Measures to prevent iron deficiency conditions test. Prevention of iron deficiency conditions in children. Pharmaceutical care when using oral iron supplements

In the Sverdlovsk region, patients with diabetes mellitus (according to the national register 2015)

Consequences of late complications of diabetes mellitus Diabetic retinopathy The leading cause of blindness in adults 1.2 Diabetic nephropathy The leading cause of end-stage renal failure 3.4 Cardiovascular diseases The prevalence of MI is 2-4 times higher than in the population 5 Diabetic neuropathy The leading cause of non-traumatic amputation of the lower extremities 7.8 8/10 diabetic patients die from CV complications 6 1. UKPDS Group. Diabetes Res 1990;13(1):1– Fong DS et al. Diabetes Care 2003;26(Suppl 1):S99–S HDS. J Hypertens 1993;11(3):309– Molitch ME et al. Diabetes Care 2003;26(Suppl 1):S94–S Kannel WB et al. Am Heart J 1990;120:672– Gray RP et al. In Textbook of Diabetes 2nd Edition, Kings Fund. London: British Diabetic Association, Mayfield JA et al. Diabetes Care 2003;26(Suppl 1):S78–S79

Natural history of the development of type 2 diabetes Ramlo-Halsted BA, Edelman SV. Prime Care 1999; 26: Nathan DM. N Engl J Med 2002; 347: Insulin secretion Hyperinsulinemia Insufficiency Years Pre-diabetes Insulin resistance Postprandial glucose Fasting glucose Decreased glucose utilization by peripheral tissues Increased glucose production by the liver Microangiopathies Macroangiopathies Type 2 diabetes Incretin secretion Obesity Physical inactivity Excessive nutrition Gestational diabetes

Risk groups for developing type 2 diabetes All people aged 45 years All people with overweight and obesity (BMI 25 kg/m2) + the presence of 1 risk factor – Family history of diabetes (parents or siblings with type 2 diabetes) – Habitually low physical activity. – Gestational diabetes mellitus or history of large birth – Arterial hypertension (140/90 mmHg or drug antihypertensive therapy) – HDL cholesterol 0.9 mmol/l and/or triglyceride level 2.82 mmol/l – Polycystic syndrome ovaries – Presence of cardiovascular diseases – Prediabetes, previously identified Algorithms for providing specialized care to patients with diabetes mellitus, edited by I.I. Dedova, M.V. Shestakova: 7th issue, Moscow, 2015

25 kg/m 2 + 1 of the risk factors With a normal result - 1 time in 3 " title="Screening Screening tests: fasting plasma glucose or OGTT with 75 g of glucose Age at the start of screening Groups in which screening is carried out Frequency of examination Any adult With a BMI>25 kg/m2 + 1 of the risk factors With a normal result - 1 time in 3" class="link_thumb"> 6 !} Screening Screening tests: fasting plasma glucose or OGTT with 75 g of glucose Age at the start of screening Groups in which screening is carried out Frequency of examination Any adult With a BMI>25 kg/m from risk factors With a normal result - 1 time in 3 years Persons with prediabetes - 1 time per year > 45 years With normal body weight in the absence of risk factors With normal results - once every 3 years Algorithms for providing specialized care to patients with diabetes mellitus, edited by I.I. Dedova, M.V. Shestakova: 7th issue, Moscow, 2015 25 kg/m2 + 1 of the risk factors With a normal result - 1 time in 3 "> 25 kg/m 2 + 1 of the risk factors With a normal result - 1 time in 3 years Persons with prediabetes - 1 time per year > 45 years C normal body weight in the absence of risk factors With a normal result - once every 3 years Algorithms for providing specialized care to patients with diabetes mellitus edited by I.I. Dedov, M.V. Shestakova: 7th issue, Moscow, 2015 "> 25 kg/ m 2 + 1 of the risk factors With a normal result - 1 time in 3 " title="Screening Screening tests: fasting plasma glucose or OGTT with 75 g of glucose Age at the start of screening Groups in which screening is carried out Frequency of examination Any adult With BMI >25 kg/m2 + 1 of the risk factors If the result is normal – 1 time in 3"> title="Screening Screening tests: fasting plasma glucose or OGTT with 75 g of glucose Age at the start of screening Groups in which screening is carried out Frequency of examination Any adult With BMI>25 kg/m 2 + 1 of the risk factors With a normal result - 1 time in 3"> !}

Rules for conducting OGTT OGTT should be carried out in the morning against the background of at least 3 days of unlimited nutrition (more than 150 g of carbohydrates per day) and normal physical activity. The test should be preceded by an overnight fast for 8–14 hours (you can drink water). The last evening meal should contain 30-50 g of carbohydrates. After drawing blood on an empty stomach, the subject should drink 75 g of anhydrous glucose or 82.5 g of glucose monohydrate dissolved in 250–300 ml of water within no more than 5 minutes. Smoking is not permitted during the test. After 2 hours, blood is drawn again. To prevent glycolysis and erroneous results, determination of glucose concentration is carried out immediately after blood collection, or the blood should be centrifuged immediately after collection, or stored at a temperature of 0–4°C, or collected in a tube with a preservative (sodium fluoride). Algorithms for providing specialized care to patients with diabetes mellitus, edited by I.I. Dedova, M.V. Shestakova: 7th issue, Moscow, 2015

OGTT is not performed against the background of an acute illness against the background of short-term use of drugs that increase the level of glycemia (glucocorticoids, thyroid hormones, thiazides, beta-blockers, etc.) Algorithms for providing specialized care to patients with diabetes mellitus, edited by I.I. Dedova, M.V. Shestakova: 7th issue, Moscow, 2015

Diagnosis Glucose (venous plasma) above 7.0 mmol/l on an empty stomach or capillary whole blood glucose above 6.1 mmol/l Blood glycohemoglobin above 6.5% Blood glucose above 11.1 mmol/l at any time of the day. At least 2 indicators in the diabetic range. In the absence of symptoms of acute metabolic decompensation, the diagnosis should be made on the basis of two numbers that are in the diabetic range, for example, a double HbA1c determination or a single HbA1c determination + a single glucose determination. Algorithms for providing specialized care to patients with diabetes mellitus, edited by I.I. Dedova, M.V. Shestakova: 7th issue, Moscow, 2015

Glycohemoglobin as a diagnostic criterion for diabetes An HbA1c level of 6.5% was selected as a diagnostic criterion for diabetes. An HbA1c level of up to 6.0% is considered normal. The study must be performed using a method for determining HbA1c certified in accordance with the National Glycohemoglobin Standardization Program (NGSP) or the International Federation of Clinical Chemists (IFCC) and standardized according to the reference values ​​adopted in the Diabetes Control and Complications Trial (DCCT)

Standardized equipment for determining the level of HbA1c was installed by the Ministry of Health in 2014 in 11 health care facilities: 1. GBUZ SO "Serovskaya GB 1" 2. GBUZ SO "Krasnoturinskaya GB 1" 3. GBUZ SO "Irbitskaya Central City Hospital" 4. GBUZ SO "Alapaevskaya Central City Hospital" ", 5. GBUZ SO "City Hospital 3 Kamensk-Uralsky", 6. GBUZ SO "City Hospital 1 Asbest", 7. GBUZ SO "City Hospital 1 Pervouralsk", 8. GBUZ SO "Revdinskaya City Hospital", 9. GBUZ SO "Krasnoufimskaya Central District Hospital", 10. GBUZ SO "Demidov City Hospital of Nizhny Tagil", 11. GBUZ SO "Sverdlovsk Regional Clinical Hospital 1".

Regulatory documents Order of the Ministry of Health of the Russian Federation No. 899 n – On approval of the procedure for providing medical care to the adult population in the field of “Endocrinology” - primary health care is prescribed in common for an endocrinologist, local therapist and general practitioner (general functions) Order of the Ministry of Health of the Russian Federation No. 1344 n – On approval of the procedure for conducting dispensary observation

In accordance with the order of the Ministry of Health of the Russian Federation dated 1344 n “On approval of the procedure for conducting dispensary observation.” Type 2 diabetes mellitus without insulin is subject to clinical observation by a therapist or general practitioner (family doctor) once every 3 months

Regulations on the organization of medical care for patients with diabetes mellitus in the Sverdlovsk region (draft) Local therapists, general practitioners (family doctors) perform the following functions: carry out diagnostics in order to identify diabetes mellitus and other disorders of carbohydrate metabolism (establish the fact of the presence of diabetes mellitus diabetes or prediabetes), conduct screening in risk groups, provide medical care on an outpatient basis based on standards of medical care, refer patients for specialized medical care to an endocrinologist in accordance with routing at least once every 12 months (more often if necessary).

The procedure for planned actions in case of suspected diabetes mellitus: 1. Clarify the degree of carbohydrate metabolism disorder - a general practitioner or an acute respiratory disease physician 2. For newly diagnosed diabetes mellitus, it is necessary to: a) recommend diet, physical activity and metformin (if there is a BMI of more than 25 kg/m2 2 and in the absence of contraindications), recommend self-monitoring of glycemia b) refer to an endocrinologist in accordance with the routing - clarification of the type of diabetes mellitus (if necessary) - entry of data into the Diabetes Mellitus Register - determination of individual treatment goals (target values ​​of fasting and after meals glycemia, target HbA1 c) If insulin is suspected (clinic of severe decompensation), refer to an endocrinologist with the indication “cito! – do you need insulin? – consultation on the day of application or within 3 working days

Dispensary appointment (examination) by local therapists, general practitioners (family doctors) once every 3 months - includes the collection of complaints and anamnesis, physical examination. In particular, in each examination it is necessary to indicate: data on self-monitoring of glycemia, the patient’s weight dynamics, body mass index, blood pressure, the presence or absence of ulcerative lesions on the lower extremities (visual examination). At least once a year, a palpation assessment of the pulsation of the arteries of the feet is performed at the appointment. Purpose and evaluation of laboratory and instrumental studies: once a month - glycated hemoglobin At least once a year: general blood test, general urine test, blood biochemistry (AST, ALT, bilirubin, total cholesterol, total protein, creatinine, potassium, sodium , calculation of glomerular filtration rate), albuminuria or daily proteinuria, ECG, fundus examination by an ophthalmologist (with pupil dilation), fluorography or chest x-ray

Indications for consultation with an endocrinologist for type 2 diabetes mellitus (by referral from a general practitioner, general practitioner) (draft): Newly diagnosed diabetes mellitus At least once every 12 months as planned - to monitor the condition and correct treatment Before the expiration of 12 months - in case of failure to achieve target levels of compensation of carbohydrate metabolism (according to self-monitoring and/or glycated hemoglobin) on current glucose-lowering therapy for 6 months. Target levels of carbohydrate metabolism compensation and the type of glucose-lowering therapy are determined by an endocrinologist. Doses of glucose-lowering drugs can be adjusted over time by the therapist to achieve target levels of compensation for carbohydrate metabolism. Before the expiration of 12 months - in case of non-standard course of the disease, the appearance of new symptoms (signs of progression of complications of diabetes mellitus or signs of other endocrine diseases)

Inpatient treatment Treatment in a 24-hour hospital according to indications according to the territorial affiliation - is carried out on the basis of intermunicipal medical centers (IMC) in specialized endocrinology departments in accordance with Annexes 4, 5, 6 to the order of the Ministry of Health of the Russian Federation dated n, or in therapeutic departments with licensed endocrinology beds , where treatment is carried out by an endocrinologist. If indicated, patients with diabetes mellitus are sent to the Sverdlovsk Regional Clinical Hospital 1 (hereinafter referred to as the Regional Clinical Hospital 1) - for residents of the region - or to the Municipal Autonomous Institution "City Clinical Hospital 40" (hereinafter referred to as Regional Clinical Hospital 1). MAU "GKB 40") - for residents of Yekaterinburg Hospitalization to the endocrinology department of the State Budgetary Healthcare Institution SO "SOKB 1" is carried out by referral from endocrinologists of the consultative and diagnostic clinic "GBUZ SOSOKB 1" (after an in-person consultation or teleconsultation).

Algorithm for individualized selection of therapy goals for HbA1 with Age Young Middle Elderly or life expectancy

HbA1c, % FPG, mmol/l FPG 2 hours after meals, mmol/l

Initiation of treatment for type 2 diabetes Metformin - first-line therapy - prescribe after making sure there are no contraindications (history, OBC, medical history) Refer to an endocrinologist for newly diagnosed type 2 diabetes: Data in the Register Individual goals (fasting and postprandial glycemia, HbA1 with ) Recommendations for treatment (correction) Monitoring 1 time in 3 months (HbA1 s and self-monitoring diaries), If the target level is not achieved, refer to the endocrinologist again no later than after 6 months. When target indicators are achieved, refer to an endocrinologist once every 12 months.

Over the past decades, metformin has revolutionized the treatment of type 2 diabetes worldwide. Despite the presence of about 10 classes of drugs on the market for the treatment of type 2 diabetes, metformin remains the most widely used drug in the 1st line of treatment for type 2 diabetes Chacra AR. Am J Ther 2014;2:198–210. Metformin is the most studied and widely used drug in the 1st line of treatment for type 2 diabetes.

Effects of metformin Metformin reduces the relative risk of cardiovascular events in patients with type 2 diabetes (UKPDS)¹ Metformin has demonstrated long-term benefits on cardiovascular events (metabolic memory effect)² Metformin therapy provides significant reduction in glycemia¹ Compared with existing DSPs, metformin has a neutral effect on weight body or leads to a slight decrease³ 1. UKPDS 34 Lancet 1998;352: Holman RR et al. NEJM 2008;359(15): Nathan DM et al. Diab Care 2009;32(1):

Algorithms for specialized medical care for patients with RAE DM Lifestyle changes At the “debut” of DM2 HbA1c from 6.5 to 7.5% Stage 1 Start of therapy Monotherapy: Met and DPP-4 aGLP-1 Alternative: SM*; Glinides, TZD, Acarbose * SM except glibenclamide Stage 2 Intensification of therapy Continue initial therapy Combination of 2 drugs except irrational combinations Reduction of HbA1c

Stage 1 Start of therapy Insulin ± Other drugs Alternative: Combination of 2 - 3 drugs (basis - SM) Stage 2 Intensification of therapy Intensification of insulin therapy Combination of 2 or 3 drugs except irrational combinations Reduction of HbA1c 1.5% Reduction of HbA1c 9.0% Algorithms specialized medical care for patients with RAE diabetes In any combination of 2 or 3 drugs, the use of metformin is recommended in the absence of contraindications 9.0% Algorithms for specialized medical care for patients with RAE diabetes In any combination of 2 or 3 drugs, the use of metformin is recommended in the absence of contraindications">

Limitations of immediate-release metformin therapy Taking the drug several times a day, which reduces patient adherence to therapy 1 Adverse events from the gastrointestinal tract, which are observed in 20-30% of patients 2.3 About 60% of patients with type 2 diabetes do not achieve treatment goals 4 1 Paes AHP et al. Diabetes Care 1997;20(10): Garber AJ et al. Am J Med 1997;103: Krentz AJ et al. Drug Saf 1994;11: Saaddine JB et al. Ann Intern Med 2006;144:465-74

Polypharmacy is the main problem in the treatment of type 2 diabetes Morning Day Evening At night Metformin Glibenclamide Atorvastatin Bisoprolol Ramipril Felodipine Aspirin Mononitrate Amitriptyline Sildenafil Example of daily therapy for a patient with type 2 diabetes 60%-75% of patients with type 2 diabetes in the ACCORD, ADVANCE, PROactive and RECORD studies took 5 drugs per day ACCORD study group. N Engl J Med 2008;358: ADVANCE collaborative group. N Engl J Med 2008;358: Dormandy JA et al. Lancet 2005;366: Home PD et al. N Engl J Med 2007;357:28-38 ITC-CMC-GXR-SKO-29.Dec.2014

Metformin extended release. Innovative patented production technology Unique Diffusion System through the GelShield Barrier ensures a gradual and uniform release of metformin from the Glucophage Long tablet - T Cmax prolonged action tablets - 7 hours. – T C max of regular release tablets - 2.5 hours. Before oral administration After oral administration Timmins P. Clin Pharmacokinet 2005;44:721-9

Any adverse events from the gastrointestinal tract Nausea Dyspeptic symptoms Abdominal bloating Flatulence Constipation Abdominal pain Extended-release metformin compared with IR metformin in patients with newly diagnosed type 2 diabetes Blonde. Curr Med Res Opin 2004; 20:565– % - 75% 1 year of therapy % of patients p

Dosage regimen: patients who were first prescribed Glucophage Long: 1. Instructions for medical use Glucophage Long 500 mg LSR / Instructions for medical use Glucophage Long 750 mg LP Dose titration is carried out based on glycemic control indicators. If the target glycemic level is not achieved, the dose of the drug should be increased.

Transferring patients from metformin NV to extended-release metformin The principle of dose-by-dose conversion or prescribing a dose as close as possible to the one used 1. Instructions for medical use Glucophage Long 500 mg LSR / Instructions for medical use Glucophage Long 750 mg LP

MET SM TZD iDPP-4 BASAL INSULIN BASAL INSULIN aGPP-1 Rational combinations of hypoglycemic drugs Algorithms for specialized medical care for patients with diabetes mellitus 6th edition Diabetes mellitus. 2013;(1S): DOI: /DM20131S1-121
Teleconsultations at GBUZ SO "SOKB 1" - since 2013 Orders of the Ministry of Health SO 370-p from and 1013-p from In order to establish contact for the first time, write a letter to our teleconsultation center: ru or call:

THANK YOU FOR YOUR ATTENTION! ru ru (343) , ru (343)

In cases where the prevalence of iron deficiency conditions in a particular region exceeds 40%, for the purpose of mass prevention of anemia in adults and children, it is recommended to carry out a number of measures aimed at the timely detection, elimination and prevention of the development of this pathology.

MASS PREVENTION

Fortification. This procedure involves fortifying foods widely consumed by the population with iron. Typically this role is played by bread or pasta. To successfully prevent anemia, it is necessary that the percentage of the population consuming this product is at least 65%. However, the active implementation of fortification is complicated by a number of circumstances. The main one is the lack of a food product that optimally transports iron compounds and promotes its good absorption. Therefore, at present, the effectiveness of mass prevention does not exceed 50% among the population covered.

Supplementation. Targeted prevention of anemia in people at risk using prophylactic doses of ferrodrugs is considered more effective. Supplementation is carried out particularly in women in the 2nd and 3rd trimesters of pregnancy and during the first three months of lactation. Currently, statistics show that with coverage ranging from 50 to 95% of expectant mothers, only 67% of them receive an effective dose.

PRIMARY PREVENTION

SECONDARY PREVENTION OF IRON DEFICIENCY

Secondary prevention means early diagnosis of latent iron deficiency. Diagnostics are recommended to be carried out every time patients visit doctors, as well as during medical examinations, clinical examinations, etc., especially for people at risk. For secondary prevention, if necessary, the doctor prescribes iron-containing medications. In addition to them, hematogen can be used.

WHO IS IN RISK GROUPS

These include persons:

• with low socio-economic status (dysfunctional families, refugees, migrants);
• who have previously been diagnosed with iron deficiency anemia;
• who have a history of lead poisoning;
• on a vegetarian diet;
• whose lifestyle includes active physical activity and professional athletes;
• with gastrointestinal diseases;
• females of childbearing age, especially after multiple pregnancies or frequent births.

Children also at risk include:

• whose mothers refused breastfeeding or interrupted it after four months of age;
• born prematurely or with low birth weight;
• those who receive large amounts of cow's milk or whose diet contains mainly plant-based products;
• developmentally delayed or with special needs due to their health status.

The well-being of a nation is determined by its level of health, one of the components of which is nutrition. It is a necessary condition for normal life activity and performance, resistance to diseases, and an active life position both in adulthood and in childhood.

However, the negative trends of recent decades have affected the health of citizens of the entire state, which is reflected in a significant reduction in life expectancy: according to this indicator, Russia lags behind developed countries by 20–25 years. Often people, especially men, die immediately after they retire.

Of course, an unbalanced diet plays a significant role in such sad statistics, when the diet is overloaded with fats and carbohydrates, but there is a constant lack of proteins, vitamins, and microelements, including fluorine, iron, potassium, iodine, and calcium. The reason for such imbalances in nutrition may be hidden both in a significant decrease and loss of purchasing power of Russian citizens, and in a lack of knowledge in matters of proper healthy nutrition. When filling the food basket, citizens of our country are often guided solely by their own taste preferences, without thinking about the importance of providing the body with micronutrients that are not synthesized by the body itself, but come there exclusively from the outside. In this case, the main task is to ensure regular and sufficient intake of micronutrients for the body in accordance with the physiological norm.

The importance of this point was highlighted at the international conference of the World Health Organization, which was held in the early 90s in the capital of Italy. It was noted that the lack of micronutrients in the daily diet of the population is relevant even for developed countries, and in countries with a low standard of living it has become a threat on a global scale. If measures to effectively correct micronutrient deficiency are not taken in a timely manner, they can cause the formation of a number of common chronic diseases and low levels of health for entire generations, which will directly affect the quality of life of the population of our country.

Iron– an essential microelement, deficiency of which can be expressed in various forms:

• prelatent,
• latent,
• Iron-deficiency anemia.

The prevalence of this disease among some categories of the population of the Russian Federation ranges from 20 to 80%, and so far the situation remains quite serious. This is evidenced by the resolution of the Chief State Sanitary Doctor of the Russian Federation G.G. Onishchenko. dated 05.05.2003 No. 91 “On measures to prevent diseases caused by iron deficiency in the nutritional structure of the population.” The document provides data according to which the incidence of anemia has doubled over the past decade and the reason for this is a diet poor in vitamins and microelements. Infants in the first year of life, children under 3 years of age, as well as women with different stages of pregnancy and nursing mothers are at particular risk.

Iron deficiency in a child’s body has particularly devastating consequences: almost all organs and systems of the child function in a slow mode, the immune system suffers, and there is an increasing lag in the mental and physical development of children.

This problem is being studied at the international level, comparative analyzes of the nutrition of the population of different countries are carried out, including taking into account eating habits and the objective current conditions of food production. Studies have shown that severe forms of iron deficiency anemia (IDA) are directly related to the lack of iron in the daily diet of various population groups, and they are also a consequence of the lack of prevention, which involves taking iron-containing drugs.

As it turned out, a deficiency of this microelement in any form causes a negative impact on health in general, including disruptions in the functioning of the central nervous system, cardiovascular and digestive systems, slows down the processes of hematopoiesis and tissue regeneration, causing immunity disorders, infectious diseases, slowdown intellectual and physical development of children, loss of ability to work in adults.

In this regard, the World Health Organization has developed a program for fortifying foods with iron, which is recommended for implementation in most countries of the world. Based on this document, our own national programs for the prevention of iron deficiency were adopted. There is such a program in the Russian Federation, according to which state policy concerning healthy nutrition of the population involves the production of iron-fortified products, as well as the production of biologically active additives (BAA) for food with anti-anemic effects.

Thus, the relevance of carrying out work on clinical nutritional research is dictated by the need to take urgent measures to prevent and eliminate iron deficiency in the population of our country, especially children and adolescents.

PREVENTION AND TREATMENT OF HUMAN IRON DEFICIENCY CONDITIONS

According to WHO, iron deficiency- a truly widespread disease. Of the 7 billion people who make up the world's population, about 2 billion suffer from iron deficiency to one degree or another. Currently, in medical circles this disease is called sideropenia. Sideropenia is particularly widespread in third world countries, where the low standard of living of the population does not allow sufficient diversification of the diet. However, in developed countries the picture is not so good; the reasons for this phenomenon are:

• insufficient iron content in the diet,
• disruption of absorption processes in the intestine,
• depletion of microelement reserves due to blood loss,
• increased need for iron in children and adolescents during intensive growth,
• pregnancy,
• lactation period.

Of no small importance is the low iron content in the soils of certain territories, such as the Vladimir, Yaroslavl, Kostroma, Ivanovo and Vologda regions of the Central Federal District, as well as in the Northern Urals, in the highlands of Central Asia.

Per kilogram of a healthy person’s weight there is approximately 60 mg of the microelement, thus the total amount of iron approaches 5 g. Most of it is contained in blood hemoglobin, but it also accumulates in the spleen, liver, muscle tissue myoglobin, brain and bone marrow, oxidative enzymes groups. More than 7 dozen enzymes, including the proteins lactoferrin and transferrin, are the main iron stores in the body.

In the muscles of an adult man, myoglobin contains 100 mg of iron, in women - 30-50 mg less, in newborns after full-term pregnancy - 400 mg, and in premature babies - only 100 mg.

If a microelement accumulates in the body in insufficient quantities, then they speak of iron deficiency - an iron deficiency state of the body. Its variety is the clinical-hematological syndrome with the abbreviation IDA, when a lack of iron provokes a failure of hemoglobin synthesis in the body.

According to WHO information, three quarters of anemia of various origins were caused by anemic IDA syndrome, which in absolute numbers amounted to more than 200 million people. Women of the fertile period of life, expectant mothers at various stages of pregnancy, as well as preschool children are at particular risk. In the United States, 25% of children under the age of two are susceptible to iron deficiency anemia, and in Russia this figure is already 50%. Children of senior preschool and primary school age also develop anemia quite often, their share is 20%.

Due to intense blood loss, 90% of women in these groups have some degree of iron deficiency, 30% of the remaining Russian women also have hidden iron deficiency. These indicators are higher in such regions of our country as the North Caucasus, eastern Siberia, and the Arctic.

Thus, they can develop iron deficiency anemia at any time.

As a rule, the initial symptoms of sideropenia do not alarm potential patients. Systolic murmur, tachycardia, dizziness, general weakness, shortness of breath, pale skin are attributed to fatigue or stress. In fact, all these symptoms are caused by a lack of oxygen in the tissues and organs, which causes IDA. Without receiving proper treatment, the body continues to degrade and disturbances appear in the functioning of the immune, respiratory systems, central nervous system, gastrointestinal tract, and cardiovascular system. Sideropenia becomes the precursor of many serious diseases, the causes of which could be eliminated by increasing iron intake. Such unpleasant signs of sideropenia as brittle nails, hair loss, changes in taste and olfactory sensations are also familiar to most people.

Thus, practically no disease in children and adults can be completely cured without eliminating IDA, which can have two pathogenetic expressions:

1) insufficient activity of tissue respiration enzymes;

2) incomplete supply of oxygen to the body.

Diagnosis of VDN is based on establishing laboratory signs of anemia itself and iron deficiency in the body (Table 1).

Table 1.

Indicators of iron, erythrocyte and hemoglobin metabolism in healthy people, patients with IDA and patients with IDD.

The World Health Organization and the American Committee on Nutrition and Nutritional Supplements consider iron microelements to be of critical importance in the treatment of anemia. It is impossible to correct the balance of iron in the body by changing the diet or using herbal medicine. They can act as maintenance therapy after the treatment itself, but they cannot fully replace it. Russian scientist A. Alperin created the most comprehensive classification of IDA, where this pathology is divided by severity, stages and form. According to his classification, severe anemia implies a hemoglobin level in the body of less than 70 g/l, moderate anemia corresponds to 70-90 g/l, and mild is estimated at Hb from 90 to 110 g/l.

IRON DEFICIENCY CONDITIONS IN CHILDREN AND ADOLESCENTS.

As medical statistics from the Department for Maternity and Child Protection of the Ministry of Health of the Russian Federation show, in our country various degrees of VHD are diagnosed in 30% of children of preschool and primary school age, as well as in almost all women with different stages of pregnancy. The consequence of this is frequent acute respiratory viral infections, infections of the digestive system, and deaths. For example, when contracting salmonellosis, children with high hemoglobin levels tolerate this disease more easily than small patients with IDA.

The lack of a microelement also causes damage to the brain activity of the developing child’s body. Apathy, inhibited reactions, dull mood, moodiness - all these deviations in behavior indicate iron deficiency anemia in a growing body. If a child is not interested in studying, he complains of deteriorating memory and concentration, then this also applies to the symptoms of IDA.

A control group of schoolchildren who were diagnosed with a mild form of anemia showed reduced mental development: their IQ was 25 points lower, and solving problems took 4.08 seconds, compared to 1.81 seconds for children without anemia.

Table 2.

Symptoms of clinical polymorphism depending on age.

Pharmaceutical care:
treatment of iron deficiency anemia

I. A. Zupanets, N. V. Bezdetko, National Pharmaceutical University

Blood is a vital medium of the body. It performs numerous and varied functions: respiration, nutrition, excretion, thermoregulation, maintaining water and electrolyte balance. The protective and regulatory functions of blood are well known due to the presence of phagocytes, antibodies, biologically active substances, and hormones in it.

The most common blood disease is iron deficiency anemia. According to WHO, more than half of the population of various countries suffers from iron deficiency anemia. It affects all age groups of the population, but most often occurs in children, adolescents and pregnant women. In many countries, the issue of preventing and treating anemia is becoming a social problem. The presence of iron deficiency reduces the quality of life of patients, disrupts their ability to work, and causes functional disorders in many organs and systems. To prevent and eliminate iron deficiency conditions, a whole group of iron-containing drugs has been successfully used, the range of which is continuously replenished and updated. The pharmacist’s recommendations on choosing the optimal drug and the conditions for its rational use will help to significantly improve the well-being and quality of life of patients with iron deficiency conditions, as well as contribute to the timely prevention of the development of iron deficiency in “risk groups”.

The role of iron and its metabolism in the human body

The body of an adult contains 2-5 g of iron, and a newborn contains 300-400 mg. However, despite its low content, iron is a unique microelement in its importance, which is presented in various molecular systems: from complexes in solution to macromolecular proteins in the membranes of cells and organelles. In particular, iron is an important constituent of hemoglobin, myoglobin and iron-containing enzymes.

First of all, the role of iron is determined by its active participation in tissue respiration, which is an indispensable condition for the existence of any living cell. Iron is part of chromoprotein proteins that provide electron transfer in biological oxidation chains. These chromoprotein proteins include cytochrome oxidase, an enzyme of the respiratory chain that directly interacts with oxygen, as well as cytochrome components localized in the membranes of mitochondria and the endoplasmic reticulum. As part of heme, iron is one of the components of hemoglobin, a universal molecule that ensures the binding, transport and transmission of oxygen to the cells of various organs and tissues, as well as myoglobin, a heme-containing protein of muscle tissue. In addition, iron is involved in a number of other biologically important processes occurring at the cellular and molecular level, in particular, in the processes of cell division, biosynthesis of DNA, collagen, and the functional activity of various parts of the immune system.

About 60-65% of the total iron reserve in the body is contained in hemoglobin, 2.5-4% in bone marrow, 4-10% in myoglobin, 0.1-0.5% in iron-containing enzymes and 24-26 % in the form of iron depot in the form of ferritin and hemosiderin.

Iron absorption is a complex process. Iron absorption occurs predominantly in the initial part of the small intestine. It is important to note that the greater the iron deficiency in the body, the larger the zone of its absorption in the intestine; in case of anemia, all parts of the small intestine are involved in the absorption process. Iron is transported from the intestinal mucosa into the blood using active cell transport mechanisms. This process occurs only with normal mucosal cell structure, which is supported by folic acid. Transport through the cells of the intestinal mucosa occurs both by simple diffusion and with the participation of a special carrier protein. This protein is most intensively synthesized during anemia, which ensures better absorption of iron. The protein transports iron only once; subsequent iron molecules carry new molecules of the carrier protein. Their synthesis takes 4-6 hours, so more frequent intake of iron supplements does not increase its absorption, but increases the amount of unabsorbed iron in the intestine and the risk of side effects.

There are two types of iron: heme and non-heme. Heme iron is part of hemoglobin. It is contained only in a small part of the diet (meat products), is well absorbed (20-30%), its absorption is practically not affected by other food components. Non-heme iron is found in the free ionic form of ferrous (Fe II) or ferric iron (Fe III). Most dietary iron is non-heme (found primarily in vegetables). The degree of its absorption is lower than that of heme and depends on a number of factors. Only divalent non-heme iron is absorbed from food. To “convert” ferric iron into divalent iron, a reducing agent is needed, the role of which in most cases is played by ascorbic acid (vitamin C).

Iron is absorbed in both heme and non-heme forms. A balanced daily diet contains about 5-10 mg of iron (heme and non-heme), but no more than 1-2 mg is absorbed.

During absorption in the cells of the intestinal mucosa, ferrous iron Fe2+ is converted into oxide Fe3+ and binds to a special carrier protein, transferrin, which transports iron to hematopoietic tissues and sites of iron deposition. Transferrin is synthesized by the liver. It is responsible for transporting iron absorbed in the liver, as well as iron coming from destroyed red blood cells for reuse by the body. Under physiological conditions, only about 30% of the iron-binding capacity of plasma transferrin is used.

Iron is deposited in the body in the form of proteins ferritin (most of it) and hemosiderin. Ferritin is an iron oxide/hydroxide enclosed in a protein shell, apoferritin. It is found in virtually all cells, providing a readily available reserve for the synthesis of iron-containing compounds and presenting iron in a soluble, non-ionic, non-toxic form. The cells richest in ferritin are the precursors of red blood cells in the bone marrow, macrophages and reticuloendothelial cells of the liver. Hemosiderin is found in macrophages of the bone marrow and spleen, and liver cells. It is considered to be a reduced form of ferritin in which the molecules have lost part of the protein coat and clumped together. The rate of iron mobilization from hemosiderin is slower than from ferritin. With an excess of iron in the body, its proportion deposited in the liver in the form of hemosiderin increases.

The body's ability to remove iron is limited. Most of the iron from destroyed red blood cells (more than 20 mg daily) reenters hemoglobin. The total loss of iron during desquamation of skin and intestinal cells reaches about 1 mg per day, about 0.4 mg is excreted in feces, 0.25 mg in bile, less than 0.1 mg in urine. These losses are common for men and women. In addition, each woman loses 15-25 mg of iron during one menstruation. During pregnancy and breastfeeding, she requires an additional 2.5 mg of iron per day. Taking into account that the daily intake of iron from food is only 1-3 mg, during these physiological periods women have a negative iron balance. As a result, by the age of 42-45 years, a woman approaches severe iron deficiency.

Iron-deficiency anemia

Iron deficiency occurs as a result of a mismatch between the body's need for iron and its supply (or loss). The development of iron deficiency can be divided into two stages:

1. latent iron deficiency ferritin iron levels and transferrin saturation are reduced, hemoglobin levels are reduced, there are no clinical signs of iron deficiency;
2. iron deficiency anemia (clinically pronounced iron deficiency) a disease in which the iron content in the blood serum, bone marrow and depot is reduced; as a result, hemoglobin formation is disrupted, hypochromic anemia and trophic disorders in tissues occur.

The most common causes of iron deficiency anemia in adults

• Blood loss repeated and prolonged bleeding of the uterus, gastrointestinal (peptic ulcer, hemorrhoids, ulcerative colitis), pulmonary (cancer, bronchiectasis).
• Increased iron consumption pregnancy, lactation, intensive growth, puberty, chronic infectious diseases, inflammatory processes and neoplasms.
• Impaired iron absorption gastric resection, enteritis; taking medications that reduce iron absorption.
• Reducing the amount of iron received from food.

The most common causes of iron deficiency anemia in children

In children, the need for iron per 1 kg of body weight is much greater than in adults, since the children's body requires iron not only for hematopoiesis processes, but also for intensive tissue growth. Thus, a child in the first half of life should receive at least 6 mg of iron per day (60% of the daily requirement of an adult), in the second half of the year - 10 mg (as an adult), in adolescence (11-18 years) - 12 mg per day.

Due to the greater need, children suffer from iron deficiency much more than adults. According to available data, about 60% of preschool children and a third of schoolchildren suffer from iron deficiency anemia in Ukraine. The main causes of iron deficiency in children of all age groups are:

• insufficient intake of iron into the fetus’s body (premature pregnancy, maternal anemia, late toxicosis of pregnancy);
• artificial feeding (in children under 1 year);
• acute and/or chronic infectious diseases;
• unbalanced diet predominance in the diet of flour and dairy dishes, in which the iron content is relatively low;
• insufficient consumption of meat products;
• intensive growth.

Symptoms of hidden iron deficiency

Hidden iron deficiency occurs most often in childhood, as well as in adolescents and young women. Women lose 12-79 mg of iron per 1 menstrual bleeding (on average 15 mg), losses during each pregnancy, during childbirth and during lactation 700-800 mg (up to 1 g). Early signs of developing iron deficiency are:

• weakness, increased fatigue;
• anxiety, lack of concentration;
• decreased ability to work;
• psychological lability;
• headaches in the morning;
• decreased appetite;
• increased susceptibility to infections.

Symptoms of iron deficiency anemia

If measures aimed at preventing the development of iron deficiency in “risk groups” are not taken, iron deficiency is not compensated for in the early stages, and iron deficiency anemia (IDA) develops.

In the clinical picture of IDA, several specific symptoms and syndromes can be identified.

Characteristic specific (sideropenic) symptoms of iron deficiency include:

• perversion of taste (consumption of chalk, clay, eggshells, toothpaste, raw cereals, raw meat, ice);
• distortion of the sense of smell (attracted by the smells of dampness, lime, kerosene, exhaust gases, acetone, shoe polish, etc.).

Hypoxic syndrome occurs as a result of oxygen starvation of tissues with sufficient severity of anemia. It manifests itself with the following symptoms:

• pallor of the skin and mucous membranes;
• bluish lips;
• dyspnea;
• tachycardia;
• stitching pain in the heart;
• weakness, constant feeling of fatigue;
• decreased emotional tone;
• children's mental retardation.

Epithelial tissue damage syndrome develops as a result of decreased synthesis of iron-containing enzymes and disruption of tissue metabolic processes. Characteristic manifestations:

• dry skin;
• fragility, hair loss;
• brittleness and striation of nails;
• cracks in the skin of the legs and arms;
• stomatitis;
• decreased muscle tone, muscle weakness;
• imperative urge to urinate, urinary incontinence when laughing and sneezing, bedwetting;
• damage to the stomach and intestines unstable stool, impaired gastric secretion, in 50% of patients atrophic gastritis.

Hematological syndrome characteristic changes in the clinical blood test.

Diagnostic criteria for iron deficiency anemia are:

• reduction in the number of red blood cells to 1.5-2.0 x 1012 / l,
• decrease in hemoglobin in children of the first 5 years of life below 110 g/l, in children over 5 years of age and adults - below 120 g/l;
• the decrease in color index is less than 0.85.

Frequency of the most common symptoms of IDA in different age groups

Measures to prevent iron deficiency conditions

A necessary component of the prevention of iron deficiency is a nutritious diet in all age groups with a sufficient content of meat products.

Prevention of iron deficiency in children should begin even before birth, for which it is recommended that women take iron supplements throughout the entire period of pregnancy, especially in the last trimester.

Prevention of iron deficiency conditions, especially in children, reduces their risk of infectious diseases and promotes more complete mental and physical development of the child.

Principles of rational therapy of iron deficiency anemia

It is impossible to eliminate iron deficiency, and especially iron deficiency anemia, without iron supplements - only with a diet consisting of iron-rich foods. Iron from medications can be absorbed 15-20 times more than from food.

In the treatment of iron deficiency conditions, preference is given to oral iron supplements. Treatment with iron preparations should begin with small doses, increasing them after a few days to avoid overdose and toxic reactions.

To correct iron deficiency conditions, the body should receive about 0.5 mg of iron/kg of body weight daily. Since normally only 10% of iron is absorbed from the gastrointestinal tract, and in case of anemia up to 25% of iron, about 2 mg/kg of body weight should be prescribed, which is 100-200 mg of Fe (II) per day in adults. Higher doses are pointless (since iron absorption is limited by physiological mechanisms) and only increase side effects.

You should not stop treatment with iron supplements after the content of hemoglobin and red blood cells has normalized: in order to create a “depot” in the body, you should continue taking the medications for another 1-2 months.

Possible side effects when taking iron supplements

A number of side effects may occur when taking oral iron supplements:

• gastrointestinal disorders: nausea, vomiting, intestinal colic, diarrhea/constipation;
• darkening of teeth;
• false reaction to occult blood in the stool;
• facial hyperemia, feeling of heat (rarely);
• allergic reactions (rare);
• decrease in blood pressure;
• tachycardia.

The most common dyspeptic disorders (in 50% of patients) are associated with the irritating effect of iron ions on the mucous membrane of the gastrointestinal tract. It should be noted that the severity of side effects from the gastrointestinal tract is related to the amount of unabsorbed drug: the better the drug is absorbed, the better it is tolerated and produces fewer side effects.

Iron poisoning

Acute poisoning with oral iron supplements in adults is extremely rare. However, since many iron preparations have an attractive form, the development of severe poisoning in children is possible if a large amount of the drug is accidentally taken. Taking more than 2 g is fatal; taking less than 1 g (ferrous sulfate) results in hemorrhagic gastroenteritis, necrosis with nausea, hematemesis, bloody diarrhea and vascular shock within one to several hours. Death may occur 8-12 hours after ingestion. Poisoning often leaves sharp scars in the stomach area (pyloric stenosis) and significant liver damage.

Treatment includes inducing vomiting, taking milk and eggs to form an iron-protein complex, and gastric lavage with a 1% NaHCO3 solution to form sparingly soluble iron carbonate. Subsequently, deferoxamine is given 5-10 g in 100 ml of saline through a gastric tube, as well as 0.5-1 g intramuscularly or, if the patient is in shock, 15 mg/kg/h as a long-term infusion for 3 days.

Deferoxamine is a weak base that is highly selective for iron and forms chelate compounds with it, which are not absorbed in the intestine and are easily removed from the blood through the kidneys.

Criteria for the effectiveness of iron therapy

The effectiveness of iron supplements is judged by laboratory criteria - the results of a blood test over time. By the 5-7th day of treatment, the number of reticulocytes (young red blood cells) should increase by 1.5-2 times compared to the initial data. Starting from the 7-10th day of therapy, the hemoglobin content increases, after 2-4 weeks a positive dynamics of the color indicator is noted.

Clinical signs of improvement appear much earlier (after 2-3 days) compared to normalization of hemoglobin levels. This is due to the supply of iron to enzymes, the deficiency of which causes muscle weakness.

Comparative characteristics of iron preparations for oral use

Numerous iron preparations presented on the pharmaceutical market of Ukraine can be divided into groups depending on their composition and clinical and pharmaceutical properties.

Comparative characteristics of iron-containing preparations for internal use

Preparations containing ferrous iron Fe(II): iron sulfate, iron fumarate, iron chloride, iron gluconate. Different preparations contain different amounts of iron, the ability of which to be absorbed varies: 12-16% for iron sulfate, 7-9% for iron lactate, 5-6% for iron chloride, 14-16% for iron fumarate, 20 -22% for iron gluconate.

A number of Fe(II) complex preparations contain mucoproteosis, prevent irritation of the gastrointestinal mucosa by iron ions, promote the slow release of iron ions, increase its bioavailability and improve tolerability.

Ferrous iron preparations have a number of common disadvantages: they can cause darkening of teeth and gums in patients, dyspeptic symptoms (nausea, vomiting, epigastric pain, constipation or diarrhea), allergic reactions such as urticaria. In case of an overdose of Fe(II) preparations, cases of severe poisoning are possible, especially in children, which is associated with the activation of free radical oxidation processes and hyperproduction of active radicals. This leads to metabolic and functional disorders in the body, primarily the cardiovascular system.

Preparations containing ferric iron Fe(III). Ferric iron is practically not absorbed in the gastrointestinal tract. However, complex organic compounds of Fe(III) with a number of amino acids and maltose are significantly less toxic than Fe(II), but no less effective. Immobilization of Fe(III) on amino acids ensures its resistance to hydrolysis in the gastrointestinal tract and high bioavailability, due to the slow release of the drug and its more complete absorption, as well as the absence of dyspeptic phenomena.

It is rational to highlight multicomponent drugs, containing, along with iron ions, additional substances that promote erythropoiesis (vitamins B B6, B9, B12); stimulating iron absorption (ascorbic acid, succinic acid, amino acids); multivitamin preparations containing iron.

Pharmaceutical care when using oral iron supplements

• Treatment with iron supplements is recommended under the supervision of a physician.
• Treatment with iron supplements should be accompanied by periodic blood tests.
• It is recommended to prescribe iron supplements to children after consulting a pediatrician.
• Iron deficiency anemia should be treated mainly with drugs for internal use (Fe II).
• The use of iron supplements should be combined with optimization of the diet, with the mandatory introduction of meat dishes into the menu.
• Iron supplements should not be prescribed to children against the background of inflammatory processes (ARVI, sore throat, pneumonia, etc.), since in this case iron accumulates at the site of infection and is not used for its intended purpose.
• The inclusion of ascorbic acid in complex iron preparations improves the absorption of iron (as an antioxidant, ascorbic acid prevents the conversion of Fe-II ions into Fe-III, which are not absorbed into the gastrointestinal tract) and makes it possible to reduce the prescribed dose. Iron absorption also increases in the presence of fructose and succinic acid.
• Taking combination drugs that, along with iron, contain copper, cobalt, folic acid, vitamin B12 or liver extract, makes it extremely difficult to control the effectiveness of iron therapy (due to the hematopoietic activity of these substances).
• During pregnancy, taking multivitamin preparations containing iron (glutamevit, complevit, oligovit, etc.) is indicated as a prophylactic measure.
• You should not simultaneously prescribe medications that form non-absorbable complexes with iron (tetracyclines, chloramphenicol, calcium supplements, antacids).
• Iron ions form insoluble salts that are not absorbed and then excreted in feces, with food components such as phytin (rice, soy flour), tannin (tea, coffee), phosphates (fish, seafood).
• Since iron forms complexes with phosphates, at excessively high doses in children, the absorption of phosphates can be reduced so much that this will lead to rickets.
• It is rational to take iron supplements 30-40 minutes before meals, which promotes better absorption. At the same time, with this regimen, symptoms of irritation to the gastric mucosa are more likely to occur.
• Oral iron supplements should be taken at least 4 hours apart.
• Do not chew tablets and pills containing iron!
• After taking iron supplements, you should rinse your mouth, and liquid preparations (syrups, solutions for internal use) are best administered through a straw.
• Taking iron supplements orally leads to darkening of stool and may give false positive results for occult blood tests.
• The simultaneous administration of iron preparations orally and parenterally (intramuscularly and/or intravenously) should be completely excluded!
• Parenteral administration of iron supplements should only be done in a hospital!
• Iron supplements should be stored out of the reach of children.

Literature

1. Bokarev I.N., Kabaeva E.V. Treatment and prevention of IDA in outpatient practice // Ter. archive. - 1998. - No. 4. - pp. 70-74.
2. Zmushko E.I., Belozerov E.S. Drug complications. - St. Petersburg: Peter, 2001. - 448 p.
3. Kazakova L. M. Iron deficiency and prevention in the practice of a pediatrician. Methodological recommendations. - M., 1999. - 23 p.
4. Compendium 2001/2002 drugs / Ed. V. N. Kovalenko, A. P. Viktorova. - K.: Morion, 2002. - 1476 p.
5. Krasnova A. Iron is inside us // Pharmacist.- 1998.- No. 19-20.- P. 59-61.
6. Krivenok V. A necessary component of the treatment of iron deficiency anemia // Pharmacist. - 2002. - No. 18. - P. 44.
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The primary prevention of iron deficiency is proper, nutritious nutrition.

Secondary prevention is the active detection of latent iron deficiency and iron deficiency anemia during medical examinations and medical examinations.

1. Antenatal prevention: According to WHO recommendations, an iron supplement at a dose of 60 mg/kg per day is used in the 2nd and 3rd trimesters of pregnancy and during 3 months of lactation (supplementation regimen).

A pregnant woman's menu should include foods rich in protein - up to 120 g per day (meat, liver, cheese, fish), fruits, vegetables, vitamins and microelements. Iron absorption is reduced by excessive consumption of large amounts of milk and plant foods.

2. Postnatal prevention:

Nonspecific preventive measures for IDA include: natural feeding with the timely introduction of complementary foods: assorted vegetable puree (potatoes, beets, carrots, cabbage, zucchini, etc.), pureed beef or veal liver mixed with vegetable puree from 5 months, meat minced meat from 7 months, etc. In the diet, you should limit white porridges (semolina, rice, bearberry), giving preference to buckwheat, barley, pearl barley, and millet. Porridge should be cooked in water or, better yet, in vegetable broth.

Specific preventive measures (taking iron supplements) for children at risk (premature babies, those born from multiple pregnancies, etc.) must begin at 2 months of age, continuing until the end of the first year of life; full-term children at risk from 4 months for 3-6 months.

The prophylactic dose of iron supplements for children under 3 years of age is 1-1.5 mg/kg per day, for children over 3 years old - 1/3 - ½ daily therapeutic dose of elemental iron (according to N.P. Shabalov).

Specified terms for monitoring hematological indicators to confirm the effect of therapy: hemoglobin monthly during the period of clinical observation (1 year), after 1, 3, 4 and 6 months from the start of therapy, monitoring the level of serum iron, TCV and ferritin.

Vaccination is carried out after normalization of hemoglobin levels (with reduced hemoglobin, vaccinations are immunologically ineffective).

Forecast. The prognosis of the disease is favorable, cure should occur in 100% of cases. So-called “relapses” of the disease are possible with: the use of low doses of iron supplements; ineffectiveness of oral ferrodrugs; reducing the duration of treatment for patients; treatment of patients with chronic posthemorrhagic anemia with an unknown and unknown source of blood loss.