy in

325 mg (105 mg iron) for sustained release, folic acid women who are at high risk of developing iron and

350 micrograms. Net price 30-tab pack = £1.32. folic acid deficiency; they should be distinguished from

Label: 25

those used for the prevention of neural tube defects in Dose ADULT and CHILD over 12 years, 1 tablet daily before food women planning a pregnancy (see p. 508).

It is important to note that the small doses of folic acid With ascorbic acid

Ferrograd C contained in these preparations are inadequate for the c (Teofarma) DU treatment of megaloblastic anaemias.

Tablets , f/c, red, dried ferrous sulphate 325 mg (105 mg iron) for sustained release, ascorbic acid

Some oral preparations contain ascorbic acid to aid 500 mg (as sodium salt). Net price 30-tab pack = absorption of the iron but the therapeutic advantage of

£1.71. Label: 25

such preparations is minimal and cost may be increased. Dose ADULT and CHILD over 12 years, 1 tablet daily before food

9.1.1 Iron-deficiency anaemias BNF 57