HAEMETINICS

INTRODUCTION
 Haemetinics.
 The most important site of formation of red blood
cells in adults is the bone marrow.
 The process by which the formation of RBCs
occurs is known as erythropoesis.
ERYTHROPOESIS
 Monitoring of oxygen level in the blood is carried
out by kidney.
Contd.
 FOR ERYTHROPOESIS BODY NEEDS
 Iron
 Folic acid
 Vit.B12
 Erythropoietin
 IRON
 As part of the protein haemoglobin
 Iron also helps our muscles store and use oxygen.
 Iron is a part of enzymes
 Act as electron transporter: Vital for life.
 Must be in ferrous (Fe+2) state for activity. Ferric (Fe+3)
ions cannot transport electrons or O2
DISTRIBUTION OF IRON IN
THE BODY
Total body iron in the adult is 2.5-5 gm

1) Haem iron (ferroprotoporphyrin) (75 %) :

 Haemoglobin ( Hb
 Myoglobin ( in muscles)
 Oxidoreductive enzymes eg. cytochrome,peroxidase,
catalase
2) Non-haem iron protein (25 %) :
 Ferritin, hemosiderin, transferrin,iron sulfur protein,
holoenzyme containing iron.
ABSORPTION OF IRON
 Absorption of iron occur in intestinal mucosal cells in
the duodenum and upper jejunum .

 Iron ions undergo two important changes of oxidation

state during digestion and absorption.
Inhibitors: phytates, tannins, iron overload, antacids.
Facilitators: ascorbate, citrate, amino acids, iron
deficiency.
Competitors: lead, cobalt, strontium, manganese, zinc
 GI ABSORPTION OF IRON
Fe Fe2+
Fe
Fe Fe

Blood circulation

Fe
Fe Fe Fe
Fe2+
Fe3+ Fe
Fe3+
Ferritin
Fe
Fe
Fe
Fe Fe
Fe Fe
Fe Fe Fe Fe
Fe Fe BOUND TO APOFERRITIN
TRANSFERRIN

Bone marrow
Fe
Fe
for use or storage

TRANSFERRIN
IRON DEFICIENCY
 Iron deficiency ranges from depleted iron stores without
functional or health impairment to iron deficiency with
anemia, which affects the normal motor function or mental
functions.
 Signs and symptoms of iron deficiency
 Feeling tired and weak
 Slow cognitive and social development during childhood
 Difficulty maintaining body temperature
 Decreased immune function, which increases susceptibility
to infection
 Glossitis (an inflamed tongue)
Contd.
 Causes of deficiency:
1) Blood Loss
 Gastrointestinal Tract
 Menstrual Blood Loss
 Urinary Blood Loss (Rare)
2) Increased Iron Utilization
 Pregnancy
 Infancy
 Adolescence
 Polycythemia
3) Malabsorption
 Tropical Sprue
 Gastrectomy
 Chronic atrophic gastritis
UNWANTED EFFECTS
1) Oral
Nausea, Vomiting, Epigastric Pain, Heart burn, Metallic
taste, Diarrhoea.
2) Parenteral
Pain at site of injection, Pigmentation of the skin, Fever,
Headache, Joint pain, Flushing, palpitation, Lymph node
enlargement.
Acute iron toxicity
Chronic iron toxicity
Treatment of acute and chronic iron toxicity
CLINICAL USES
 Haemetinic
 Astringent
 Disinfectant
 Arsenic antidote
 Inadequate absorption (e.g. following gastractomy)
 Chronic blood loss (e.g. with menorrhagia, hookworm,
colon cancer)
 Increased demand (e.g. in pregnancy and early infancy)
 Inadequate dietary intake (uncommon in developed
countries)
IRON PREPARATIONS
A)Iron chelators
• sodium ferredetate
• ferric tri glycinate
• ferrous bi glycinate
B) Iron amino acid complexes
• Ferrous Aminoate
• Ferrous Glycine sulphate
• Ferrous Succinylate
C) Iron complexes
• Ferrous Gluconate
• Iron Dextran Fe content :15%
• Iron Sorbitrol Citric Acid Complex
 Vitamin B12
 Vitamin B12 belongs to the family of cyanocobalamine
 Serves as a cofactor for two important reactions in humans
 The vitamin B12 used medically is hydroxocobalamin.
 Vitamin B12 is carried in the plasma by binding proteins
called transcobalamins.
 The daily absorption of vitamin B12 is 5 mcg/day
PHARMACOKINETIC
ASPECTS
 Vitamin B12 is present in the food as a protein conjugates.
Gastric acid and proteolytic enzymes release free vitamin
B12 in the stomach and duodenum. Parietal cell of stomach
secrete a specific glycoprotein known as intrinsic factor.
Which forms a complex with vitamin B12(extrinsic factor)
this complex is absorbed in the distal ileum by a highly
specific receptor mediated transport system
 Storage and excretion:
Excess vit. B12 is stored in the liver. If for any reason any
intestinal Vit. B12absorption is stopped, the normal hepatic
store will last for 5 years. It is only after this period that
deficiency anemia will be manifested.Vit- B12 is excreted
in bile but most of reabsorbed by enterohepatic circulation.
Contd.
Biochemical reactions
Vitamin B12 is required for two main biochemical reactions:
1) Conversion of methyl-FH4 to FH4 .
2) Isomerisation of methylmalonyl-CoA to succinyl-CoA
Causes of deficiency
 Decreased production of intrinsic factor
 Gastrectomy
 Helicobacter pylori infection
 Crohn's disease
 Vitamin B12 requirement also increased in pregnancy,
thyrotoxicosis, hemolytic anemia, hemorrhage,
malignancy, liver or kidney disease.
CLINICAL USES
Vit. B12 is used in treatment of:
 Pernicious anemia

 Neurologic and psychiatric disorder

 Megaloblastic anemia

 As dietary suppliments
FOLIC ACID
 Folic acid is the term commonly used for
pteroylmonoglutamic acid.
 In its reduced form of tetrahydrofolate, it serves as an
important mediator of many reactions.
 Some aspects of folate structure and metabolism are deal
with several important antibacterial and anticancer drugs
that interfere with folate synthesis in micro-organisms.
 Daily requirements of Folic acid is 50–100 mcg/day.
CAUSES OF DEFICIENCY
 Dietary deficiency
 Decreased absorption
 Chronic hemolytic anemia
 Pregnancy
 Malabsorption due to drugs: phenytoin, phenobabarbiton,
isoniazide, and oral contraceptives
 Use of anti-folate compounds: methotrexate or rarely of
pyrimethamine and trimethoprime, prevent conversion of
H2 folate to H4 folate
PHARMACOKINETIC
ASPECTS
 Dietary folate, which is primarily polyglutamate form of
tetahydro folate, is hydrolyzed by the enzyme –
glutamyltransferase,within the brush border of the
intestinal mucosal. Ascorbic acid protects the active H4
folate from oxidation. Tetrahydro folate is absorbed as
monoglutamate and transported bound to folate binding
plasma protein. It is utilized in the tissues, and stored in the
liver.
 Folic acid undergoes enterohepatic circulation.Trace
amount of folic acid are excreted in the urine and stool.
BIOCHEMICAL REACTION
Dihydrofolate (FH2) and tetrahydrofolate (FH4) act as
carriers and donors of methyl groups (1-carbon transfers)
in a number of important metabolic pathways. For
example, FH4 is essential for DNA synthesis because of its
role as cofactor in the synthesis of purines and
pyrimidines. It is also necessary for reactions involved in
amino acid metabolism.
The role of folate and vitamin B12 in the conversion of
homocysteine to methionine has been implicated in the
role of elevated blood homocysteine concentrations and
premature CVD as well as premature occlusive vascular
disease.
CLINICAL USES
 Treatment of megaloblastic anaemia resulting from folate
deficiency
 Treatment or prevention of toxicity from methotrexate, a
folate antagonist
 Prophylactically in individuals at hazard from developing
folate deficiency, for example: pregnant women and before
conception (especially if there is a risk of birth defects)
premature infants
 Patients with severe chronic haemolytic anaemias,
including haemoglobinopathies (e.g. sickle cell anaemia).
HAEMOPOETIC GROWTH
FACTORS
1) Erythropoetin
2) Colony-stimulating factors
 1) ERYTHROPOETIN
 Erythropoietin the first haemopoietic growth factor to be isolated
and characterized from urine of severely anaemic patients.
 It is a 165 amino acid peptide produced by using recombinant
DNA technology. And is a 165 amino acid peptide
 Erythropoietin is produced in Juxtatubular cells in the kidney and
also in macrophages.
 Its action is to stimulate generation and proliferation of RBC.
 Erythropoietin (EPO) is a sialoglycoprotein hormone
 Anaemia and hypoxia are sensed by kidney cells, rapid secretion
of EPO and act on erythroid marrow:
 Stimulates proliferation of colony forming cells of erythroid

series.
 It regulate the blood cell proliferation & differentiation in

bone marrow.
 Induces haemoglobin formation and erythroblast maturation.

 EPO binds to specific receptor on the surface of its target cells –

alters phosphorylation of intracellular proteins and induces
erythropoiesis in a dose dependent manner.
 It has no effect on RBC life span.
ERYTHROPOESIS

The two form of recombinant human Erythropoietin

Epoietin alpha
Epoietin beta.
Mechanism of action
 Mechanism:
 The kidney is the site of production of endogenous erythropoietin.
 Its action is to stimulate committed erythroid progenitor cells to
proliferate and generate erythrocytes and production is increased when
there is anaemia the bone marrow is stimulate to produce more RBC,
leading to correction of anaemia non anaemic individual have serum
erythropoietin concentration less than 20 IU/L with progressive anaemia,
these levels rise and may be 100-500 IU/L in renal disease where serum
erythropoietin level do not increase with progressive anaemia,
exogenous erythropoietin is effective.
 PATIENTS CONSIDERED
FOR ERYTHROPOIETIN
 Recombinant human erythropoietin is indicated for patients who
have anemia (Hct < 30%) due to inadequate endogenous
erythropoietin levels.
 It can be used in carefully selected patients with:
 Severe chronic renal disease
 Some anemia associated with malignancy
 Anemia caused by radiation or cytotoxic chemotherapy
 HIV treatment.
 Impending surgery, to reduce allogeneic blood transfusion
 Use
 The availability of exogenous recombinant human erythropoietin has helped
patients with chronic renal failure where endogenous levels are low.
 Haemoglobin levels and RBC counts improve remarkably, obviating the need
for blood transfusions failure to respond to erythropoiein in such patients may
be due to concurrent iron or folate deficiency, which can be supplemented.
 Erythropoietin has been useful in primary anaemias and in secondary
anaemias.
 It has also been successfully in anaemias associated with zidovudine treatment
in HIV infection, prematurity anaemias. Endogenous erythropoietin levels are
usually low in this condition.
Use
 The primary indication for epoetin is anaemia of chronic
renal failure
 Anaemia associated with the HIV infected patient.
 Cancer chemotherapy induced anaemia
 Anaemia of chronic renal failure.
 Prevention of the anaemia that occurs in premature infants.
 To increase the yield of autologous blood before blood
donation.
 It also used to mobilize peripheral blood stem cells in
transplantation
 ADVERSE EFFECTS

 Exogenous erythropoietin is thrombotic manifestation and hypertension

following rapid increases in RBC counts and haemoglobin levels.
 Allergic reactions are comparatively uncommon.
 Iron deficiency can be induced because more iron required for the enhance
erythropoiesis.
 Epoetin is non immunogenic. Iron deficiency can be induced
 Sudden increase in haematocrit, blood viscosity and peripheral vascular
resistance.
 There have been rare reports of pure red cell aplasia, possibly connected with
development of antibodies directed against erythropoietin.
 Transient influenza-like symptoms are common.
 Encephalopathy with headache, disorientation and sometimes convulsions.
 CONTRAINDICATION
 R-HuEPO is contraindicated in patients with:
 Anemia that would respond adequately to iron replacement alone
 Uncontrolled hypertension
 Hypersensitivity to mammalian cell-derived products to (human)
albumin
 Anemia caused by acute blood loss
 PHARMACOKINETIC
ASPECTS AND RESISTANCE
 R-HuEPO given s.c required substantial - up to 50% less dose to
achieve Hb levels comparable to those achieved with full i.v
dose administration.
 R-HuEPO resistance can be the result of the following
causes:
 Infection or inflammation
 Chronic blood loss
 Folate or vitamin B12 deficiency
 Osteitis, fibrosa, multiplemyeloma, malnutrition, hemolysis,
hemoglobinopathies (alpha or beta thalassemias, sickle cell
anemia.
Formulation
 PREPARATIONS:
HEMAX 2000 IU/ml vials
EPREX 2000 IU, 4000 IU and 10000 IU in 1 ml prefilled syringes
ZYROP (epoetin β) 2000 IU and 4000 IU vials.

Like EPO , another factor that colony stimulating factor have been
identified that stimulate bone marrow production of RBC,
granulocytes, macrophages & platelet
 2) COLONY-STIMULATING FACTORS

 Two colony stimulating factor are G-CSF and GM-CSF now

used in therapy.

 Mechanism of action:
 GCSF has ability to mobilize haematopoietic stem cell and
increase their concentration in peripheral circulation.
 GM-CSF is multipotential haematopoietic growth factor which
stimulates proliferation and differentiation of progenitor cells of
granulocytes and erythrocyte.
 GCSF activate phagocytic activity of neutrophills and prolong
their life span in circulation.
 ACTION:

 They are now produced by DNA recombinant technology.

 GM-CSF is produced by many cells type and influences at least five of the eight lines of
blood cell development.
 G-CSF is produced by monocytes fibroblast and endothelial cells, and it controls
primarily the development of neutrophills.
 GCSF activate phagocytic activity of neutrophills and prolong their life span in
circulation.
 GCSF has ability to mobilize haematopoietic stem cell and increase their concentration
in peripheral circulation.
 These factor helps in the use of peripheral blood stem cells instead of one marrow cells
in haematopoietic stem cell transplantation.
 GM-CSF is multipotential haematopoietic growth factor which stimulates proliferation
and differentiation of progenitor cells of granulocytes, erythroid.
 It stimulates function and long activity of maturity neutophills and acts in concern with
interleukin-2 to stimulate T cell proliferation and may be involved in proliferation.
 CLINICAL USES
 To reduce the severity/duration of neutropenia induced by
1) cytotoxic drugs during anticancer chemotherapy
2) intensive chemotherapy
3) necessitating autologous bone marrow rescue
4) following bone marrow transplant.
5) HIV
 To harvest progenitor cells.
 In aplastic anaemia.
 There is dramatic increase in neutropill count, which may associate in decrease in
infection and neutropenic fever.
 These factors are administerd after autologous stem cells transplantation taken from bone
marrow or peripheral blood, and help speed of recovery from the severe neutropenia
cause by chemotherapy.
 It also used to mobilize prpheral blood stem cells in transplantation which has largely
replaced bone marrow transplantation.
 UNWANTED EFFECTS
 GM-CSF produce fever and cause skin rashes, muscle pain.
 With I.V. infusion, a syndrome of flusing, hypotension, tachycardia,
breathlessness, nausea and vomiting occurred, these is reversed by giving
oxygen and I.V. fluid.
 GCSF produced mild dysuria and reversible abnormality in lever function.
 pain at the site of injection.