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erythropoiesis-stimulating agent

Indications: 1) hypoplastic anemia & blood hemoglobin < 10 g/dL [4] a) anemia of chronic disease - anemia of chronic renal failure - *anemia of malignancy - may reduce need for RBC transfusions - increases risk for thromboembolic events & death [8] - may improve quality of life [8] - *anemia of HIV b) anemia caused by antineoplastic agents - indicated only in non-curative regimens [4] 2) anemia due to hemorrage - *surgery Contraindications: - no benefit for anemia in systolic heart failure [3] - hospitalized patients without symptoms of anemia or end organ damage - hospitalized patients with improving renal function - blood hemoglobin > 11 g/dL - blood hemoglobin > 10 g/dL with anemia of chronic renal failure - cancer patients (associated with increased mortality) [4] - may worsen hypertension [4] Dosage: - check serum iron, TIBC, ferritin before initiating erythropoiesis-stimulating agent - maintain transferrin saturation > 30% & serum ferritin > 500 ng/mL - do not check serum erythropoietin [4] Adverse effects: - increase incidence of cardiovascular events when blood hemoglobin > 11 g/dL or history of stroke [4] - erythropoietin Ab resulting in red cell aplasia with or without other cytopenias [4] - erythropoiesis-stimulating agents & cancer are both associated with an increased risk of thrombosis [10] - worsening hypertension [4] Laboratory: - erythropoietin in serum not useful for determining eligibility for erythropoiesis-stimulating agent [4] - complete blood count (CBC) - target hemoglobin is 11 g/dL - transferrin saturation - target is > 20% - serum ferritin - target is > 100 ng/mL [4] Notes: - inappropriate prescribing common [2] - target blood hemoglobin of 11-12 g/dL [7] - discontinue if blood hemoglobin > 12 g/dL [4] - achieved blood hemoglobin levels of 10.2-13.6 g/dL not associated with better quality of life than levels of 7.4-12 g/dL in patients with chronic kidney disease [9] - maintaining serum ferritin > 100 ng/mL with iron saturation of >= 20% is recommended [4]

Interactions

drug adverse effects of erythropoiesis-stimulating agents

Specific

darbepoetin-alfa (Aranesp) epoetin-alfa (Epogen, Procrit, Eprex) epoetin-beta (Neorecormon, Recormon, Mircera) epoetin-delta (Dynepo) epoetin-omega (Epomax) epoetin-zeta (Silapo, Retacrit) peginesatide (Omontys)

General

hematologic agent pharmaceutical growth factor

References

  1. Prescriber's Letter 17(4): 2010 ESA APPRISE Oncology Program for Cancer Patients Using Procrit, Epogen, or Aranesp COMMENTARY: ESA APPRISE Oncology Program for Cancer Patients Using Procrit, Epogen, or Aranesp CHART: Drugs with Special Prescribing and Dispensing Requirements Detail-Document#: 260422 (subscription needed) http://www.prescribersletter.com
  2. Aspinall SL et al. Impact of pharmacist-managed erythropoiesis-stimulating agents clinics for patients with non-dialysis-dependent CKD. Am J Kidney Dis 2012 Sep; 60:371. PMID: 22633556
  3. Swedberg K et al. Treatment of anemia with darbepoetin alfa in systolic heart failure. N Engl J Med 2013 Mar 10 PMID: 23473338 http://www.nejm.org/doi/full/10.1056/NEJMoa1214865
  4. Medical Knowledge Self Assessment Program (MKSAP) 16, 17, 18, 19. American College of Physicians, Philadelphia 2012, 2015, 2018, 2021. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  5. Solomon SD, Uno H, Lewis EF, Eckardt KU et al Erythropoietic response and outcomes in kidney disease and type 2 diabetes. N Engl J Med. 2010 Sep 16;363(12):1146-55 PMID: 20843249
  6. Bohlius J, Schmidlin K, Brillant C et al Recombinant human erythropoiesis-stimulating agents and mortality in patients with cancer: a meta-analysis of randomised trials. Lancet. 2009 May 2;373(9674):1532-42 PMID: 19410717
  7. Locatelli F, Aljama P, Canaud B et al Target haemoglobin to aim for with erythropoiesis-stimulating agents: a position statement by ERBP following publication of the Trial to reduce cardiovascular events with Aranesp therapy (TREAT) study. Nephrol Dial Transplant. 2010 Sep;25(9):2846-50 PMID: 20591813
  8. Tonia T, Mettler A, Robert N et al Erythropoietin or darbepoetin for patients with cancer. Cochrane Database Syst Rev. 2012 Dec 12;12:CD003407 PMID: 23235597
  9. Collister D et al. The effect of erythropoietin-stimulating agents on health- related quality of life in anemia of chronic kidney disease: A systematic review and meta-analysis. Ann Intern Med 2016 Feb 16 PMID: 2688184 http://annals.org/article.aspx?articleid=2491918
  10. Bohlius J, Bohlke K, Castelli R et al. Management of cancer-associated anemia with erythropoiesis-stimulating agents: ASCO/ASH clinical practice guideline update. Blood Adv 2019 Apr 23; 3:1197 PMID: 30971397 Free PMC Article http://www.bloodadvances.org/content/3/8/1197