Pharmacology, part 15: Cardiovascular Medications - Antianemic Agents
In this article, we cover the vitamins and minerals that are essential to the production of red blood cells. The Nursing Pharmacology video series follows along with our Pharmacology Flashcards, which are intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI, and NCLEX.
When you see this Cool Chicken, that indicates one of Cathy's silly mnemonics to help you remember. The Cool Chicken hints in these articles are just a taste of what's available across our Level Up RN Flashcards for nursing students!
Folic acid - folate, vitamin B9
Folic acid (Folate, Vitamin B9) is a water-soluble B vitamin. Folate occurs naturally in food and folic acid is the synthetic form of this vitamin used in supplements and fortified foods.
Folic acid is used to treat megaloblastic anemia, which is a condition where bone marrow produces unusually large, structurally abnormal, immature red blood cells.
Folic acid is also used to treat microcytic anemia, a condition in which the body’s tissues and organs do not get enough oxygen. Lastly, and perhaps more importantly, folic acid is used to prevent neural-tube defects in developing fetuses. Neural tube defects are birth defects of the brain, spine, or spinal cord such as spina bifida (spine and spinal cord don't form properly) and anencephaly (born without parts of the brain and skull).
Mode of action
Folic acid works by stimulating the production of red blood cells, white blood cells and platelets.
Side effects of folic acid are fairly minimal and can include a rash and change the color of the patient's urine to a more intense yellow color.
Cyanocobalamin - vitamin B12
Cyanocobalamin (vitamin B12) is a man-made form of vitamin B12 used to prevent and treat pernicious anemia. Pernicious anemia is a type of vitamin B12 deficiency that results from the impaired absorption of vitamin B12 due to the lack of a substance known as intrinsic factor (IF). Intrinsic factor (IF) is produced by the stomach lining and binds vitamin B12 so that it can be absorbed in the intestines.
In order for cyanocobalamin to be an effective treatment for pernicious anemia, it must be given through the nasal, sublingual, or intramuscular route instead of orally due to the lack of intrinsic factor (IF) in the intestines. Without IF, the medication will not be absorbed and therefore will not effectively treat the B12 deficiency.
Cynthia keeps babblin’ about her pernicious anemia. Quit complaining and go take some cyanocobalamin.
Nursing care and patient teaching
There are a few important points to remember when caring for a patient taking cyanocobalamin. First, higher doses of folic acid can mask a B12 deficiency, resulting in cognitive decline. It’s important to ensure you’re not masking signs of a B12 deficiency by loading the patient up with folic acid. Second, vegetarians will need to ensure they are getting a sufficient intake of vitamins B9 and B12 because deficiencies in these vitamins can occur with vegetarians if they're not careful about their diet.
Iron supplements - ferrous sulfate (oral) & iron dextran (IV/IM)
Ferrous sulfate and iron dextran are medications used to treat and prevent iron deficiency anaemia. Iron helps the body to make healthy red blood cells, which carry oxygen around the body. Iron is an essential component needed for hemoglobin, myoglobin and many other enzymes found in the body. Ferrous sulfate is administered through the oral route and iron dextran is given through the Intravenous (IV) or intramuscular (IM) route.
Side effects with ferrous sulfate can include GI upset, constipation, teeth staining and can cause black colored stool. Iron dextran can cause hypotension and flushing. When giving iron via an IV or IM, it can cause staining at the injection site.
When caring for a patient taking iron supplements it’s important to let the patient know that they could experience both staining of the teeth and dark discolored stool. It’s also important that the patient be getting enough vitamin C as vitamin C is very important for iron absorption. Patients can, in fact, take their iron supplement with orange juice to promote absorption. The patient should also be encouraged to change their diet and increase their intake of iron-rich foods so they aren’t reliant on supplements.
Patients should avoid taking their iron supplements with dairy products, as calcium can decrease iron absorption.
When administering iron dextran to a patient it’s important to use the z-track method. Iron supplements should also NOT be given with meals and should be administered either 1 hour before or 2 hours after eating. Patients should also increase fluid and fiber intake to help prevent the side effect of constipation.
I’m furious that my teeth got stained from ferrous sulfate (my iron supplement).
Okay. In this video, we are going to talk about vitamins and minerals that are important for red blood cell production. If you are following along with cards, I'm on card 47 in our Pharm 2.0 edition.
Let's first talk about folic acid, or vitamin B9.
So folic acid is used to treat megaloblastic anemia, which is where the body produces these abnormally large, or mega-sized, red blood cells that are immature. It's also used for microcytic anemia. And then perhaps most importantly, it's used to prevent neural-tube defects in developing fetuses. And this is going to be a super important point for you to know for the NCLEX and for your nursing school exams.
So folic acid, it stimulates the production of red blood cells, white blood cells, and platelets.
Side effects are fairly minimal. They can include a rash as well as changing the urine a little more intensely yellow color.
Now let's talk about vitamin B12, which is cyanocobalamin.
So this is used to treat pernicious anemia. Pernicious anemia is an issue where a person doesn't produce intrinsic factor in their stomach. And that intrinsic factor is needed for absorption of B12. So they don't produce that intrinsic factor and therefore B12 isn't being absorbed, so they have this B12 deficiency.
So we can use Cyanobalamin to help correct this deficiency, but we're not going to give it orally, right? If they lack this intrinsic factor. Because it's not going to be absorbed. So we have to give it through the nasal route in order for it to be effective.
So side effects of cyanocobalamin include hypokalemia, GI upset, as well as possible hypersensitivity.
My little silly tip for remembering cyanobalamin, if you look at the word, it starts with C-Y, so I think of the name Cynthia. And then my tip is "Cynthia keeps babbling about her pernicious anemia, and she needs to quit complaining and just go take her cyanobalamin," because it kind of looks like Cynthia babbling. So I think about her babbling about her pernicious anemia. So that will help you to remember that cyanobalamin is used for pernicious anemia.
Another couple of important points. Higher doses of folic acid can mask a B12 deficiency, and this can result in cognitive decline. So we want to make sure that we are not masking signs of a B12 deficiency by loading up with folic acid.
Also, vegetarians will just need to be careful that they are getting sufficient intake of B9 and and B12 because deficiencies in these vitamins can occur with vegetarians if they're not careful about their diet.
Now, let's talk about iron supplements which are given for iron deficiency anemia.
So we can give ferrous sulfate, which is given through the oral route, or iron dextran, which is given through the IV or IM route.
So iron is basically an essential component needed for hemoglobin, myoglobin, and many enzymes in the body.
If a patient is getting oral iron supplements, so if they're getting ferrous sulfate, we do need to be aware of some of the side effects here. It can cause GI upset. Specifically, constipation is fairly common. It can also teeth staining. So you may want to give it with a straw to try to kind of bypass the teeth and not have that staining.
It also causes kind of dark green, black colored stool, which can be alarming to the patient if you don't give them a heads-up. So you definitely want to do some patient teaching that it will discolor their stool, and that is harmless.
If we are giving iron via the IV or IM route with iron dextran, it can cause staining at the IV site. It can also cause hypotension and flushing. When we're giving iron dextran, we want to use the Z-track method, right where you kind of pull the skin, do the injection, and then let the skin go.
Also keep in mind that vitamin C is very important for iron absorption, so we want to make sure the patient is getting plenty of vitamin C through foods that are rich in vitamin C, in order to allow for that absorption of iron.
We are also going to give iron not with meals, so we want to give it one hour before or two hours after meals, and if they're taking the ferrous sulfate, like we mentioned can cause constipation, then we would recommend that our patient increase their fluid and fiber intake to help prevent that constipation.
We always want to keep our eye on supplements, out of the reach of children, to prevent fatal toxicity.
And then always you want to encourage your patient to always increase their intake of iron-rich foods in addition. So we don't want them to just rely on these supplements. They should really try to change their diet as well, to make sure they're getting sufficient iron.
So the tip I have for iron is that "I'm furious that my teeth got stained from ferrous sulfate." So furious and ferrous kind of look similar, and that helps me to remember that a key side effect of ferrous sulfate is teeth staining. So if you get furious about that ferrous sulfate teeth staining, then you can try using a straw, and that might work better.
In my next video, we will talk about medications that are used to correct electrolyte imbalances in the bloodstream. So thank you so much for watching. I'll be back with more good information!
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