Nama : Dr dr H Irza Wahid SpPD KHOM

Tempat / Tgl Lahir : Padang / 23 Nov 1967

Telp : 075161952 / 08126605439
email : irzawahid_drsppd@yahoo.co.id

Pendidikan : S1 FK Unand 1993

: Sp1 FK Unand 2003
: Sp 2 Kolegium IPD 2007
: S3 FK Unand 2014

Pekerjaan saat ini:

- Ka Divisi HOM Bag. IPD FK Unand / RS M Djamil Pdg
- KPS Ilmu Peny. Dalam FK Unand / RS M Djamil Pdg
- Ka Instalasi Rawat Inap Non Bedah RS M Djamil Pdg
- Ka Unit Onkologi Terpadu RS M Djamil Pdg
- Ketua POI Cabang Sumbar
ERYTROPOIESIS AND ANEMIA APPROACH IN
INTERNAL MEDICINE

Dr dr H IRZA WAHID SpPD KHOM FINASIM

SUBDIVISION OF HEMATOLOGY & MEDICAL ONCOLOGY
DEPARTEMENT OF INTERNAL MEDICINE
FACULTY OF MEDICINE ANDALAS UNIVERSITY
Anemic Ranges of Hemoglobin and Hematocrit Values
WHO(2011)
*These are only guidelines and some physicians feel the thresholds should be higher for adults.

Age/Sex (yrs) Hemoglobin Hematocrit (%)

(g/dL)
Children (0.5-4) < 11.0 < 33
Children (5-12) < 11.5 < 35
Children (12-15) < 12.0 < 36
Adult Men < 13.0 < 39
Non-pregnant < 12.0 < 36
Women
Pregnant < 11.0 < 33
Women
 GEJALA DAN TANDA ANEMIA

Hb Hipoksia Kompensasi
kardiovaskular
Pucat angina pektoris
Kardiomegali
Mukosa claudicatio intermiten
Palpitasi
Kulit tinitus Dispneu
berkunang bising sistolik
cepat lelah gagal jantung
 DIAGNOSIS ANEMIA

Gradasi
anemia ringan : sedang : berat :

Morfologi
mikro / normo / makrositer -- hipo/normo/hiperkrom

Patofisiologi
defisiensi aplastik hemolitik perdarahan

Etiologi
Cacing, low intake, ggn imun, trauma, chronic disease
 Gradation of Anemia

NCCN 2017
 Gradation of Anemia
Diagnostic Categories Hemoglobin

Moderately Severe < 10 g/dl

Severe < 9 g/dl

Very Severe < 8 g/dl

Williams Manual of Hematology 2017

 MORFOLOGI

MCV (80-96.1) fL
Mikrositik Normositik Makrositik

MCH (27.5-33.2) pg
Hipokrom Normokrom Hiperkrom

MCHC (33.4-35.5)%
Hipokrom Normokrom Hiperkrom

Peripheral Blood Smear

PATOFISIOLOGI

Aplastik

Defisiensi

Hemolitik

Perdarahan

Penyakit Kronik
IRON METABOLISM
Eritropoetin (efek pleotrofik)

Anti
apoptosis

Anti
Anti oksidan
inflamasi

aktivitas
Mobilisasi
faktor
EPC
transkiripsi
 PENGKAJIAN STATUS BESI

SERUM IRON
TOTAL IRON BINDING CAPASITY
SATURASI TRANSFERIN (SI / TIBC )
FERITIN
Algoritma Diagnosis Anemia
 ETIOLOGI

Infeksi

Autoimun

Trauma

Kongenital

Penyakit Kronik

ETC
NEJM 2015
 MANAJEMEN

Etiologi / Penyakit Dasar

Supportif
Suplemen zat besi, vit B12, asam folat
Eritropoietin
Transfusi darah

Komplikasi
Terapi kelasi besi
 TREATMENT OF IRON
DEFICIENCY ANEMIA.
deficiency anemia is treated with oral or
- Iron
parenteral iron preparation.

- Oral iron corrects the anemia just as rapidly and
completely as parenteral iron in most cases

if iron absorption from the GIT is normal.
 ORAL
IRON SUPPLEMENT
IMPORTANT POINTS ABOUT IRO N
SUPPLEMENT.
Before using iron medication, check if you
are allergic to any drugs or food dyes, or if
you have:

iron overload syndrome

)
hemolytic anemia (a lack of red blood cells
porphyria (a genetic enzyme disorder that
causes symptoms affecting the skin or
nervous system)

thalassemia (a genetic disorder of red

blood cells)
liver or kidney disease
if you are an alcoholic; or
if you receive regular blood transfusion.
 IMPORTANT POINTS ABO UT
IRON SUPPLEMENT.

- Most iron medication are taken on n

e
ampty stomach, at least 1 hour before
or 2 hours after meal.
- Avoid antibiotic such as iprofloxacin ,
demeclocycline , doxycycline , levofloxacin,
lomefloxacin , minocyclin norfloxacin ,
ofloxacin , or tetracycline.
- Avoid antacids within 2 hours before o
after meals when taking your iron
medication
 ORAL IRON THERAPY
Oral iron treatment may require 3-6
months to replenish body stores.
 Ferrous sulfate is the DOC
for iron deficiency anemia.
Dosage: 325 mg tid, which
provides 180 mg of iron
daily of which 10mg is
usually absorbed.
Patients who cannot
tolerate iron on an empty
stomach should take it with
food.
Administration: PO
 SANGOBION

Fe gluconate 250 mg, manganese sulfate 200

mcg, copper sulfate 200 mcg, vitamin C 50
mg, folic acid 1000 mcg, vitamin B12 7.5 mcg,
sorbitol 25 mg
 HEMOBION

Tiap kapsul Hemobion mengandung vitamin

dan mineral : Besi Fumarat 360 mg, Asam
Folat 1,5 mg, Vitamin B12 15 mcg, Kalsium
Karbonat 200 mg, Kolekalsiferol
(Cholecalciferol) 400 I.U., dan Asam Askorbat
/ Vitamin C 75 mg.
 BIONEMI

Fe fumarate 360 mg, folic acid 1.5 mg,

vitamin B12 15 mcg, vitamin C 75 mg, vitamin
D3 400 iu, Ca carbonate 200 mg
COMMON ADVERSE EFFEC TS
OF ORAL IRON THERAPY
Nausea
Epigastric discomfort
Abdominal cramps
Constipation and diarrhea.
Black stool
These effects are usually dose-relate d.
 CONTRAINDICATIONS
- Avoid antibiotic such as ciprofloxacin
, demeclocycline , doxycycline ,
levofloxacin, lomefloxacin , minocyclinor
norfloxacin , ofloxacin , or tetracycline.
- Avoid antacids within 2 hours before
o after meals when taking your iron
medication e,

r
 INDICATION FOR PARENTERAL IRON THERAPY
Established Indication
Failure of oral therapy
Iron intolerance or with low iron levels that are refractory to treatment
(eg. After gastrectomy or duodenal bypass, with Helicobacter pylori infection, or with celiac
disease, atrophic gastritis, inflamatory bowel disease, or genetically induce IRIDA*)
Need for quick recovery
(e.g with severe iron deficiency in the second or third trimester of pregnancy or with chronic
bleeding that is not manageable with oral iron, as may occur in patients with congenital
coagulation disorders)
Substitution for blood transfusion when not accepted by patient for religious reasons
Use of erythropioesis-stimulating agents in chronic kidney disease
Potential Indication
Anemia of chronic kidney disease (without treatment of erythropoiesis-stimulating agents)
Persistent anemia after use of erythropoiesis-stimulating agents in patients with cancer who are
receiving chemotherapy
Anemia of chronic disease unresponsive to treatment with erythropoiesis-stimulating agents
alone
Potential Indication with Insufficient Supporting Data
Iron defiency in heart failure
Transfusion-sparing strategy in surgical patients
NEJM 2015
 Iron Preparation for Intravenous Use
Formulation
Ferric gluconate (Ferlecit)
Iron sucrose (Venofer,
Rinofer, Nefrofer)
Iron dextran (cosmofer)
Ferumoxytol
Ferric carboxymaltose
(Ferinject)
Iron isomaltoside (Monofer)
Dose per infusion
Standard Maximum per Single Infusion
125 mg/10-60 min 250 mg/60 min
100-400 mg/2-90 min 300 mg/2hr
100 mg/2 min 1000 mg (1-4 hr)
510 mg/>1 min 510-1020 mg/15-60 min
750-1000 mg/15-30 min 750-1000 mg/15-30 min
20 mg/kg of body 20 mg/kg of body weight/15
weight/15 min min
 Terapi Erytropoeitin Stimulating Agent

Anemia pasien kanker

Anemia pasien Gagal Ginjal Kronik

Anemia calon pasien operasi elektif (diperkirakan

kehilangan darah 900-1800ml)

Terapi anemia pada pasien HIV yang mendapatkan

terapi dengan AZT
 30 - 77 % cancer pt experienced anemia

Cancer infiltration to bone marrow

Blood loss due to cancer angiogenesis
Therapy-induced (chemo/radiotherapy)
directly correlated (Bone marrow suppression)
erithropoetin suppression (nephrotoxic)
Anemia of chronic disorder (proinflamatory cytokines)

ANEMIA
Weiss G, et al.N Eng J Beguin Y.Haematologica.2002;87:1209-
Med.2005;352(10):1011-23. 221.
 Anemia in Cancer
Patient
Anemia is common in cancer patients
cancer pt + chemotherapy : > 80 %
anemia
Severety of anemia severity of disease
and therapy
Symptoms of anemia QOL
Anemia is directly corellated to survival
and therapeutics response

Abels. Eur J Cancer. 1993;29A(suppl 2):S2. Groopman and Itri. J Natl Cancer Inst. 1999;91:1616.
Bron et al. Semin Oncol. 2001;28(suppl 8):1. Littlewood. Semin Oncol. 2001;28(suppl 8):49.
DeRienzo and Saleem. Tex Med. 1990;86:80. Spano, JP; Khayat, David.The Oncologist.2008;13(suppl 3);27
 WARNING

ESAs shortened overall survival and/or time to

progression in clinical studies in pt with breast ca,
head and neck ca, lymphoid, and non-small cell
lung ca when dosed to target Hb 12g/dL

WARNING
Studies have reported possible decreased survival in
cancer patients receiving ESA for correction of anemia
(analyses of 8 studies & target Hb > 12 g/dL)

ESAs : Erythropoiesis Stimulating Agents

Now returning to RBC transfusion ?

Recent study has shown that RBC transfusion:

(a retrospective study of 70.542 patients)

increased venous thromboembolism

(OR 1.60; 95% CI, 1.53 1.67)
increased arterial thromboembolism
(OR 1.53; 95% CI, 1.46 1.61)
increased in-hospital mortality
(OR 1.34; 95%CI, 1.29 1.38)

OR: Odds Ratio; 95%CI: 95% Confidence Interval

arch Intern Med.2008;168(21):2377-81

 Dosage and Titration

Note : Hb level needed to avoid transfusion : 10 - < 12g/dL

Journal of Clin Oncol. ASCO Guidelines of Epoetin and Darbepoetin.2008.vol 26(1).www.asco.org

 Eritropoietin Discontinuation

Chemotherapy has finished (until periode of 6 weeks

after chemotherapy)
Recovered from anemia (Hb 12 g/dL)
Unresponsive within 8-9 weeks of therapy
NCCN Clinical Practice Guidelines in Oncology.Cancer- and Chemotherapy-Induced Anemia.V.2.2014

Observation Recommendation
Hb level titrated to maintain in asymptomatic zone
Ht level high target of Ht (42 3%) was found to have an
increased number of vascular events (arterial and venous)
Blood pressure
Spano JP, et al.The Oncologist.2008;13:27-32
ERYTHROPOETIN USE IN
CKD PATIENT
PERNEFRI 2001
RENAL ANEMIA

Menurunnya produksi epo >>

Deff besi, hemolitik, inflamasi

53
 Berapa Target Hemoglobin pada pasien

NKF KDOQI1

Menurut kelompok kerja KDOQI , target hemoglobin bagi pasien gangguan ginjal kronis
dialisis maupun non-dialisis, pemberian eritropoetin disarankan mencapai 11,0 12,0 g/dL.

Pada pasien gangguan ginjal kronis dialisis dan non dialisis yang diberikan eritropoetin,
target hemoglobin disarankan tidak melebihi 13.0 g/dL.

EUROPEAN RENAL BEST PRACTICE8

Menurut Kelompok kerja ERBP, nilai hemoglobin 1112 g/dl secara umum
direkomendasikan pada pasien gangguan ginjal kronis tanpa melewati kadar
hemoglobin > 13 g/dl.

PERNEFRI9

Menurut PERNEFRI, target hemoglobin pada pasien gangguan ginjal adalah > 10
g/dL
Started if Hb Target Hb
<10 g/dl 10-12 g/dl

EPO

Protective Hb > 13g/dl

effect not allowed
56
57
 Dosis ESA pada pasien hemodialisis dan predialisis
dewasa

ESA 50 iu/kgBB 1-3 x seminggu

Hemoglobin naik
STATUS BESI
>2 /dL/bulan 1-2 /dL/bulan <1g/dL/bulan
Ferritin<100ug/L Ferritin>100ug/L
Setelah 4 minggu
transferin sat.
Kurangi dosis transferin sat. >20%
% hypocromic
25%/ Frekuensi <20% red cell <10%
Tingkatkan % hypocromic red
Eprex dosis
cell
>10%
25 iu/kg/BB

Pertahankan dosis Eprex Besi Parenteral Besi Oral

Sampai Hb 10- 12
g/dL

Perdarahan ?
Hb 10-12 g/dL
Tetap berikan Eprex, dengan dosis dan Infeksi ?
frekuensi yang Keganasan ?
disesuaikan Kekurangan Besi ?

Note : Dosis maksimum tidak melebihi 200 iu/kg BB 3x

seminggu
59
T H A N K Y O U