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9.1.2 - 9.1.6 Megaloblastic, hypoplastic, haemolytic and renal anaemias

9.1.2 Drugs used in megaloblastic anaemias

Folic acid tablets, syrup
Hydroxocobalamin injection


1. Hydroxocobalamin has replaced cyanocobalamin as a source of B12 as it is excreted much less rapidly than cyanocobalamin, allowing maintenance doses to be given at 3-monthly intervals.

2. Folic acid is indicated for the correction of folate deficiency and for the prevention of neural tube defects in early pregnancy. Prevention of neural defects: an expert advisory group of the Department of Health recommends folate supplementation for all women periconceptionally in addition to a folate rich diet. Women who have been pregnant with a foetus with neural tube defect, or patient recieving certain antieleptic therapy - 5mg daily; other women 400micrograms daily. These supplements should be taken prior to conception and during the first 12 weeks of gestation.

3. It should never be given alone in the presence of vitamin B12 deficiency; anaemia may respond but neuropathy could be precipitated.

4. Folate supplementation may reduce serum levels of phenytoin.

5. Folic acid 400microgram tablets may be purchased as food supplements.


9.1.3 Drugs used in hypoplastic, haemolytic and renal anaemias

- Epoetin alfa injection (Eprex®)
- Epoetin beta injection (NeoRecormon®)
- Darbepoetin

Click here for NICE TA 323 for use in cancer treatment induced anaemia.



1. Patients under the care of the Trust will have Erythropoietin prescribed and monitored by the hospital. GPs should not be asked to prescribe the drug.

2. Subcutaneous injection of erthropoietin alfa is contraindicated in patients with Chronic Renal failure due to risk of pue red cell aplasia.

3. Epoetin beta has been associated with an increased risk of retinopathy in pre-term infants. See DSU.

4. Recombinant human erythropoietin treatment has been associated with very rare cases of life-threatening severe cutaneous adverse reactions, including Stevens-Johnson syndrome  and toxic epidermal necrolysis. See DSU update Link

Sickle cell disease

Hydroxycarbamide tablets

Iron overload (all RED drugs)

Desferrioxamine mesilate injection - first-ine treatment
Deferasirox dispersible tablets - children and adolescents guidelines.
Deferiprone tablets, oral solution - alternative in renal impairment; weekly monitoring of FBC essential


9.1.4 Drugs used in autoimmune thrombocytopenic purpura

Anagrelide (consultant haematologist use only) - see note below
Eltrombopag tablets - see NICE TA 205: 'Eltrombopag for the treatment of chronic immune (idiopathic) thrombocytopenic purpura'
Romiplostim injection - see NICE TA 221: 'Romiplostim for the treatment of chronic immune (idiopathic) thrombocytopenic purpura'


Anagrelide is available for second line treatment of patients with 'at risk' essential thrombocythaemia (after hydroxyureaand low dose aspirin). Serious cardiovascular events have been reported. It should be specialist initiated.

An 'at risk' essential thrombocythaemia patient is defined by one or more of the following:

  • >60 years of age

  • platelet count >1000 x109/L


  • history of a thrombo-haemorrhagic event

Eltrombopag (Revolade): reports of interference with bilirubin and creatinine test results. If bilirubin and/or creatinine test results are inconsistent with clinical observations, request re-testing using another method to determine the validity of the result (link to Drug Safety Update)  

9.1.6 Drugs used in neutropenia

Filgrastim injection - monitor patient for capillary leak syndrome: symptoms include: generalised body swelling; puffiness (which may be associated with less-frequent urination); difficulty breathing; abdominal swelling; and tiredness - see MHRA DSU.



For links to BNF sections:

9.1.2 Drugs used in megaloblastic anaemias

9.1.3 Drugs used in hypoplastic, haemolytic, and renal anaemias

9.1.4 Drugs used in platelet disorders

9.1.6 Drugs used in neutropenia