pharm module 7: hematopoietic agents

where does hematopoiesis normally occur?

• in red bone marrow

• requires Vit B, Vit C, copper, iron, other nutrients

Erythropoietin trade name

• epoetin alfa

what are the uses for erythropoietin (epoetin alfa)

• CKD incduced anemia 

• chemotherapy induced anemia 

• zidovudine induced anemia 

what is erythropoietin (epoetin alfa)

• hormone that stimulates RBC production

MOA of erythropoietin (epoetin alfa)

• secreted when kidneys sense reduction in oxygen

• body experiences hypoxia or hemorrhage

• increased erythropoietin is decreased oxyfen nreaching the kidneys

what si the black box warning of erythropoietin (epoetin alfa)?

• Death, MI, Stroke, venous thromboembolism, thrombosis of vascular access

  • death is drom thromboembolism 

what is the adverse effect of erythropoietin (epoetin alfa)

• hypertension - give this med with ace inihibitors

  • watch for blood pressure 

drug-drug inreractions with erythropoietin (epoetin alfa)

• androgens (testosterone)

  • can increase blood viscosity (tickness), resulting in an increased response from epoetin alfa

  • effectiveness will be greatly decreased in pt w/ iron deficiency or other vitamin depleted states

what should you assess before giving erythropoietin (epoetin alfa)

• blood pressure 

what should you assess/evaluate during erythropoietin (epoetin alfa) administration

• injection - inspect vial, do not shake it)

• evaluate iron stores and nutritional status during treatment 

  • iron, ferritin, provide a diet high in portein and carbohydrates 

• monitor hgb and bp

what should you evaluate after giving erythropoietin (epoetin alfa)

• CBC

• key concept (dyspnea)

what should you teach the pt when taking arythropoietin (epoitin alfa)

• may cayse bone pain - give an analgesic for it

• adequate intake of iron, folic acid, and vitamin B12

• proper self-admin techniques

  • gently rotate vial 

  • keep refrigerated 

  • vials are single use onlyl/discard remaining medicine 

filgastrim (neupogen, granix) MOA

• leukopoietic growth factor 

• reocmbinant DNA technology 

what is the similar Filgastrim for home use

• TBO-filgastrim (Granix)

filgastrim trade name

• neupogen

• granix

what does filgastrim (neupogen,granix) reduce/produce

• reduces the incidence of severe neutropenia

• produced dose-dependent increase in circulating neutrophils 

• reduces the incidence of infection, need for hospitalization, and need for IV antibiotics 

• used for chronic neutropneia or neutropenia r/t chemotherapy

  • drug calls under a class called colony stimulating factors aka leukopoietic growth factors 

what factor is filgastrim?

• granulocyte colony-stimulating factor

  • leukopoietic growth factor

  • recombinant DNA technology

what is filgastrim used for?

• cancer

• bone marrow transplantation

• congenital neutropenia 

• severe chronic neutropenia 

what are some side effects of filgastrim (neupogen, granix)

• bone pain (r/t bone marrow stimulation > causes pressure/pain)

• anemia (bone marrow temporarily prioritizes WBCs over RBCs > mild anemia)

• constipation, dirrahea, vomiting (rapid GI mucosal stimulaltion)

• oral pain (rapid dividing of mucosal cells > mouth soreness/ulcers)

• asthenia, malaise (r/t increased metabolic demand & inflammation response)

filgastrim (neupogen,granix) selected safety information

• leukocytosis (too many WBCs)

• splenic rupture (overactive neutrophil production > enlarged spleen)

• glomerulonephritis (immune activation / WBC overproduction > kidney inflammation)

• capillary leak syndorme (cytokine-induced vessel leak>fluid shifts>hypotension and edema)

filgastirm (neupogen,granix) pre administer assessment

• assess status of immunizations to include pneumococcal vaccine, meningococcal, seasonal influenza vaccine 

• latex allergy (neupogen)

what else should you assess/implement when giving filgastrim?

• analgesics for bone pain 

• maintain meticulous infection control measures 

• monitor temperature and for signs and symptoms of infection 

• monitor for hepatic toxicity 

• monitor CBC twice weekly

what should you evaluate for when giving filgastrim?

• neutrophil count 

  • discontinue when neutrophil count 10,000/mm3 after the chemotherapy induced ANC nadir

MOA oprelvekin (neumega)

• stimulate activity of megakaryocytes and thrombopoietin

  • single megakaryocyte can produce thousands of platelets 

  • megakaryocyte activity is controlled by the hormone thrombopoieten, which is produced by liver

  • functionally equivalent to interleukin-11 (I L-11) which is a substance secreted by monocytes and lymphocytes that signal cells in the immune system to respond to infection 

trade name oprelvekin

neumega

what are the uses of oprelvkein (neumega)

• increase production of platelets 

what are some adverse effects of oprelvekin (neumega)

• fluid retention 

• cardiac dysrhythmias 

• effects on the eye 

what are you supposed to assess for regarding platelets with oprelvekin (interleukin-11)

• assess platelet count

• Greatest risk < 50,000/mm3

what should you monitor in pt when taking oprelvekin (interleukin-11)

• monitor for fluid retention

• protect pt from trauma (soft toothbrush, avoid injections, venipunctures, razors)

• monitor the pt for petechiae, ecchymosis, bleeding of gums, nosebleeds, occult or frankk blood in stools, urine, and/or vomitus 

pt instructions for oprelvekin (interleukin-11)

• immediately report edema, change in urinary output, body weight or dyspnea 

• avoid trauma

• teach pt to report signs of bleeding

• wear shoes when ambulating

what should you evaluate post admission of oprelvekin (interleukin-11)?

• monitor recovery of platelet count (aim for 50,000 mm/dL)

what is anemia?

• blood has reduced capacity to carry oxygen

  • hemorrhage 

  • excessive erythrocyte destruction 

  • insufficient erythrocyte synthesis 

what is the cause for anemia?

• anemia is a sign not a disease 

• find the underlying pathology 

what are the signs and symptoms of anemia?

• decrease exercise tolerance 

• fatigue and lethargy, dizziness, fainting 

• increase HR and RR

• heart failure 

what is macrocytic-normochromic anemia?

• large, abnormally shaped erythrocytes w/ normal hemoglobin concentration

examples of macrocytic-normochromic anemia?

• pernicious anemia, folate-deficiency, anemia

what is microcytic-hypochromic anemia?

• small abnormally shaped erythrocytes with decreased hemoglobin concentration

examples of microcytic-hypochromic anemia?

• iron-deficiency anemia

• thalassemia 

what is normocytic-normmochromic anemia?

• destruction or depletion of normal erythroblasts or mature erythrocytes

examples of normocytic-normochromic anemia?

• aplastic  anemia

• hemorrhagic anemia 

• seickle-cell anemia 

• hemolytic anemia

where is vitamin B12 secreted?

• stomach cells

• required for vitamin B12 metabolism

what are the outcomes of lacking intrinsic factor thus leading to vitamin B12 deficiency?

• inflammatory disease of stomach

• surgical removal of stomach

• strict vegetarin diet 

what is cyanocobalamin (nascobal) used for? what are their forms?

• replaced B12

• SC: purified form of vit B12 that is indicated for pts with vitamin B12 deficiency anemia 

• nasal formulation: maintenance only

adverse effects of cyanocobalamin (nascobal)

• diarrhea 

• hypokalemia is possible, thus seriums potassium levels are monitored periodically 

• arthalgia, dizziness, or headache (Rare)

how is cyanocobalamin (nascobal) administered?

• most often by weekly, bi-weekly, monthly IM 

• oral (mixed with juices, admin quickly to avoid degradation)

what should you assess regarding the effect of cyanocobalamin (nascobal)

• reverses most signs and symptoms of deficiency within a few days or week s

• improves memory loss, confusion, unsteadiness, tingling/numbness, moodiness, LOC changes

cyanocobalamin trade name

nascobal

what is the most common anemia?

ferrous sulfate

different ferrous’ ??

• ferrous sulfate (20-30% elemental iron)

• ferrous fumarate (contains 33% elemental iron)

• ferrous gluconate (contains 12% elemental iron)

adverse effects of ferrous sulfate 

• GI (food helps with symptoms but decreases absorption 50-70%)

• constipation

how do you give ferrous sulfate to a pt?

• Z track method - deep muscle

• IV prevent infiltration bc iron is highly irritating to tissues 

• do not crush tablets or empty contents of capsules 

• do not give tablets or capsules within 1 hour of bedtime 

what shuld you monitor when giving ferrous sulfate?

• monitor hemoglobin Hgb or hematocrit Hct

what is the antidote for acute iron intoxication?

• deferoxamine (Desferal)

pt teaching for ferrous sulfate

• constipation nis common

• use straw for oral forms 

• may darken stools 

• store medicine safely (children can fatally overdose - black box)

• food instructions

  • dairy inhibits absorption 

  • vitaminc c (strawberries and orange juice) increases absorption

black box warning for ferrous sulfate?

• fatal overdoses in children?