preventia si tratamentul anemiei

8/3/2019 Preventia Si Tratamentul Anemiei

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CuplulCuplul FierFier--CupruCupru esteeste

necesarnecesar pentrupentru preventiapreventiasisi tratamentultratamentul anemieianemiei


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1 ANEMIA FERIPRIVA

CUPLUL Fe -Cu

FACTORI CARE INFLUENTEAZA ALEGEREA TRATAMENTULUI

2

3

Cuprins:


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Istoric:

WHO 1968:

a condition in which the hemoglobin content of the blood is lower than normal as a

result of a deficiency of one or more essential nutrients, regardless of the cause

of such deficiency.

Iron deficiency was present in 4099% of the pregnant women studied and was

undoubtedly responsible for the major proportion of anemia

1989

Iron deficiency anaemia is the most prevalent nutritional disorder in the world

today. . . Iron deficiency is by far the commonest nutritional cause of anaemia; it

may be associated with a folate deficiency, especially during pregnancy. Other

nutrient deficiencies, such as vitamin B-12, pyridoxine (PN) and copper are of

little public health significance because of their infrequency.

2004

the prevalence of anaemia has often been used as a proxy for IDA. Although this

approach may be useful in settings where iron deficiency is known to be the

major cause of anaemia, it is not valid in settings where the etiology of anaemia

is more complex


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5

Cauze:

Dieta: la copii si la varstnici

Absorbtie deficitara

Utilizare crescuta ( de exemplu in caz de sarcina, alaptare

sau in perioada de crestere)

Utilizare deficitara (afectiuni cronice)

Sangerare

Deficienta altor micronutrienti: Cupru, B12, acid folic


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0

2

4

6

8

10

12

0 10 20 30 40 50 60 70

Men

Women

Required iron intake

(mg Fe/1000 kcal)

Stoltzfus, 1997

Pregnancy

Necesarul de Fier


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Prevalenta anemiei feriprive

Normal (


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1 ANEMIA FERIPRIVA

CUPLUL Fe -Cu


2

3

Cuprins:


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Homeostazia Fierului si a

Cuprului Puncte de interactiune

James F Collins. Metabolic crossroads of iron and

copper, Nutrition Reviews Vol. 68(3):133147


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Transportul celular al Fe si al Cu

Puncte de interactiune

James F Collins. Metabolic crossroads of iron andcopper, Nutrition Reviews Vol. 68(3):133147


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Transportul celular al Fe si al CuPuncte de interactiune

James F Collins. Metabolic crossroads of iron andcopper, Nutrition Reviews Vol. 68(3):133147


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Cuplul Fier-Cupru

Metabolismul Fe

Ceruloplasmina

Absorbia fierului prin mucoasa intestinal i, n special,transportul su prin membrana bazolateral a enterocitelor

Deplasarea fierului de la nivelul esuturilor n care este depozitat(ficat, mucoasa intestinal, etc), prin catalizarea reaciei

Fe2+ Fe3+

Fixarea fierului de transferin i transportarea sa ctre mduvaosoas, unde se produc hematiile

Deficienta de Fe si Cu determina anemie si afectarea transportului intestinal al

fierului este asociata cu patologii care includ anemia afectiunilor cronice si

hemocromatoza ereditara

James F Collins


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Cuplul Fier-Cupru

Sintezei hemoglobinei (citocrom oxidaz)

Catalizeaz reacia Fe2+ Fe3+n eritroblati (precursoriihematiilor)

Transferul fierului intracitoplasmatic

ctre mitocondrii,

urmat de ncorporarea sa n moleculele de hemoglobin

Hematopoieza

Cu2+joac un rol esenial n maturizarea celulelor hematopoieticestimulnd hematopoieza

Aportul deficitar de Cu2+ cauzeaz anemie i neutropenie, ambele

putnd fi corectate prin suplimentarea cu Cu2+


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Ceruloplasmina este necesara pentru efluxul de Fe din ficatul matern

Pacientii cu aceruloplasminemia au un nivel crescut de Fe in ficat

Transferul fierulul la fat este compromis

nivelul fierului seric si hepatic al fatului scade

Given the high incidence of maternal anaemia during pregnancy,

and that many of those who are prescribed iron supplements show

no significant improvement, it is tempting to conclude that at least

some of the cases are a consequence of low copper . when considering

supplementing iron, copper status must also be taken into accountH. J. McArdle,Rowett Research Institute, Aberdeen, UK.

Deficitul de Cupru - femei insarcinate

Transportul Fe si

Cu prin placenta


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Deficitul de Cupru -adulti

Procent important de anemii neexplicate dar asociate

cu deficit de Cupru

Un numar semnificativ de pacienti care au fostdiagnosticati cu anterior cu deficit de vitamina B12 au

deasemenea hipocrupemie nediagnosticata

Calin I. Prodan, Hypocupremia Associated With PriorVitamin B12 Deficiency, American Journal of Hematology 82:288290 (2007)


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Aport neadecvat

Prematuritate

Malabsorbtie Pierdere excesiva de Cupru

Doze mari de Fier

Deficitul de Cupru - copii


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Manganul

Rol : Activarea diverselor sisteme enzimatice i, n consecin, n

diverse tipuri de metabolism celular de la nivelul oaselor, lipidelor,

carbohidrailor i proteinelor.

In protejarea mpotriva radicalilor liberi

o Catalizeaz reacia de dismutaie a peroxidului de hidrogen

(H2O2) n ap i oxigen (superoxid dismutaz)

Manganul interfera cu metabolismul fierului si al cuprului

este importanta suplimentarea cu mangan cand se

administreaza Fe + Cu

Abraham J. & Giachetti I. (1992). Apports nutritionnels conseills pour la population franaise. Technique et documentation, Paris.Finley J. W. and Davis A. C. D. Manganese deficiency and toxicity: Are high or low dietary amounts of manganese cause for concern? BioFactors, 1999, vol. 10.no1, pp. 15-24.


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1 ANEMIA FERIPRIVA

CUPLUL Fe -Cu


2

3

Cuprins:


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Ce tratament alegem?

Fier sau Fier + Cu + ?

Saruri feroase vs saruri ferice?

Eficienta si complianta

1

2

3

4

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Solutie sau tablete?


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Fe sau Fe +Cu?

Time course of papers published on the copper/iron connection. The papers

represent the authors non-systematic, and certainly incomplete, collection of

references that primarily concern both iron and copper metabolism (534

articles through February, 2002)P. Fox- The copper-iron chronicles: The story of an intimate relationship,Biometals 2003


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Fe sau Fe +Cu?

Combinatia Fier- Cupru in tratamentulanemiei a fost studiata clinic inca din 1928

Combinatia Fier- Cupru a determinat un

raspuns maxim in regenerarea hemoglobinei,

fata de monoterapia cu Fier, care a determinat

un raspuns neadecvat, printr-o cresteremoderata a hemoglobinei.

(C. A. ELVEHJEM, IRON VERSUS IRON AND COPPER IN THE

TREATMENT OF ANEMIA IN INFANTS, American Journal of Disease ofChildren, 1937

Curves showing the ineffectiveness of therapy during the

first few weeks of life (cases 1 and 2) and curvesshowing the interference by infection with the effect of

treatment (cases 3, 4 and 5).


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Fe sau Fe +Cu?

(C. A. ELVEHJEM, IRON VERSUS IRON AND COPPER IN THE TREATMENT OF ANEMIA ININFANTS, American Journal of Disease of Children, 1937

Curves comparing the hemoglobin response to 25 mg. of iron plus

1 mg. of copper with that to 25 mg. of iron alone


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Saruri feroase vs saruri ferice?

Sarurile ferice sunt disociate Fe2+ sau Fe3+

Fierul se absoarbe sub forma de Fe2+

It has been shown that preparations containing ferrous salts (+2) aremore easily absorbed than those containing ferric salts (+3) since the

former can be immediately absorbed by the duodenal mucosa. The

study reported here reveals that oral ferrous gluconate in liquid form is

more effective and above all better tolerated than other solid or liquid

formulations containing elementary iron. ( Casparis, Minerva Ginecol

1996)

Gluconatul feros in forma lichida este mai eficient si mai bine tolerat

decat alte formulari solide sau lichide de fier (Ghidul Societatii

Britanice de Gastroenterologie 2005)


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Solutie sau tablete?

Indiferent de varsta, se recomanda

forma lichida

Iron deposition in the upper GI

tract is common in patients takingiron tablets. It is frequently

associated with mucosal disruption

in the oesophagus and stomach

(Kaye P, Abdulla K, Wood J, James P, Foley S,

Ragunath K & Atherton J (2008) Histopathology 53,

311317)


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Patterns of iron deposition. A, Oesophageal ulcer showing crystalline iron coating the surface (pattern A) and haemosiderin in granulation

tissue (pattern B) (H&E). B, Gastric biopsy specimen showing surface iron (pattern A) with underlying reactive gastritis (H&E). C,

Gastric biopsy specimen with haemosiderin in lamina propria (pattern B) (H&E). D, Gastric biopsy specimen showing more subtle

focal iron deposition engulfed by foreign body giant cell (H&E). E, Perls Prussian Blue stain showing iron (blue) in glandularepithelium (pattern C). F, Duodenal biopsy specimen showing haemosiderin in histiocytes at villous tips (pattern D) (H&E)


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EficientaIron Polymaltose Versus Ferrous Gluconate in the Prevention

of Iron Deficiency Anemia of Infancy

Lutfi Jaber, MD J Pediatr Hematol Oncol 2010;32:585588

Valoarea medie a Hb semnificativ mai mare in grupul tratat cu gluconat feros

(12.040.09 g/dL vs. 11.680.11, p>0.014)

Valoarea Hb


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Efficacy of Tothema in the treatment of iron

deficiency anemia in early childhood withconcomitant copper deficiency

Eficienta si Complianta

Mtvarelidze Z et al. Georgian Med News 2005; (121):68-71

Protocol:Tothma 5mg/kg/zi pn la normalizarea Hb i apoi

2 mg/kg/zi, pana la 3 luni

Criterii de includere:42 pacienti 0,4 i 3 ani

grupa I : prematuri (n = 16)

grupa II : copii nscui la termen, cu diaree

prelungit i natural (n = 11)

grupa III : copii nscui la termen, care nu prezint diaree

Grupa martor: copii de aceeai vrst, dar sntoi (n = 24).

Criterii de evaluare:- Bilanuri clinice i biologice (Hematologic: Hb, eritrocite, reticulocite, morfo-

eritrogram;

- Biochimice: fier seric, CTF, cupru, ceruloplasmin; Radio-imunologice : feritin

realizate nainte i dup tratament.


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Eficienta si Complianta

Concluzie: Tothma este un medicament eficace n

tratamentul anemiei prin caren de fier la

copiii de vrst mic, care prezint o caren de cupru asociat

Tothma permite corectarea nivelului rezervelor de fierdar i de cupru

Tothma previne apariia formelor rezistente de anemie prin caren

de fier

Tothma administrat copiilor de vrst mic este bine tolerat, cu efecte

nedorite rare i trectoare

Rezultate:Eficacitate clinic :

- ameliorarea strii generale

- diminuarea rapid a simptomelor de anemie

Eficacitate paraclinic:

- normalizarea complet a parametrilor

hematologici, biochimici i a feritineidup 3 luni de tratament


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Eficientasi Complianta

Anmouth S.Y. New developments in the treatment of iron deficiency anaemia in childrenMedical journal Of Diseases, Newborns and Children, 2001

93 Copii de la 6 luni -16 ani

Grup 1-Hb : 95

.5

+/- 0.12Grup 2 Hb : 78.9+/- 0.34 g/l

Evaluarea eficientei clinice (simptome) si de laborator (Hb) dupa

tratamentul cu Tothema


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Eficientasi CompliantaRezultate:

Tratament eficient in tratamentul atat la copii mici cat si la adolencentiCrestere rapida si semnificativa a Hb atat in cazurile moderate cat

si cele mai severe

Bine tolerat


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TOT`HEMA

1

IDA :Deficienta

multipla

Cuplu Fe-Cu

2Saruri

feroase

3

Solutie

Profilaxia si Tratamentul

Anemiei Feriprive

Eficienta,

Complianta

Gluconat Feros 50 mg

Gluconat de Cupru 0.7 mg

Gluconat de Mangan 1.33 mg

4

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