Dr. Mika L Tobing, SpPD-KHOM,FINASIMSub Bag Hematologi-Onkologi Medik

Bagian Ilmu Penyakit Dalam

FK UNDIP – RS Dr. Kariadi

• Gangguan kronik yg sering dijumpai

• 1/3 s/d ½ wanita sehat di USA cadangan besi nol

• 10% dari jml ini menderita Anemia defisiensi Fe

Tahapan Defisiensi Fe

• Iron depletion (cadangan besi / - )

• Iron deficiency (SI saturasi transferrin rendah)

• Iron deficiency Anemia

• Intake yg non adekwat• Malabsorbsi• Perdarahan kronik (Chronic Blood Loss)• Hamil & menyusui• Hemolisis intravaskular &

Hemoglobinuria• Kombinasi

Causes of true iron deficiency

Increased loss of ironBleeding

MenorrhagiaGastrointestinalSurgeryTraumaChildbirthExcessive phlebotomyBlood donationsFactitious

Chronic hemoglobinuriaMechanical heart valve hemolysisParoxysmal nocturnal

hemoglobinuria

Decreased intake of ironDietary deficiency

Limited meatMalabsorbtion

SprueAchlorhydria :

Gastric atrophyPartial gastrectomyProton pump inhibitorsInflammatory bowel

diseaseIncreased utilization of iron

PregnancyRapid growth

Fe sintesis Hb eritropoesis aktifitas sitokrom

• Disfungsi neurologik

sekresi asam lambung

• Atrofi mukosa mulut & lambung

• Gejala umum Anemia

• Korelasi nilai Hb dgn gejala tidak jelas

• Irritabilitas, nyeri kepala

• Perlambatan respons neurologik

• Pica

• Pucat, lidah licin & merah

• Stomatitis, cheilitis angularis

• Koilonychia

• Perdarahan retina

• Splenomegalia

Laboratorium

• Anisositosis, ovalositosis ringan, sel target

• Elongasi Elliptositosis Hipokromik (sel pensil)

• Hipokromia progresif (MCH rendah)

• Mikrositosis (MCV rendah)

• Retikulosit rendah /

Laboratorium

• Jumlah E, Hb, Ht • Trombositosis (50-75% penderita)• BMA : - Selularitas & ratio ME

bervariasi- Sideroblast / nol- Eritroblast kecil

• SI : / normal• TIBC : • Serum Ferritin : < 10 mg/L

Cause of Hypochromic Anemia

SI TIBC %Sat BMSI

Iron Deficiency

Thalassemias

Sideroblastic Anemias

Chronic disease

*

- N

*

- N

- N

*

- N

- N

SI = Serum Iron, TIBC = Total Iron binding Capacity, Sat = SaturationBMSI = Bone Marrow Storage Iron* SI and TIBC occasionally normal in iron deficiency

Laboratorium

• Anamnesis & laboratorium

• Bila dijumpai Chronic Blood Loss diperlukan pemeriksaan endoskopik saluran cerna

Pengobatan

Oral Iron Therapy Diet rendah tdk cukup Aman & murah Hindari hematinic ganda

Jgn diberikan bersama makanan, antasida, H2 antagonis

Diteruskan selama 12 bln sesudah Hb normal Dosis total 150-200 mg besi elemental (1 tablet

sulfas ferron (325 mg) mengandung 65 mg besi elemental)

Dosis 3 – 4 kali/hari 1 jam sebelum makan Efek samping : Intoleransi gastrointestinal

Parenteral Iron Therapy

Keadaan malabsorbsi

tidak kooperatif

Intoleransi thd preparat oral

Iron Dextran : berisi 50 mg besi elemental im / iv

Diteruskan selama 12 bln sesudah Hb normal

Hati-hati reaksi Anaphylaxis

Pengobatan

Medications and foods that reduce iron absorption

Antacids (alkaline liquids, H2-blockers, proton pump inhibitors)

Tetracyclines (especially doxycycline)Pancreatic enzyme supplementsBiphosphonatesCholestyramineCalcium supplementsTeaDairy productsPhosphonates (vegetables)

Medications malabsorbed because of the coadministration of iron

Quinolone antibioticsBiphosphonatesCefdinirLevodopa, carbidopa, methyldopaThyroxinePenicillamineMycohenolate mofetilZinc or copper salts

Intravenous iron supplements

FDA-approved dosingAWP perdose*

Ferric gluconate complex in sucrose (Ferrlecit; 12.5 mg/mL iron)

125 mg iron in 10 mL over at least 10 minutes

orSome dose plus 90 mL 0.9% sodium chloride over 1 hour

$ 86

Iron sucrose (Venofer : 20 mg/mL iron)

100 mg iron in 5 mL into dialysis line at 1 mL/min

orSame dose plus 95 mL 0.9% sodium chloride over at least 15 minutes

$ 69

Average wholesale price (2003 Drug Topics Redbook)