Erythropoiesis Stimulating Agents
Number: 0195
Commercial CPB | Medicare CPB
Table Of Contents
PolicyApplicable CPT / HCPCS / ICD-10 Codes
Background
References
Brand Selection for Medically Necessary Indications
As defined in Aetna commercial policies, health care services are not medically necessary when they are more costly than alternative services that are at least as likely to produce equivalent therapeutic or diagnostic results. Epogen, Procrit, and Mircera epoetin products are more costly to Aetna than other epoetin products. There is a lack of reliable evidence that Epogen, Procrit, and Mircera are superior to the lower cost epoetin products: Retacrit and Aranesp for medically necessary indications. Therefore, Aetna considers Epogen, Procrit, and Mircera to be medically necessary only for members who have a contraindication, intolerance or ineffective response to the available equivalent alternatives Retacrit and Aranesp.
Policy
Note: Requires Precertification:
Precertification of erythropoiesis stimulating agents (Aranesp, Epogen, Procrit, Retacrit, Mircera) is required of all Aetna participating providers and members in applicable plan designs. For precertification of erythropoiesis stimulating agents, call (866) 752-7021 (commerical), or fax (888) 267-3277. For Medicare Part B plans, call (866) 503-0857, or fax (844) 268-7263.
Note: Requirements regarding pretreatment hemoglobin level exclude values due to a recent transfusion. All members must be assessed for iron deficiency anemia and have adequate iron stores (defined as a serum transferrin saturation [TSAT] level greater than or equal to 20% within the prior 3 months) or are receiving iron therapy before starting erythropoiesis stimulating agents (Epogen, Procrit, Retacrit, Aranesp and Mircera). Members may not use these agents concomitantly with other erythropoiesis stimulating agents.
Epoetin alfa (Epogen, Procrit) and epoetin alfa-epbx (Retacrit)
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Criteria for Initial Approval
Aetna considers erythropoietin therapy epoetin alfa (Epogen/Procrit) or epoetin alpha-epbx (Retacrit) medically necessary for any of the following indications when criteria are met:
- Anemia due to chronic kidney disease (CKD) - for treatment in members with pretreatment hemoglobin less than 10 g/dL; or
- Anemia due to myelosuppressive chemotherapy - for treatment in members with nonmyeloid malignancy and pretreatment hemoglobin is less than 10 g/dL; or
- Anemia in myelodysplastic syndrome (MDS) - for treatment in members with pretreatment hemoglobin less than 10 g/dL whose pretreatment serum erythropoietin (EPO) level is less than 500 mU/mL; or
- Reduction of allogeneic red blood cell transfusion in members undergoing elective, noncardiac, nonvascular surgery when the pretreatment hemoglobin is 13 g/dL or less; or
- Anemia in rheumatoid arthritis (RA) - for treatment in members with pretreatment hemoglobin less than 10 g/dL; or
- Anemia due to hepatitis C treatment - for treatment in members with pretreatment hemoglobin less than 10 g/dL who are receiving ribavirin in combination with either interferon alfa or peginterferon alfa; or
- Anemia due to zidovudine in HIV-infected members - for treatment in members currently receiving zidovudine with pretreatment hemoglobin less than 10 g/dL whose pretreatment serum EPO level is less than 500 mU/mL; or
- Anemia in members whose religious beliefs forbid blood transfusions - for treatment in members with pretreatment hemoglobin less than 10 g/dL; or
- Anemia in primary myelofibrosis (MF), post-polycythemia vera MF, or post-essential thrombocythemia MF - for treatment in members who meet all of the following criteria:
- Pretreatment hemoglobin less than 10 g/dL; and
- Pretreatment serum EPO level less than 500 mU/mL; or
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Anemia due to cancer - for treatment in members who have cancer and are undergoing palliative treatment.
Aetna considers all other indications as experimental and investigational (for additional information, see Experimental and Investigational and Background sections).
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Continuation of Therapy
Note: Requirements regarding current hemoglobin level exclude values due to a recent transfusion. All members must be assessed for iron deficiency anemia and have adequate iron stores (defined as a serum transferrin saturation [TSAT] level greater than or equal to 20% within the prior 3 months) or are receiving iron therapy before continuation of treatment with Epogen, Procrit and Retacrit. Members may not use Epogen/Procrit/Retacrit concomitantly with other erythropoiesis stimulating agents.
For all indications below: for continutation of therapy after at least 12 weeks of ESA treatment, all members (including new members) must show a response with a rise in hemoglobin of greater than or equal to 1 g/dL. Members who completed less than 12 weeks of ESA treatment and have not yet responded with a rise in hemoglobin of greater than or equal to 1 g/dL may continue erythropoietin therapy for up to 12 weeks to allow for sufficient time to demonstrate a response.
Aetna considers continuation of epoetin alfa (Epogen/Procrit) or epoetin alpha-epbx (Retacrit) therapy medically necessary for the following indications when criteria are met:
- Anemia due to CKD - when the current hemoglobin is less than 12 g/dL; or
- Anemia due to myelosuppressive chemotherapy - in members with nonmyeloid malignancy and current hemoglobin is less than 12 g/dL; or
- Anemia in MDS - when the current hemoglobin is less than 12 g/dL; or
- Anemia in RA - when the current hemoglobin is less than 12 g/dL; or
- Anemia due to hepatitis C treatment - when the member meets all of the following criteria:
- Member is receiving ribavirin in combination with either interferon alfa or peginterferon alfa; and
- The current hemoglobin is less than 12 g/dL; or
- Anemia due to zidovudine in HIV-infected members - in members receiving zidovudine when the current hemoglobin is less than 12 g/dL; or
- Anemia in members whose religious beliefs forbid blood transfusions - when the current hemoglobin is less than 12 g/dL; or
- Anemia in primary myelofibrosis, post-polycythemia vera myelofibrosis or post-essential thrombocythemia myelofibrosis - when the current hemoglobin is less than 12 g/dL; or
- Anemia due to cancer - in members who have cancer and are undergoing palliative treatment.
Darbepoetin alfa therapy (Aranesp)
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Criteria for Initial Approval
Aetna considers erythropoietin therapy darbepoetin alfa (Aranesp) medically necessary for any of the following indications when criteria are met:
- Anemia due to chronic kidney disease (CKD) - for treatment in members with pretreatment hemoglobin less than 10 g/dL; or
- Anemia due to myelosuppressive cheomtherapy - for treatment in members with nonmyeloid malignancy and pretreatment hemoglobin is less than 10 g/dL; or
- Anemia in myelodysplastic syndrome (MDS) - for treatment in members with pretreatment hemoglobin less than 10 g/dL whose pretreatment serum erythropoietin (EPO) level is less than 500 mU/mL; or
- Anemia in members whose religious beliefs forbid blood transfusions - for treatment in members with pretreatment hemoglobin less than 10 g/dL; or
- Anemia in primary myelofibrosis (MF), post-polycythemia vera MF, or post-essential thrombocythemia MF - for treatment in members who meet all of the following criteria:
- Pretreatment hemoglobin less than 10 g/dL; and
- Pretreatment serum EPO level less than 500 mU/mL; or
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Anemia due to cancer - for treatment in members who have cancer and are undergoing palliative treatment.
Aetna considers all other indications as experimental and investigational (for additional information, see Experimental and Investigational and Background sections).
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Continuation of Therapy
Note: Requirements regarding pretreatment hemoglobin level exclude values due to a recent transfusion. All members must be assessed for iron deficiency anemia and have adequate iron stores (defined as a serum transferrin saturation [TSAT] level greater than or equal to 20% within the prior 3 months) or are receiving iron therapy before continuation of treatment with Aranesp. Members may not use Aranesp concomitantly with other erythropoiesis stimulating agents.
For all indications below: for continutation of therapy after at least 12 weeks of ESA treatment, all members (including new members) must show a response with a rise in hemoglobin of greater than or equal to 1 g/dL. Members who completed less than 12 weeks of ESA treatment and have not yet responded with a rise in hemoglobin of greater than or equal to 1 g/dL may continue erythropoietin therapy for up to 12 weeks to allow for sufficient time to demonstrate a response.
Aetna considers continuation of darbepoetin alfa therapy (Aranesp) medically necessary for the following indications when criteria are met:
- Anemia due to chronic kidney disease (CKD) - when the current hemoglobin is less than 12 g/dL; or
- Anemia due to myelosuppressive chemotherapy - in members with nonmyeloid malignancy and current hemoglobin is less than 12 g/dL; or
- Anemia in myelodysplastic syndrome (MDS) - when the current hemoglobin is less than 12 g/dL; or
- Anemia in members whose religious beliefs forbid blood transfusions - when the current hemoglobin is less than 12 g/dL; or
- Anemia in primary myelofibrosis, post-polycythemia vera myelofibrosis, or post-essential thrombocythemia myelofibrosis - when the current hemoglobin is less than 12 g/dL; or
- Anemia due to cancer - in members who have cancer and are undergoing palliative treatment.
Methoxy polyethylene glycol-epoetin beta (Mircera)
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Criteria for Initial Approval
Aetna considers erythropoietin therapy methoxy polyethylene glycol-epoetin beta (Mircera) medically necessary for the treatment of anemia due to chronic kidney disease (CKD) when the pretreatment hemoglobin is less than 10 g/dL.
Aetna considers all other indications as experimental and investigational (for additional information, see Experimental and Investigational and Background sections).
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Continuation of Therapy
Note: Requirements regarding current hemoglobin level exclude values due to recent transfusion. All members must be assessed for iron deficiency anemia and have adequate iron stores (defined as a serum transferrin saturation [TSAT] level greater than or equal to 20% with the prior 3 months) or are receiving iron therapy before continuation of treatment with Mircera. Members may not use Mircera concomitantly with other erythropoiesis stimulating agents.
Aetna considers continuation of methoxy polyethylene glycol-epoetin beta (Mircera) therapy medically necessary for the following indication when criteria are met:
Anemia due to chronic kidney disease (CKD):
- When the current hemoglobin is less than 12 g/dL and member has shown a response to therapy with a rise in hemoglobin of greater than or equal to 1 g/dL after at least 12 weeks of ESA therapy; or
- In members who have not completed 12 weeks of ESA therapy.
For sodium ferric gluconate complex (Ferrlecit), see CPB 0575 - Intravenous Iron Therapy.
Dosing Recommendations
Epogen/Procrit (epoetin alpha), Retacrit (darbepoetin alfa)
Adults with anemia due to CKD:
The recommended starting dose for adults is 50 to 100 Units/kg 3 times weekly intravenously (IV) or subcutaneously (SC). The IV route is recommended for persons on hemodialysis.
Pediatrics with anemia due to CKD:
The recommended starting dose for pediatric persons (ages 1 month or older) is 50 Units/kg 3 times weekly IV or SC.
Anemia due to Zidovudine-treated persons with HIV-infection:
The recommended starting dose in adults is 100 Units/kg as an IV or SC injection 3 times per week.
Anemia due to Cancer Chemotherapy:
- Initiate only if the hemoglobin is less than 10 g/dL, and if there is a minimum of two additional months of planned chemotherapy. Use the lowest dose of ESA necessary to avoid RBC transfusions.
- Adults:
- 150 Units/kg SC 3 times per week until completion of a chemotherapy course or
- 40,000 Units SC weekly until completion of a chemotherapy course.
- Pediatrics (5 to 18 years):
600 Units/kg IV weekly until completion of a chemotherapy course. - After the initial 4 weeks of ESA therapy, if hemoglobin increases by less than 1 g/dL and remains below 10 g/dL, increase dose to:
- 300 Units/kg three times per week in adults or
- 60,000 Units weekly in adults
- 900 Units/kg (maximum 60,000 Units) weekly in pediatrics
- After 8 weeks of therapy, if there is no response as measured by hemoglobin levels or if RBC transfusions are still required, discontinue ESAs.
- Refer to the Full Prescribing Information for dose adjustments.
- Notes:
- Use ESAs only for anemia from myelosuppressive chemotherapy
- ESAs are not indicated for persons receiving myelosuppressive chemotherapy when the anticipated outcome is cure
- Discontinue following the completion of a chemotherapy course.
Reduction of allogeneic red blood cell (RBC) transfusions in persons undergoing elective, noncardiac, nonvascular surgery:
The recommended Epogen regimens are:
- 300 Units/kg per day SC for 15 days total: administered daily for 10 days before surgery, on the day of surgery, and for 4 days after surgery
- 600 Units/kg SC in 4 doses administered 21, 14, and 7 days before surgery and on the day of surgery.
Source: Amgen, 2018; Hospira, 2020; Janssen, 2018
Aranesp (darbepoetin alfa therapy)
For adults with anemia due to CKD on dialysis:
The recommended starting dose is 0.45 mcg/kg intravenously or subcutaneously as a weekly injection or 0.75 mcg/kg once every 2 weeks as appropriate. The intravenous route is recommended for persons on hemodialysis.
For adults with anemia due to CKD not on dialysis:
The recommended starting dose is 0.45 mcg/kg body weight intravenously or subcutaneously given once at four-week intervals as appropriate.
For pediatrics with anemia due to CKD:
The recommended starting dose for pediatric persons (less than 18 years) is 0.45 mcg/kg body weight administered as a single subcutaneous or intravenous injection once weekly; persons not receiving dialysis may be initiated at a dose of 0.75 mcg/kg once every 2 weeks.
Conversion from Epoetin alfa to Aranesp in persons with anemia due to CKD on dialysis:
Aranesp is administered less frequently than epoetin alfa.
- Administer Aranesp once weekly in persons who were receiving epoetin alfa 2 to 3 times weekly.
- Administer Aranesp once every 2 weeks in persons who were receiving epoetin alfa once weekly.
Anemia due to Cancer Chemotherapy:
- Initiate only if the hemoglobin is less than 10 g/dL, and if there is a minimum of two additional months of planned chemotherapy. Use the lowest dose of ESA necessary to avoid RBC transfusions.
- The recommended starting dose and schedules are:
- 2.25 mcg/kg every week subcutaneously until completion of a chemotherapy course
- 500 mcg every 3 weeks subcutaneously until completion of a chemotherapy course
- Refer to the Full Prescribing Information for dose adjustments.
- Notes:
- Use ESAs only for anemia from myelosuppressive chemotherapy
- ESAs are not indicated for persons receiving myelosuppressive chemotherapy when the anticipated outcome is cure
- Discontinue following the completion of a chemotherapy course.
Source: Amgen, 2019
Mircera (methoxy polyethylene glycol-epoetin beta)
Adults with anemia due to CKD:
The recommended starting dose of Mircera for the treatment of anemia in adult CKD who are not currently treated with an ESA is 0.6 mcg/kg body weight administered as a single intravenous (IV) or subcutaneous (SC) injection once every two weeks. The IV route is recommended for persons receiving hemodialysis because the IV route may be less immunogenic.
Pediatrics with anemia due to CKD:
Administer Mircera IV once every 4 weeks to pediatric persons (ages 5 to 17 years) whose hemoglobin level has been stabilized by treatment with an ESA. Administer Mircera as an IV injection at the dose (in micrograms) based on the total weekly ESA dose at the time of conversion (see below):
| Epoetin alfa | Darbepoetin alfa |
|---|---|
| 4 x previous weekly epoetin alfa dose (Units) / 125 e.g., 4 x 1500 Units of epoetin alfa per week/125 = 48 mcg of Mircera once every 4 weeks |
4 x previous weekly darbepoetin alfa dose (mcg) / 0.55 e.g., 4 x 20 mcg of darbepoetin alfa per week/0.55 = 145.5 mcg of Mircera once every 4 weeks |
Source: Hoffman-La Roche, 2018
National Comprehensive Cancer Network (NCCN)
Chemotherapy-Induced Anemia:
- Persons undergoing palliative treatment, may consider ESAs by FDA dosing/dosing adjustments
- Alternative regimen recommendations include the following:
- Darbepoetin alfa 100 mcg fixed dose every week by subcutaneous (SC) injection. May increase darbepoetin alfa to up to 150-200 mcg fixed dose every week by SC injection; or
- Darbepoetin alfa 200 mcg fixed dose every 2 weeks by SC injection. May increase darbepoetin alfa to up to 300 mcg fixed dose every 2 weeks by SC injection; or
- Darbepoetin alfa 300 mcg fixed dose every 3 weeks by SC injection. May increase darbepoetin alfa to up to 500 mcg fixed dose every 3 weeks by SC injection; or
- Epoetin alfa 80,000 units every 2 weeks by SC injection; or
- Epoetin alfa 120,000 units every 3 weeks by SC injection.
Source: NCCN Clinical Practice Guidelines for Hematopoietic Growth Factors, Version 1.2022
Experimental and Investigational
Aetna considers erythropoiesis stimulating agents experimental and investigational for all other indications, including the following conditions, because its use in these situations is not supported by the peer-reviewed medical literature (not an all-inclusive list):
- Acute renal injury
- Anemia associated only with radiotherapy
- Anemia associated with chronic obstructive pulmonary disease
- Anemia due to bleeding (other than indications for high-risk surgery (e.g., colectomy, hip replacement, and knee replacement) and for special circumstance members above)
- Anemia due to folate deficiency, B-12 deficiency, iron deficiency, hemolysis, or bone marrow fibrosis
- Anemia in Castleman's disease
- Anemia in Gaucher's disease
- Anemia in paroxysmal nocturnal hemoglobinuria (PNH)
- Anemia in persons with erythropoietin-type resistance due to neutralizing antibodies
- Anemia of prematurity
- Aplastic anemia
- Autonomic dysfunction
- Bacterial/fungal/parasitic/viral infections (except anemia due to hepatitis C treatment and anemia due to zidovudine in HIV-infected members)
- Before surgery for craniosynostosis correction
- Beta thalassemia minor
- Brain injury in term and preterm infants
- Cardiogenic shock-associated anemia
- Cerebral hypoxia/ischemia
- Cognitive decline in persons with bipolar disorder, depression, or schizophrenia
- Connective tissue disease
- Diabetic neuropathy
- Ehlers Danlos syndrome
- Friedreich's ataxia
- Guillain-Barre syndrome
- Hemolytic anemia
- Hereditary hemochromatosis
- Hypoxic ischemic encephalopathy
- Immediate correction of severe anemia
- Inflammatory bowel disease
- Ischemic heart disease
- Multiple sclerosis
- Myocardial infarction
- Neonatal encephalopathy
- Nephron-protection in persons undergoing kidney transplantation
- Optic neuritis
- Oral mucositis
- Out-of-hospital cardiac arrest
- Physiologic anemia of pregnancy
- Postural tachycardia syndrome
- Prevention and treatment of anemia in pre-term or low birth-weight infants
- Prophylactic use to prevent anticancer chemotherapy-induced anemia
- Prophylactic use to prevent tumor hypoxia
- Sarcoidosis
- Scoliosis surgery
- Sepsis-associated anemia
- Sickle cell anemia
- Stroke/subarachnoid hemorrhage
- Systemic lupus erythematosus
- Thrombocythemia (excludes anemia in post-essential thrombocythemia myelofibrosis)
- Traumatic brain injury
- Treatment of hemolysis anemia associated with prosthetic valve
- Vasculitis.
Background
Erythropoietin therapy (e.g., EPO, Epogen [epoetin alfa], Procrit [r-HuEPO], Retacrit [epoetin alfa-epbx], Mircera [methoxy polyethylene glycol-epoetin beta], and Aranesp [darbepoietin alfa]) is used to stimulate red blood cell (RBC) production in the bone marrow, thereby correcting anemia, minimizing the need for transfusion requirements, and improving the quality of life for patients.
Epogen and Procrit
U.S. Food and Drug Administration (FDA)-Approved Indications:
- Epoetin alfa is indicated for the treatment of anemia due to chronic kidney disease (CKD), including patients on dialysis and not on dialysis to decrease the need for red blood cell (RBC) transfusion.
- Epoetin alfa is indicated for the treatment of anemia due to zidovudine administered at ≤ 4200 mg/week in HIV-infected patients with endogenous serum erythropoietin levels of ≤ 500 mUnits/mL.
- Epoetin alfa is indicated for the treatment of anemia in patients with non-myeloid malignancies where anemia is due to the effect of concomitant myelosuppressive chemotherapy, and upon initiation, there is a minimum of two additional months of planned chemotherapy.
- Epoetin alfa is indicated to reduce the need for allogeneic RBC transfusions among patients with perioperative hemoglobin > 10 to ≤ 13 g/dL who are at high risk for perioperative blood loss from elective, noncardiac, nonvascular surgery. Epoetin alfa is not indicated for patients who are willing to donate autologous blood preoperatively.
Compendial Uses:
- Symptomatic anemia in patients with myelodysplastic syndromes (MDS)
- Anemia in rheumatoid arthritis
- Anemia due to hepatitis C treatment with ribavirin in combination with either interferon alfa or peginterferon alfa
- Anemia in patients whose religious beliefs forbid blood transfusions
- Symptomatic anemia in patients with primary myelofibrosis, post-polycythemia vera myelofibrosis, or post-essential thrombocythemia myelofibrosis
- Cancer patients who are undergoing palliative treatment
Epoetin alpha, available as Epogen and Procrit, is a glucoprotein manufactured by DNA technology which has the same biological effects as endogenous erythropoietin. Erythropoietin is a glucoprotein which stimulates the production, maturation, and release of red blood cells.
Epoetin alfa contains the identical amino acid sequence of isolated natural erythropoietin and thus maintains a proliferating pool of red blood cell progenitors and stimulates maturation of these cells into functional red blood cells.
Epoetin alfa for intravenous or subcutaneous use carries a black box waring for increased risk of death, myocardial infarction, stroke, venous thromboembolism, thrombosis of vascular access and tumor progression or recurrence.
For persons with chronic kidney disease, in controlled trials, patients experienced greater risks for death, serious cardiovascular reactions, and stroke when administered ESAs to target a hemoglobin level of greater than 11 g/dL. The labeling states that no trial has identified a hemoglobin target level, ESA dose, or dosing strategy that does not increase these risks. The FDA labeling recommends using the lowest ESA dose sufficient to reduce the need for red blood cell (RBC) transfusions.
For persons with cancer, ESAs shortened overall survival and/or increased the risk of tumor progression or recurrence in clinical studies of patients with breast, non-small cell lung, head and neck, lymphoid, and cervical cancers. To decrease these risks, as well as the risk of serious cardiovascular and thromboembolic reactions, the labeling recommends using the lowest dose needed to avoid RBC transfusions. The labeling recommends using ESAs only for anemia from myelosuppressive chemotherapy. ESAs are not indicated for patients receiving myelosuppressive chemotherapy when the anticipated outcome is cure. The labeling recommends discontinuing ESAs following completion of a chemotherapy course.
For use of ESAs peri-surgery, due to the increased risk of deep venous thrombosis (DVT), DVT prophylaxis is recommended.
Procrit and/or Epogen should not be used in persons with a known hypersensitivity to mammalian cell-derived products or a known hypersensitivity to human albumin. ESAs should not be used in patients with known erythropoietin-type resistance due to neutralizing antibodies.
Uncontrolled hypertension-hypertensive encephalopathy and seizures have been observed. Blood pressure should be adequately controlled prior to initiation of ESA therapy, and must be closely monitored and controlled during therapy.
ESAs should not be used prophylactically to prevent chemotherapy induced anemia or to reduce tumor hypoxia.
Epoetin alfa treatment in patients with grossly elevated serum erythropoietin levels (e.g., greater than 200 milliunits/milliliter) is not recommended.
ESAs are not recommended for persons with a previous episode of pure red cell aplasia during treatment with epoetin alpha, darbepoetin alfa, or methoxy polyethylene glycol-epoetin beta.
ESAs should not be used in any anemia in cancer that is due to bone marrow fibrosis.
Prior to initiation of therapy, the patient's iron stores, including transferrin saturation and serum ferritin, should be evaluated. According to the literature, transferrin saturation should be at least 20 % and ferritin at least 100 ng/ml. In addition, since ferritin is an acute phase reactant, it may be falsely elevated (to the normal range) in iron deficient dialysis patients. Therefore, the best guide for iron supplementation in this group of patients is an iron saturation greater than 20 %. In addition, the patient should have adequate serum folate levels (3.6 to 20 ng/ml) and normal Vitamin B12 levels (reference range varies and must be provided).
According to the United States Food and Drug Administration (FDA)-approved labeling of Procrit, the initial recommended dose of erythropoietin for anemia due to cancer chemotherapy in adults is 150 units/kg 3 times per week, or 40,000 units weekly. For pediatric patients, a starting dose of 600 Units/kg (maximum 40,000 units) is recommended. The labeling recommends reducing the dose by 25 % when the hemoglobin approaches 12g/dL, or the hemoglobin increases by more than 1 g/dL in any 2-week period. The labeling recommends that the dose be withheld if the patient's hemoglobin exceeds 12 g/dL, until the hemoglobin falls below 11 g/dL, at which point the dose should then be restarted at 25 % below the previous dose. For persons receiving erythropoietin 3 times per week, the labeling recommends that the dose of erythropoietin be increased to 300 units/kg 3 times per week if the response is not satisfactory (i.e., there is no reduction in transfusion requirements or a rise in hemoglobin) after 8 weeks to achieve and maintain the lowest hemoglobin level sufficient to avoid the need for transfusions and not to exceed 12 g/dL. For persons receiving erythropoietin on a weekly dosing schedule, the dose should be increased to 60,000 units weekly in adults (900 units/kg in children) if response is not satisfactory (i.e., if hemoglobin fails to increase by 1 g/dL after 4 weeks of therapy) to achieve and maintain the lowest hemoglobin level sufficient to avoid the need for transfusions not to exceed 12 g/dL.
According to the FDA-approved labeling of Procrit, the recommended range for the starting dose of erythropoietin alpha for chronic renal failure is 50 to 100 units/kg 3 times weekly for adult patients. The recommended starting dose for pediatric patients on dialysis is 50 units/kg 3 times a week. A Cochrane review by Cody et al (2005) found that there is no significant difference between once-weekly versus thrice-weekly subcutaneous administration of rHuEPO for patients with chronic renal failure on dialysis. According to the literature, dosing should be discontinued if the hematocrit has not increased within 16 weeks, indicating a non-responder. Accepted guidelines state that dosage should be decreased if the hematocrit increases by more than 4 g/dL in any 2-week period. Dosing is adjusted after 8 weeks and at monthly intervals thereafter as necessary to maintain a hematocrit of 30 to 36 %. The FDA-approved labeling for Procrit states that the dose of erythropoietin should be reduced as the hemoglobin approaches 11 g/dL or increases by more than 1 g/dL in any 2-week period. The dose should be adjusted for each patient to achieve and maintain the lowest hemoglobin level sufficient to avoid the need for RBC transfusion and not to exceed 11 g/dL. The labeling states that the dost of erythropoietin should be increased if the hemoglobin does not increase by 2 g/dL after 8 weeks of therapy, and the hemoglobin remains at a level not sufficient to avoid the need for a transfusion. The labeling states that the maintenance dose of erythropoietin should be individually titrated to achieve and maintain the lowest hemoglobin sufficient to avoid the need for transfusions and not to exceed 11 g/dL.
The FDA-approved labeling for Procrit states that increases in dose should not be made more frequently than once a month. If the hemoglobin is increasing and approaching 11 g/dL, the dose should be reduced by approximately 25 %. If the hemoglobin continues to increase, dose should be temporarily withheld until the hemoglobin begins to decrease, at which point therapy should be reinitiated at a dose approximately 25 % below the previous dose. If the hemoglobin increases by more than 1 g/dL in a 2-week period, the dose should be decreased by approximately 25 %. The labeling states that, if the increase in hemoglobin is less than 1 g/dL over 4 weeks and iron stores are adequate, the dose of erythropoietin may be increased by approximately 25 % of the previous dose. Further increases may be made at 4-week intervals until the specified hemoglobin is obtained.
Retacrit
U.S. Food and Drug Administration (FDA)-Approved Indications:
- Epoetin alfa is indicated for the treatment of anemia due to chronic kidney disease (CKD), including patients on dialysis and not on dialysis to decrease the need for red blood cell (RBC) transfusion.
- Epoetin alfa is indicated for the treatment of anemia due to zidovudine administered at ≤ 4200 mg/week in HIV-infected patients with endogenous serum erythropoietin levels of ≤ 500 mUnits/mL.
- Epoetin alfa is indicated for the treatment of anemia in patients with non-myeloid malignancies where anemia is due to the effect of concomitant myelosuppressive chemotherapy, and upon initiation, there is a minimum of two additional months of planned chemotherapy.
- Epoetin alfa is indicated to reduce the need for allogeneic RBC transfusions among patients with perioperative hemoglobin > 10 to ≤ 13 g/dL who are at high risk for perioperative blood loss from elective, noncardiac, nonvascular surgery. Epoetin alfa is not indicated for patients who are willing to donate autologous blood preoperatively.
Compendial Uses:
- Symptomatic anemia in patients with myelodysplastic syndromes (MDS)
- Anemia in congestive heart failure
- Anemia in rheumatoid arthritis
- Anemia due to hepatitis C treatment with ribavirin in combination with either interferon alfa or peginterferon alfa
- Anemia in patients whose religious beliefs forbid blood transfusions
- Symptomatic anemia in patients with primary myelofibrosis, post-polycythemia vera myelofibrosis, or post-essential thrombocythemia myelofibrosis
- Cancer patients who are undergoing palliative treatment
In 2018, the U.S. FDA approved epoetin alfa-epbx (Retacrit), a biosimilar to Epogen and Procrit (epoetin alfa), for all indications of the reference product.
The FDA approval was based on a data package submitted by the manufacturer demonstrating a high degree of similarity between Retacrit and its U.S. reference product, Epogen and Procrit.
Aranesp
U.S. Food and Drug Administration (FDA)-Approved Indications:
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Anemia Due to Chronic Kidney Disease
Treatment of anemia due to chronic kidney disease (CKD), including patients on dialysis and patients not on dialysis.
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Anemia Due to Chemotherapy in Patients with Cancer
Treatment of anemia in patients with non-myeloid malignancies where anemia is due to the effect of concomitant myelosuppressive chemotherapy, and upon initiation, there is a minimum of two additional months of planned chemotherapy.
Compendial Uses:
- Symptomatic anemia in patients with myelodysplastic syndromes (MDS)
- Anemia in patients whose religious beliefs forbid blood transfusions
- Symptomatic anemia in patients with primary myelofibrosis, post-polycythemia vera myelofibrosis, or post-essential thrombocythemia myelofibrosis
- Cancer patients who are undergoing palliative treatment
Darbepoetin alfa, available as Aranesp, and is also known as novel erythropoiesis stimulating protein (NESP), is an erythropoiesis stimulating protein closely related to erythropoietin that is produced in Chinese hamster ovary cells by recombinant DNA technology. This FDA- approved drug stimulates erythropoiesis by the same mechanism as endogenous erythropoietin. A primary growth factor for erythroid development, erythropoietin is produced in the kidney and released into the bloodstream in response to hypoxia. Erythropoietin interacts with progenitor stem cells to increase red cell production. Production of endogenous erythropoietin is impaired in patients with chronic renal failure, and erythropoietin deficiency is the primary cause of their anemia.
Darbepoetin alfa (Aranesp) is a 165-amino acid protein that differs from recombinant human erythropoietin (epoetin alfa) by containing five N-linked oligosaccharide chains, whereas epoetin alfa contains three chains. Darbepoetin alfa stimulates erythropoiesis by the same mechanism as endogenous erythropoietin (EPO). EPO is a glycoprotein that regulates the production of red blood cells by stimulating the division and differentiation of committed erythroid progenitor cells in the bone marrow.
In 2001, the FDA approved Aranesp for the treatment of anemia associated with chronic renal failure, including patients on dialysis and patients not on dialysis. In addition, Aranesp is indicated for anemia in non-myeloid neoplastic disease due to chemotherapy. Increased hemoglobin levels are not generally observed until 2 to 6 weeks after initiating treatment with Aranesp. Aranesp has an approximately 3-fold longer terminal half-life than Epoetin alfa when administered by either the IV or SC route as a single weekly injection. The dose should be started and slowly adjusted based on hemoglobin levels. The dose should be adjusted for each patient to achieve and maintain a target hemoglobin level not to exceed 12 g/dL.
Aranesp carries a black box warning for increase risk of death, myocardial infarction, strok, venous thromboembolism, thrombosis of vascular access and tumor progression or recurrence.
For persons with chronic kidney disease, in controlled trials, patients experienced greater risks for death, serious adverse cardiovascular reactions, and stroke when administered erythropoiesis-stimulating agents (ESAs) to target a hemoglobin level of greater than 11 g/dL. No trial has identified a hemoglobin target level, Aranesp dose, or dosing strategy that does not increase these risks. Use the lowest Aranesp dose sufficient to reduce the need for red blood cell (RBC) transfusions.
For persons with cancer, ESAs shortened overall survival and/or increased the risk of tumor progression or recurrence in clinical studies of patients with breast, non-small cell lung, head and neck, lymphoid, and cervical cancers. Use the lowest dose to avoid RBC transfusions. Use ESAs only for anemia from myelosuppressive chemotherapy. ESAs are not indicated for patients receiving myelosuppressive chemotherapy when the anticipated outcome is cure. Discontinue following the completion of a chemotherapy course.
Aranesp is contraindicated in uncontrolled hypertension, pure red cell aplasia (PrCA) that begins after treatment with ARanesp or other erythropoietin protein drugs, or serious allergic reactions to Aranesp. For patients with chronic kidney disease, adverse reactions in greater than or equal to 10% of Aranesp-treated patients in clinical studies were hypertension, dyspnea, peripheral edema, cough and procedural hypotension. Patiens with cancer receiving chemotherapy, adverse reactions in greater than or equal to 1% of Aranesp-treated patients in clinical studies were abdominal pain, edema, and thrombovascular events.
The safety and efficacy of darbepoetin in pediatric patients less than 18 years old with cancer has not been established. The safey and efficacy in pediatric patients less than one year of age with chronic renal failure has not been established.
Mircera
U.S. Food and Drug Administration (FDA)-Approved Indications:
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Mircera is indicated for the treatment of anemia associated with chronic kidney disease (CKD) in:
- Adult patients on dialysis and adult patients not on dialysis.
- Pediatric patients 5 to 17 years of age on hemodialysis who are converting from another erythropoiesis-stimulating agent (ESA) after their hemoglobin level was stabilized with an ESA.
Methoxy polyethylene glycol‐epoetin beta, available as Mircera, is an erythropoietin receptor activator with greater activity in vivo as well as increased half‐life, in contrast to erythropoietin. A primary growth factor for erythroid development, erythropoietin is produced in the kidney and released into the bloodstream in response to hypoxia. In responding to hypoxia, erythropoietin interacts with erythroid progenitor cells to increase red cell production. Production of endogenous erythropoietin is impaired in patients with chronic kidney disease (CKD) and erythropoietin deficiency is the primary cause of their anemia.
The U.S. Food and Drug Administration (FDA) approved methoxy polyethylene glycol-epoetin beta (Mircera) for the treatment of anemia associated with chronic kidney disease (CKD) in patients on dialysis and patients not on dialysis (Roche, 2007). Mircera was approved by the FDA in 2007, but due to the outcome of a patent infringement case in favor of Amgen, introduction of Mircera in the United States was delayed until mid-2014.
Mircera has a longer half-life than other FDA-approved erythropoiesis stimulating agents (ESAs) darbepoetin alfa and epoetin (Roche, 2007). Mircera is approved to correct and maintain stable hemoglobin levels with once-monthly or once-every-two-week dosing. The manufacturer states that Mircera offers the added convenience of storage at room temperature for extended time periods when necessary.
The Phase III data supporting the FDA approval for Mircera consisted of two correction and four maintenance studies exploring intravenous (IV) and subcutaneous (SC) Mircera at extended administration intervals (Roche, 2007). The initial registration clinical program for Mircera consisted of 10 global studies involving more than 2,700 patients from 29 countries.
In clinical trials, Mircera was as effective as commercially available agents in correcting renal anemia in patients with CRF on dialysis and not on dialysis (Roche, 2007). Up to 97.5 percent of patients who were not currently receiving an ESA achieved target Hb levels (>=11g/dL) with once-every two week dosing of Mircera. Patients maintained stable Hb levels (±1g/dL) when switched to once-monthly Mircera from a shorter-acting frequently administered ESA treatment regimen.
Mircera has a safety profile comparable to other erythropoietic agents (Roche, 2007). The most common adverse reactions are hypertension, diarrhea, nasopharyngitis, headache, and upper respiratory tract infection. In chronic renal failure, patients experienced greater risks for death and serious cardiovascular events when administered ESAa to target higher versus lower hemoglobin levels.
Mircera is contraindicated in patients with uncontrolled hypertension and in patients with a history of hypersensitivity or allergy to Mircera (Roche, 2007). Mircera is not indicated for the treatment of anemia due to cancer chemotherapy.
Pure red cell aplasia (PRCA) and severe anemia have been associated with the development of neutralizing antibodies to erythropoietin in patients treated with ESAs (Roche, 2007). PRCA was not observed with Mircera in clinical trials. The labeling recommends that, if anti-erythropoietin antibody-associated anemia is suspected, Mircera and other ESAs should be withheld.
Mircera (methoxy polyethylene glycol‐epoetin beta) is not indicated and is not recommended: in the treatment of anemia due to cancer chemotherapy; as a substitute for red blood cell (RBC) transfusions in patients who require immediate correction of anemia; nor to improve symptoms, physical functioning, or health‐related quality of life.
Mircera should not be used in persons with a known hypersensitivity to the active product or any of its excipients. Mircera should also not be used in persons with a previous episode of pure red cell aplasia during treatment with epoetin alfa, darbepoetin alfa, or methoxy polyethylene glycol‐epoetin beta.
Safety and efficacy in pediatric patients less than 18 years old with cancer have not been established. Safety and efficacy in pediatric patients less than one year of age with chronic renal failure have not been established.
There is a lack of reliable evidence that one brand of erythropoietin alpha (Procrit or Epogen) is more effective than another brand. In addition, there is a lack of reliable evidence that darbepoetin (Aranesp) is more or less effective than erythropoietin alpha for darbepoetin's established indications.
Concurrent use of ESAs with thalidomide is not recommended (increased risk of thromboembolism).
ESA Risks
Recent data indicate that about half of patients undergoing dialysis in the United States have their hemoglobin levels maintained at values above the maximum target (12 g/dL that was specified in the product labeling for erythropoietin analogs at the time the study was performed (Steinbrook, 2007). Some investigators have posited that maintaining higher hemoglobin levels may benefit patients' quality of life. However, the Correction of Hemoglobin and Outcomes in Renal Insufficiency (CHOIR) study found that maintaining higher hemoglobin levels increases patients' risk of serious and life-threatening cardiovascular complications, including death (Singh et al, 2006). The CHOIR study found that targeting a hemoglobin level of 13.5 g/dL (as compared with 11.3 g/dL) in patients with chronic kidney disease who did not yet need dialysis was associated with a significantly increased risk of a composite end point of death, myocardial infarction, hospitalization for congestive heart failure (without renal-replacement therapy), and stroke. On November 16, 2006, the day the CHOIR study was published, the FDA issued a public health advisory to "underscore the importance of following the currently approved prescribing information" by raising hemoglobin levels no higher than 12 g/dL (FDA, 2006; Steinbrook, 2006).
More recently, the FDA (2011) announced that, for patients on dialysis, erythropoiesis-stimulating agent (ESA) therapy can start when the hemoglobin level is less than 10 g/dL. But, if the hemoglobin level approaches or goes over 11 g/dL, the dose of the drug should be lowered or therapy stopped. FDA's announcement applies to patients with early-stage kidney failure as well as those on dialysis, the treatment for late-stage kidney failure. The previous labeling of ESAs recommended keeping patients' hemoglobin levels between 10 g/dL and 12 g/dL. The new label does away with that specific target range, stating only that physicians should initiate ESAs if patients' hemoglobins fall below 10 g/dL." This labeling change was prompted by studies that have found that hemoglobin levels greater than 11 g/dL of blood increase the risk of stroke, heart attack, heart failure and thromboembolism and haven't been proven to provide any additional benefit to patients. The revised labeling of ESAs states that for patients with chronic kidney disease not on dialysis, ESA therapy can be started when the hemoglobin level is less than 10 g/dL. However, the goal of treatment should not be to increase hemoglobin levels to 10 or more g/dL. The FDA recommends that, if the hemoglobin level exceeds 10 g/dL, the dose of ESA should be reduced or interrupted. For patients on dialysis, ESA therapy can start when the hemoglobin level is less than 10 g/dL. But, if the hemoglobin level approaches or goes over 11 g/dL, the dose of the drug should be lowered or therapy stopped, the FDA said.
The FDA was notified in February 2007 of the preliminary results of a 681-patient, multi-center, randomized, open-label, non-inferiority study of erythropoietin alphoa compared with the standard of care in adult patients undergoing elective spinal surgery. Erythropoietin alpha was administered according to the dosage and administration section of the label for pretreatment hemoglobin values greater than 10 and less than 13 g/dL. The frequency of deep venous thrombosis in patients treated with erythropoietin alpha was 4.7 % (16 patients), more than twice that of patients who received usual blood conservation care (frequency of 2.1 %, 7 patients).
The FDA-approved labeling for erythropoietin analogs has revised product labeling that includes updated warnings, a new boxed warning, and modifications to the dosing instructions (FDA, 2007). The new boxed warning advises physicians to monitor hemoglobin and to adjust the erythropoietin analogs dose to maintain the lowest hemoglobin level needed to avoid the need for blood transfusions. The labeling states that physicians and patients should carefully weigh the risks of erythropoietin analogs against transfusion risks.
In 2007, the FDA ordered changes to the labeling of ESAs, restricting their use. The FDA instructed manufacturers to change the labeling to reflect three major changes: the drugs are "not indicated for those receiving myelosuppressive therapy when the anticipated outcome is cure"; therapy should not be initiated at hemoglobin levels of 10 g/dL and above; and doses should be withheld if hemoglobin levels exceed a level needed to avoid transfusion. The black-box warnings for ESAs were updated with information on the increased risk for death and tumor progression in patients with early breast cancer and cervical cancer. The warnings note that ESAs pose higher risks when dosed to achieve hemoglobin levels of 12 g/dL or higher, and risks at lower hemoglobin targets have not been excluded. Accordingly, physicians are advised to use the lowest dose needed to avoid RBC transfusions. Previous warnings have highlighted the risks for patients with non-small-cell lung, head and neck, and lymphoid cancers.
Futhermore, the NCCN Drugs & Biologics Compendium (2019) states erythropoiesis-stimulating agents (i.e. Epogen, Procrit, and Aranesp) are “not recommended when myelosuppressive chemotherapy is given with curative intent, for patients with cancer who are not receiving therapy, or for patients receiving non-myelosuppressive therapy” (NCCN category 2A).
Several studies have documented an increased risk of venous thromboembolism (VTE) in patients with cancer-associated anemia who are treated with the erythropoietin and darbepoetin. In an updated investigation of safety concerns related to erythropoiesis stimulating agents, Bennett and colleagues (2008) analyzed data from Phase III clinical trials published or presented between January 1993 and January 2007 to assess ESA-associated risks of VTE and mortality. The authors report that anemic patients with cancer who were treated with ESAs had a 1.55-fold increased risk of VTE and a 1.10-fold increased risk of mortality compared with patients who received placebo or standard care.
A number of clinical studies have examined the effect of erythropoietin analogs on cancer progression, apart from its effect on chemotherapy-induced anemia. Clinical observations in patients with multiple myeloma and animal studies have suggested that epoetin has an anti-myeloma effect, mediated via the immune system through activation of CD8+ T cells. Thus, the role of epoetin may go well beyond that of increasing hemoglobin levels in anemic patients, although additional studies are needed to confirm these promising results.
There are other studies, however, which raise suspicion about negative effects of erythropoietin on tumor size and survival in cancer patients (DACEHTA, 2004). In a multi-center, RCT, Leyland-Jones et al (2005) assessed the effect on survival and quality of life of maintaining hemoglobin (Hb) in the range of 12 to 14 g/dL with epoetin alfa versus placebo in women with metastatic breast cancer (MBC) receiving first-line chemotherapy. Eligible patients were randomly assigned to receive epoetin alfa 40,000 units once-weekly or placebo for 12 months. Study drug was initiated if baseline Hb was less than or equal to 13 g/dL or when Hb decreased to less than or equal to 13g/dL during the study. The primary end point was 12-month overall survival (OS). The study drug administration was stopped early in accordance with a recommendation from the Independent Data Monitoring Committee because of higher mortality in the group treated with epoetin alfa. Enrollment had been completed, with 939 patients enrolled (epoetin alfa, n = 469; placebo, n = 470). Most patients had Hb more than 12 g/dL at baseline (median Hb, 12.8 g/dL) or during the study. From the final analysis, 12-month OS was 70 % for epoetin alfa recipients and 76 % for placebo recipients (p = 0.01). Optimal tumor response and time to disease progression were similar between groups. The reason for the difference in mortality between groups could not be determined from additional subsequent analyses involving both study data and chart review. These researchers concluded that the use of epoetin alfa to maintain high Hb targets in women with MBC, most of whom did not have anemia at the start of treatment, was associated with decreased survival. Additional research is needed to clarify the potential impact of erythropoietic agents on survival when the Hb target range is 10 to 12 g/dL.
Randomized controlled clinical studies of the use of erythropoietin analogs in other types of cancer (head and neck cancer, lung cancer, lymphoproliferative disorders) have similarly found no improvements in progression-free survival or OS (Hedenus et al, 2005).
Interim results from the Danish Head and Neck Cancer Study Group trial (DAHANCA 10), an open-label, randomized trial that compared radiation therapy alone to radiation plus darbepoietin in treatment of advanced head and neck cancer found that 3-year loco-regional control was significantly worse for patients in the darbepoetin arm (p = 0.01) and OS favored those not treated with Aranesp, but the difference was not statistically significant (FDA, 2007). The trial was terminated December 2006. Results similar to the DAHANCA 10 study -- increased tumor progression and decreased survival -- were reported by Henke et al at the May 4, 2004, meeting of the FDA's Oncologic Drugs Advisory Committee.
In January 2007 the FDA was notified of the results of a 989-patient, multi-center, double-blind, randomized, placebo-controlled study of darbepoetin in anemic cancer patients who are not receiving chemotherapy (FDA, 2007). The target hemoglobin in the darbepoetin treatment group was 12 g/dL. The study results provided to the FDA show darbepoetin did not reduce the need for RBC transfusions and showed an increase in mortality in patients receiving Aranesp compared to those receiving placebo (hazard ratio 1.25; 95 % confidence interval [CI]: 1.04 to 1.51).
The FDA was notified in February 2007 of the final results of a double-blind, placebo controlled study to evaluate whether use of epoetin alpha in anemic NSCLC patients not on chemotherapy improved their quality of life (FDA, 2007). The epoetin alfa dose was titrated to maintain a hemoglobin level of 12 to 14 g/dL; epoetin alfa was dosed at 40,000 International Units (IU) every week. The study was terminated early when the data safety monitoring committee determined that the median time to death was 68 days in the epoetin alfa arm versus 131 days in the placebo arm (p = 0.040) and the majority of deaths were due to disease progression. Also treatment with epoetin alfa did not significantly reduce the need for transfusion or improve the quality of life.
In February 2007, the FDA was notified by Roche that it was suspending a study of a new ESA because of safety concerns (FDA, 2007). The study was a multi-center, randomized, dose-finding assessment of a pegylated epoetin beta product in anemic patients with Stage IIIB or IV NSCLC who were receiving first line chemotherapy. Three dosing regimens of the investigational drug were being compared with Aranesp (given according to an FDA-approved dosing regimen). The dose of pegylated epoetin beta was titrated to maintain the hemoglobin level between 11 and 13 g/dL. An interim analysis, after randomization of 153 patients, demonstrated a numerical imbalance in the number of deaths across the 4 arms of the study.
In a multicenter, randomized, double-blind, placebo-controlled trial, Wright et al (2007) found decreased OS in anemic patients with advanced non-small-cell carcinoma of the lung (NSCLC) treated with epoetin alpha. In this clinical study, the proposed sample size was 300 patients. Eligible patients were required to have NSCLC unsuitable for curative therapy and baseline hemoglobin (Hgb) levels less than 12 g/dL. Patients were assigned to 12 weekly injections of subcutaneous epoetin alpha or placebo, targeting Hgb levels between 12 and 14 g/dL. The study was intended to evaluate the effect of epoietin administration on quality of life. However, reports of thrombotic events in other trials of erythropoietin analogs prompted an unplanned safety analysis after 70 patients had been randomly assigned (33 to the active arm and 37 to the placebo arm). This revealed a significant difference in the median survival in favor of the patients on the placebo arm of the trial (63 verus 129 days; hazard ratio, 1.84; p = 0.04). Because of the poorer outcomes in the erythropoietin-treated patients, the Steering Committee closed the trial. The authors concluded that this unplanned safety analysis suggested decreased OS in patients with advanced NSCLC treated with epoetin alfa.
Erythropoiesis stimulating agents have not been proven to be effective for the treatment of aplastic anemia. Erythropoietin levels are markedly elevated in most patients with aplastic anemia. Guidelines from the British Society of Haematology (2002) state that the routine use of erythropoietin for aplastic anemia is "not recommended." The guidelines note the limitations of evidence for erythropoietin in aplastic anemia. In addition, the guidelines note that erythropoietin has the potential for inducing severe and sudden worsening of anemia due to red cell aplasia from anti-erythropoietin antibodies. The guidelines also note that there is a potential for toxicity when erythropoietin is used in combination with other drugs used routinely to treat aplastic anemia, such as cyclosporin.
Several randomized controlled trials (RCTs) have examined the effectiveness of erythropoietin in aplastic anemia. The most recent (Zeng et al, 2006) found that the addition of growth factors (erythropoietin plus granulocyte colony stimulating factor [G-CSF]) to immunosuppressive therapy did not improve outcomes over immunosuppressive therapy alone. An earlier RCT by Bessho et al (1997) compared G-CSF plus erythropoietin to erythropoietin alone, but did not include an appropriate comparison to immunosuppressive therapy, which is the current standard of care for aplastic anemia. Another earlier RCT by Shao et al (1998) compared immunosuppressive therapy to G-CSF plus erythropoietin. Limitations of the study by Shao et al (1998) compared to the most recent study by Zeng et al (2006) include its smaller size and its measurement of only intermediate outcomes (response rates) rather than survival. Both studies are limited by the use of G-CSF with erythropoietin, which does not allow us to isolate the effect of erythropoietin.
The lack of proven effectiveness of erythropoietin in aplastic anemia, coupled with the potential noted by the British Society of Haematology for the sudden and severe worsening of anemia due to red cell aplasia due to the induction of erythropoietin antibodies, plus the synergistic toxic effects of erythropoietin when combined with cyclosporin and other drugs for aplastic anemia, counsel against the use of erythropoietin as a treatment for aplastic anemia.
Regarding use of erythropoietin analogs as a treatment for cancer, a technology assessment by the Danish Centre for Evaluation and Health Technology Assessment (DACEHTA, 2004) concluded: “At present there is not sufficient evidence that EPO [erythropoietin] treatment has an effect on the cancer disease itself. Therefore, EPO treatment should not be regarded as a treatment of cancer as such, but rather as a treatment of the side effects of the chemotherapy.”
An assessment by the National Institute for Health and Clinical Excellence (NICE, 2008) of erythropoietin analog therapy for cancer chemotherapy induced anemia recommended that erythropoietin only be used as part of clinical trials that are constructed to generate robust and relevant data in order to address the gaps in the currently available evidence. The assessment reported that some studies had shown benefits with erythropoietin in terms of improved survival, but that the results of other studies were consistent with a detrimental effect. The assessment also noted that there are biologically plausible reasons to suggest possible growth-enhancing effects of erythropoietin on some tumors. The assessment therefore concluded that the true effect of erythropoietin on survival remains unknown. The assessment noted that clinical trials examining the effects of erythropoietin on various measures of health-related quality of life had significant methodological weaknesses. Although most studies suggested that erythropoietin improved health-related quality of life, the additional benefits over standard care (i.e., blood transfusions and iron therapy where indicated) were small. The assessment found that the benefits of erythropoietin in reducing the need for blood transfusions were modest: in trials comparing erythropoietin therapy to standard care involving blood transfusions, erythropoietin therapy reduced the requirement for blood transfusions by approximately 1 unit per patient overall. The assessment also reported that fatigue in patients with cancer has a number of potential contributory factors, and that it is difficult in individual cases to determine the exact contribution of anemia to this symptom.
Emerging safety concerns (thrombosis, cardiovascular events, tumor progression, and reduced survival) derived from clinical trials in several cancer and non-cancer populations prompted the CMS to review its coverage of erythropoietin analog therapy. CMS (2007) determined that erythropoietin analog therapy is not reasonable and necessary for the following clinical conditions, either because of a deleterious effect of erythropoietin analogs on the underlying disease or because the underlying disease increases their risk of adverse effects related to erythropoietin analog use. These conditions include:
- Anemia due to cancer treatment if patients have uncontrolled hypertension;
- Any anemia associated only with radiotherapy;
- Any anemia in cancer or cancer treatment patients due to folate deficiency, B-12 deficiency, iron deficiency, hemolysis, bleeding, or bone marrow fibrosis;
- Patients with erythropoietin-type resistance due to neutralizing antibodies;
- Prophylactic use to prevent chemotherapy-induced anemia;
- Prophylactic use to reduce tumor hypoxia;
- The anemia associated with the treatment of acute and chronic myelogenous leukemias (CML, AML), or erythroid cancers; and
- The anemia of cancer not related to cancer treatment.
In a phase III, multi-center, randomized, double-blind, placebo-controlled study, Smith and colleagues (2008) examined the effects of darbepoetin alpha (DA) for the treatment of anemia in patients with active cancer not receiving or planning to receive chemotherapy or radiotherapy. Patients were administered placebo or DA 6.75 microg/kg every 4 weeks (Q4W) for up to 16 weeks with a 2-year follow-up for survival. Patients who completed 16 weeks of treatment could receive the same treatment as randomized Q4W for an additional 16 weeks. The primary end point was all occurrences of transfusions from weeks 5 through 17; safety end points included incidence of adverse events and survival. The incidence of transfusions between weeks 5 and 17 was lower in the DA group but was not statistically significantly different from that of placebo. Darbepoetin alpha was associated with an increased incidence of cardiovascular and thromboembolic events and more deaths during the initial 16-week treatment period. Long-term survival data demonstrated statistically significantly poorer survival in patients treated with DA versus placebo (p = 0.022). This effect varied by baseline co-variates including, sex, tumor type, and geographic region; statistical significance diminished (p = 0.12) when the analysis was adjusted for baseline imbalances or known prognostic factors. The authors concluded that DA was not associated with a statistically significant reduction in transfusions. Shorter survival was observed in the DA arm; thus, this study does not support the use of ESA in this subset of patients with anemia of cancer.
The Centers for Medicare and Medicaid Services (CMS, 2007) has developed evidence based guidelines for dosing of erythropoietin analog therapy in persons with end-stage renal disease. CMS issued a final policy, effective April 2006, that, for claims for erythropoietin analog therapy in persons with hematocrit readings above a threshold of 39.0 % (or hemoglobin above 13.0 g/dL), the dose should be reduced by 25 % over the preceding month. Since that time, there have been several publications and an FDA “black box” warning that emphasize the risks facing end-stage renal disease patients who receive large doses of erythropoietin analogues and have higher hematocrits. In response to those concerns, CMS modified its erythropoietin analog therapy monitoring policy to provide greater restrictions on the amount of erythropoietin analogs for which payment is made at higher levels of hemoglobin. Effective for dates of service on or after January 1, 2008, for requests for payments or claims for erythropoietin analog therapy for end-stage renal disease patients receiving dialysis in renal dialysis facilities and reporting a hematocrit level exceeding 39.0 % (or hemoglobin exceeding 13.0 g/dL) for 3 or more consecutive billing cycles immediately prior to and including the current billing cycle, the erythropoietin analog dose for which payment may be made shall be reduced by 50 % of the reported dose.
The discovery that erythropoietin and its receptor are located in regions outside the erythropoietic system has led to interest in the potential role of epoetin in other tissues, such as the central nervous system (Boogaerts et al, 2005). Bath and Sprigg (2005) report that erythropoietin was neuroprotective in experimental stroke and increased functional recovery, effects possibly mediated by inhibiting apoptosis in the penumbra. They note that, in a small clinical trial, erythropoietin was well-tolerated in stroke patients. Erythropoietin for stroke is currently being assessed in Phase II clinical trials. Bath and Sprigg (2005) reported that derivatives of erythropoietin which do not alter red cell kinetics but retain their neuroprotective activity have been developed, but clinical studies of these have yet to be reported.
However, more recent evidence suggests that erythropoiesis stimulating agents may increase stroke risk. The FDA (2008) stated that erythropoietin may carry heightened mortality risk when used to improve functional outcomes in stroke patients. In a clinical trial conducted in Germany, patients with acute ischemic stroke who received intravenous Eprex brand of erythropoietin (40,000 units daily for 3 days) were more likely to die within 90 days than were those on placebo (16 % versus 9 %). In particular, death from intracranial hemorrhage occurred in 4 % of Eprex recipients and 1 % of placebo recipients. The FDA noted, however, that the dose used was "considerably higher" than the erythropoietin doses approved for the treatment of anemia.
Erythropoesis stimulating agents have not been proven to improve outcomes in persons with heart failure and anemia. The American College of Physicians clinical practice guidelines on the treatment of anemia in heart failure (Qaseem, et al., 2013) recommends against the use of erythropoiesis-stimulating agents in patients with mild to moderate anemia and heart failure or coronary heart disease (strong recommendation based on moderate quality evidence; equivalent to Grade 1B). The available evidence does not support the use of erythropoiesis-stimulating agents to treat mild to moderate anemia in patients with heart failure and suggests an increased risk of venous thromboembolism (Colucci, 2018).
In the randomized, double-blind, placebo-controlled Study of Anemia and Heart Failure Trial (STAMINA-HeFT), investigators evaluated the effects of treating anemia in patients with heart failure (Ghali et al, 2008). A total of 319 patients with symptomatic heart failure were randomized to placebo or darbepoetin for 52 weeks. The median hemoglobin level in the darbepoetin group increased by 1.5 g/dL from baseline to 12 to 14 weeks of treatment; target hemoglobin concentrations were maintained in the darbepoetin group for the remainder of the study period. At week 27, however, the groups did not differ significantly in mean change from baseline in either exercise duration or New York Heart Association functional class.
Kansagara et al (2013) evaluated the benefits and harms of treatments for anemia in adults with heart disease. Data sources included MEDLINE, EMBASE, and Cochrane databases; clinical trial registries; reference lists; and technical advisors. English-language trials of blood transfusions, iron, or ESAs in adults with anemia and congestive heart failure or coronary heart disease and observational studies of transfusion were selected for analysis. Data on study design, population characteristics, Hb levels, and health outcomes were extracted. Trials were assessed for quality. Low-strength evidence from 6 trials and 26 observational studies suggested that liberal transfusion protocols do not improve short-term mortality rates compared with less aggressive protocols (combined relative risk among trials, 0.94 [95 % CI: 0.61 to 1.42]; I2 = 16.8 %), although decreased mortality rates occurred in a small trial of patients with the acute coronary syndrome (1.8 % versus 13.0 %; p = 0.032). Moderate-strength evidence from 3 trials of intravenous iron found improved short-term exercise tolerance and quality of life in patients with heart failure. Moderate- to high-strength evidence from 17 trials of ESA therapy found they offered no consistent benefits, but their use may be associated with harms, such as VTE. The authors concluded that higher transfusion thresholds do not consistently improve mortality rates, but large trials are needed. Intravenous iron may help to alleviate symptoms in patients with heart failure and iron deficiency and also warrants further study. Moreover, they stated that ESAs do not seem to benefit patients with mild-to-moderate anemia and heart disease and may be associated with serious harms.
The American College of Obstetricians and Gynecologists' (ACOG, 2008) practice bulletin on anemia in pregnancy makes no recommendation for use of erythropoietin in pregnancy (2008). The bulletin states: "Few studies have examined the role of erythropoietin in pregnant patients with anemia." The ACOG practice bulletin cited two randomized controlled clinical studies of erythropoietin plus iron versus iron alone in anemia of pregnancy and postpartum anemia, with contrasting results (citing Breymann et al, 2001; Wagstrom et al, 2007).
Pfeffer and colleagues (2009) stated that anemia is associated with an increased risk of cardiovascular and renal events among patients with type 2 diabetes and chronic kidney disease (CKD). Although darbepoetin alfa can effectively increase Hb levels, its effect on clinical outcomes in these patients has not been adequately tested. In this study involving 4,038 patients with diabetes, CKD, and anemia, these investigators randomly assigned 2,012 patients to darbepoetin alfa to achieve a Hb level of about 13 g/dL and 2,026 patients to placebo, with rescue darbepoetin alfa when the Hb level was less than 9.0 g/dL. The primary end points were the composite outcomes of death or a cardiovascular event (non-fatal myocardial infarction, congestive heart failure, stroke, or hospitalization for myocardial ischemia) and of death or end-stage renal disease. Death or a cardiovascular event occurred in 632 patients assigned to darbepoetin alfa and 602 patients assigned to placebo (hazard ratio for darbepoetin alfa versus placebo, 1.05; 95 % CI: 0.94 to 1.17; p = 0.41). Death or end-stage renal disease occurred in 652 patients assigned to darbepoetin alfa and 618 patients assigned to placebo (hazard ratio, 1.06; 95 % CI: 0.95 to 1.19; p = 0.29). Fatal or non-fatal stroke occurred in 101 patients assigned to darbepoetin alfa and 53 patients assigned to placebo (hazard ratio, 1.92; 95 % CI: 1.38 to 2.68; p < 0.001). Red-cell transfusions were administered to 297 patients assigned to darbepoetin alfa and 496 patients assigned to placebo (p < 0.001). There was only a modest improvement in patient-reported fatigue in the darbepoetin alfa group as compared with the placebo group. The authors concluded that the use of darbepoetin alfa in patients with diabetes, CKD, and moderate anemia who were not undergoing dialysis did not reduce the risk of either of the 2 primary composite outcomes (either death or a cardiovascular event or death or a renal event) and was associated with an increased risk of stroke. For many persons involved in clinical decision making, this risk will out-weigh the potential benefits.
The findings by Pfeffer et al (2009) are in agreement with those of the CHOIR study (Singh et al, 2006) as well as the CREATE study (Drüeke et al, 2006). Singh and colleagues reported that targeting a Hb level of 13.5 g/dL (as compared with 11.3 g/dL) in patients with CKD who did not yet need dialysis was associated with a significantly increased risk of a composite end point of death, myocardial infarction, hospitalization for congestive heart failure (without renal-replacement therapy), and stroke. Furthermore, Drüeke and associates found that in patients with stage 3 or stage 4 CKD, early complete correction of anemia (Hb levels of 13.0 to 15.0 g/dL) does not reduce the risk of cardiovascular events.
Ehrenreich et al (2009) stated that many pre-clinical findings and a clinical pilot study suggested that recombinant human EPO provides neuroprotection that may be beneficial for the treatment of patients with ischemic stroke. Although EPO has been considered to be a safe and well-tolerated drug over 20 years, recent studies have identified increased thromboembolic complications and/or mortality risks on EPO administration to patients with cancer or CKD. Accordingly, the double-blind, placebo-controlled, randomized German Multicenter EPO Stroke Trial was designed to evaluate safety and effectiveness of EPO in stroke. This clinical trial enrolled 522 patients with acute ischemic stroke in the middle cerebral artery territory (intent-to-treat population) with 460 patients treated as planned (per-protocol population). Within 6 hours of symptom onset, at 24 and 48 hours, EPO was infused intravenously (40,000 IU each). Systemic thrombolysis with recombinant tissue plasminogen activator was allowed and stratified for. Unexpectedly, a very high number of patients received recombinant tissue plasminogen activator (63.4 %). On analysis of total intent-to-treat and per-protocol populations, neither primary outcome Barthel Index on Day 90 (p = 0.45) nor any of the other outcome parameters showed favorable effects of EPO. There was an overall death rate of 16.4 % (n = 42 of 256) in the EPO and 9.0 % (n = 24 of 266) in the placebo group (odds ratio [OR], 1.98; 95 % CI: 1.16 to 3.38; p = 0.01) without any particular mechanism of death unexpected after stroke. The authors concluded that based on analysis of total intent-to-treat and per-protocol populations only, this is a negative trial that also raises safety concerns, particularly in patients receiving systemic thrombolysis.
In an editorial that accompanied the afore-mentioned study, Velmahos (2010) stated that the results serve more to provoke questions than provide answers. One of the questions is that "ESA was administered subcutaneously, a method with notorious unreliable absorption among critically ill patients. How do the authors assure us about adequate levels of the drug? If drug levels are inadequate in the blood stream and organ tissues, how can we accept causation between ESA and the purported outcome improvement?". Velmahos also noted that "[n]o information is provided about the timing of ESA administration, except that it was administered "within the first 2 weeks". However, according to Figure 2 most deaths also occurred within the first 2 weeks in the no-ESA group. This means that ESA saved patients from relatively early deaths. One should assume that a single injection prevented a patient from dying the next day. What exactly is this powerful quality of ESA that can reverse death so drastically? If the effects act through an amelioration of a rampant post-traumatic cascade, how is it that ESA patients suffered more complications?"
Ehrenreich and colleagues (2007) stated that the neurodegenerative aspects of chronic progressive multiple sclerosis (MS) have received increasing attention in recent years, since anti-inflammatory and immunosuppressive treatment strategies have largely failed. However, successful neuroprotection and/or neuroregeneration in MS have not been demonstrated yet. Encouraged by the multi-faceted neuroprotective effects of rHuEPO in experimental models, these researchers performed an investigator-driven, pilot open-label study (phase I/IIa) in patients with chronic progressive MS. Main study objectives were- evaluating safety of long-term high-dose intravenous rHuEPO treatment in MS, and
- collecting first evidence of potential efficacy on clinical outcome parameters.
A total of 8 MS patients -- 5 randomly assigned to high-dose (48,000 IU), 3 to low-dose (8000 IU) rHuEPO treatment; and, as disease controls, 2 drug-naïve Parkinson patients (receiving 48,000 IU) were followed over up to 48 weeks: A 6-week lead-in phase, a 12-week treatment phase with weekly EPO, another 12-week treatment phase with bi-weekly EPO, and a 24-week post-treatment phase. Clinical and electrophysiological improvement of motor function, reflected by a reduction in expanded disability status scale (EDSS), and of cognitive performance was found upon high-dose EPO treatment in MS patients, persisting for 3 to 6 months after cessation of EPO application. In contrast, low-dose EPO MS patients and drug-naïve Parkinson patients did not improve in any of the parameters tested. There were no adverse events, no safety concerns and a surprisingly low need of blood-lettings. The authors concluded that the findings of this pilot study demonstrated the necessity and feasibility of RCTs using high-dose rHuEPO in chronic progressive MS.
Endre and colleagues (2010) performed a double-blind, placebo-controlled trial to study whether early treatment with erythropoietin could prevent the development of acute kidney injury in patients in 2 general intensive care units. As a guide for choosing the patients for treatment, these researchers measured urinary levels of 2 biomarkers:
- the proximal tubular brush border enzymes gamma-glutamyl transpeptidase, and
- alkaline phosphatase.
Randomization to either placebo or 2 doses of erythropoietin was triggered by an increase in the biomarker concentration product to levels above 46.3, with a primary outcome of relative average plasma creatinine increase from baseline over 4 to 7 days. Of 529 patients, 162 were randomized within an average of 3.5 h of a positive sample. There was no difference in the incidence of erythropoietin-specific adverse events or in the primary outcome between the placebo and treatment groups. The triggering biomarker concentration product selected patients with more severe illness and at greater risk of acute kidney injury, dialysis, or death; however, the marker elevations were transient. Early intervention with high-dose erythropoietin was safe but did not alter the outcome. Although these 2 urine biomarkers facilitated early intervention, their transient increase compromised effective triaging. Furthermore, this study showed that a composite of these 2 biomarkers was insufficient for risk stratification in a patient population with a heterogeneous onset of injury.
In a review on the potential of cytokines and growth factors in the treatment of ischemic heart disease, Beohar et al (2010) stated that cytokine therapy promises to provide a non-invasive treatment option for ischemic heart disease. Several cytokines mobilize progenitor cells from the bone marrow or are involved in the homing of mobilized cells to ischemic tissue. The recruited cells contribute to myocardial regeneration both as a structural component of the regenerating tissue and by secreting angiogenic or anti-apoptotic factors, including cytokines. To date, RCTs have not reproduced the efficacy observed in pre-clinical and small-scale clinical investigations. Nevertheless, the list of promising cytokines continues to grow, and combinations of cytokines, with or without concurrent progenitor cell therapy, warrant further investigation. In particular, the authors noted that a long-acting EPO analog, darbepoetin alpha, was safely administered to patients with acute myocardial infarction (MI), but provided no functional benefit. The administration of EPO to patients with acute MI continues to be investigated in the ongoing HEBE III and REVEAL clinical trials.
The American Society of Clinical Oncology/American Society of Hematology clinical practice guideline update on the use of epoetin and darbepoetin in adult patients with cancer (Rizzo et al, 2010) stated that for patients undergoing myelosuppressive chemotherapy who have a Hgb level less than 10 g/dL, the Update Committee recommends that clinicians discuss potential harms (e.g., thromboembolism, shorter survival) and benefits (e.g., decreased transfusions) of ESAs and compare these with potential harms (e.g., serious infections, immune-mediated adverse reactions) and benefits (e.g., rapid Hgb improvement) of RBC transfusions. Individual preferences for assumed risk should contribute to shared decisions on managing chemotherapy-induced anemia. The Committee cautions against ESA use under other circumstances. If used, ESAs should be administered at the lowest dose possible and should increase Hgb to the lowest concentration possible to avoid transfusions. Available evidence does not identify Hgb levels greaterthan or equal to 10 g/dL either as thresholds for initiating treatment or as targets for ESA therapy. Starting doses and dose modifications after response or non-response should follow FDA-approved labeling. Erythropoiesis-stimulating agents should be discontinued after 6 to 8 weeks in non-responders; they should be avoided in patients with cancer not receiving concurrent chemotherapy, except for those with lower risk myelodysplastic syndromes. Caution should be exercised when using ESAs with chemotherapeutic agents in diseases associated with increased risk of thromboembolic complications.
Endre et al (2010) performed a double-blind placebo-controlled trial to study whether early treatment with EPO could prevent the development of AKI in patients in 2 general intensive care units. As a guide for choosing the patients for treatment, these researchers measured urinary levels of 2 biomarkers, the proximal tubular brush border enzymes gamma-glutamyl transpeptidase and alkaline phosphatase. Randomization to either placebo or 2 doses of erythropoietin was triggered by an increase in the biomarker concentration product to levels above 46.3, with a primary outcome of relative average plasma creatinine increase from baseline over 4 to 7 days. Of 529 patients, 162 were randomized within an average of 3.5 hrs of a positive sample. There was no difference in the incidence of EPO-specific adverse events or in the primary outcome between the placebo and treatment groups. The triggering biomarker concentration product selected patients with more severe illness and at greater risk of AKI, dialysis, or death; however, the marker elevations were transient. Early intervention with high-dose EPO was safe but did not alter the outcome. Although these 2 urine biomarkers facilitated early intervention, their transient increase compromised effective triaging. Further, this study showed that a composite of these 2 biomarkers was insufficient for risk stratification in a patient population with a heterogeneous onset of injury.
In a systematic review of randomized trials on erythropoietin as a treatment of anemia in heart failure, Kotecha et al (2011) reviewed the effects of ESAs in chronic heart failure. An extensive search strategy identified 11 RCTs with 794 participants comparing any ESA with control over 2 to 12 months of follow-up. Published and additionally requested data were incorporated into a Cochrane systematic review (CD007613). A total of 9 studies were placebo controlled, and 5 were double blinded. Erythropoiesis-stimulating agent treatment significantly improved exercise duration by 96.8 seconds (95 % CI: 5.2 to 188.4, p = 0.04) and 6-min walk distance by 69.3 m (95 % CI: 17.0 to 121.7, p = 0.009) compared with control. Benefit was also noted for peak oxygen consumption (+2.29 ml/kg/min, p = 0.007), New York Heart Association class (-0.73, p < 0.001), ejection fraction (+5.8 %, p < 0.001), B-type natriuretic peptide (-226.99 pg/ml, p < 0.001), and quality-of-life indicators with a mean increase in hemoglobin level of 2 g/dL. There was a significantly lower rate of heart failure-related hospitalizations with ESA therapy (odds ratio 0.56, 95 % CI: 0.37 to 0.84, p = 0.005). No associated increase in adverse events or mortality (odds ratio 0.58, 95 % CI: 0.34 to 0.99, p = 0.047) was observed, although the number of events was limited. The authors concluded that meta-analysis of small RCTs suggested that ESA treatment can improve exercise tolerance, reduce symptoms, and have benefits on clinical outcomes in anemic patients with heart failure. Moreover, they stated that confirmation requires larger, well-designed studies with careful attention to dose, attained Hb level, and long-term outcomes. This is in agreement with the observations of Lipsic et al (2011) as well as Santilli et al (2011). Lipsic and colleagues (2011) stated that large-scale trials with ESAs are needed to examine the safety and effectiveness of anemia treatment in patients with heart failure. Santilli and associates (2011) stated that further studies are needed to define the magnitude of the problem and establish appropriate therapeutic strategies. It is likely that more reliable data will be derived from an ongoing randomized, double-blind, multi-center study, the RED-HF (Reduction Event with Darbepoetin alfa in Heart Failure), which aims at evaluating morbidity and mortality in a cohort of 2,600 heart failure patients with anemia treated with darbepoetin alfa.
In a prospective, randomized, double-blind, placebo-controlled trial with a dose-escalation safety phase and a single dose (60,000 U of epoetin alfa) efficacy phase, Najjar et al (2011) evaluated the safety and effectiveness of a single intravenous bolus of epoetin alfa in patients with acute ST-segment elevation myocardial infarction (STEMI). The Reduction of Infarct Expansion and Ventricular Remodeling With Erythropoietin After Large Myocardial Infarction (REVEAL) trial was conducted at 28 U.S. sites between October 2006 and February 2010, and included 222 patients with STEMI who underwent successful percutaneous coronary intervention (PCI) as a primary or rescue reperfusion strategy. Participants were randomly assigned to treatment with intravenous epoetin alfa or matching saline placebo administered within 4 hours of re-perfusion. Main outcome measure was infarct size, expressed as percentage of left ventricle (LV) mass, assessed by cardiac magnetic resonance (CMR) imaging performed 2 to 6 days after study medication administration (first CMR) and again 12 +/- 2 weeks later (second CMR). In the efficacy cohort, the infarct size did not differ between groups on either the first CMR scan (n = 136; 15.8 % LV mass [95 % CI: 13.3 to 18.2 % LV mass] for the epoetin alfa group versus 15.0 % LV mass [95 % CI: 12.6 to 17.3 % LV mass] for the placebo group; p = 0.67) or on the second CMR scan (n = 124; 10.6 % LV mass [95 % CI: 8.4 to 12.8 % LV mass] versus 10.4 % LV mass [95 % CI: 8.5 to 12.3 % LV mass], respectively; p = 0.89). In a pre-specified analysis of patients aged 70 years or older (n = 21), the mean infarct size within the first week (first CMR) was larger in the epoetin alfa group (19.9 % LV mass; 95 % CI: 14.0 to 25.7 % LV mass) than in the placebo group (11.7 % LV mass; 95 % CI: 7.2 to 16.1 % LV mass) (p = 0.03). In the safety cohort, of the 125 patients who received epoetin alfa, the composite outcome of death, MI, stroke, or stent thrombosis occurred in 5 (4.0 %; 95 % CI: 1.31 % to 9.09 %) but in none of the 97 who received placebo (p = 0.04). The authors concluded that in patients with STEMI who had successful re-perfusion with primary or rescue PCI, a single intravenous bolus of epoetin alfa within 4 hours of PCI did not reduce infarct size and was associated with higher rates of adverse cardiovascular events. Subgroup analyses raised concerns about an increase in infarct size among older patients.
In an editorial that accompanied the afore-mentioned study, Bhatt (20110 stated that "[b]ecause these findings appeared in a blinded trial, they raise further questions about the safety of epoetin alfa in the context of acute MI .... Until compelling data become available to support routine sue of these agents in patients with anemia, it would be prudent to minimize their use, especially in patients at high risk for cardiovascular disease or with an acute ischemic syndrome".
In a review on “Guillain-Barre syndrome”, Yuki and Hartung (2012) states that “eculizumab, erythropoietin, and fasudil, which have been used in the treatment of other, unrelated medical conditions, have shown promise in animal models of the Guillain-Barre syndrome, but clinical studies are lacking”.
In a review on “Mechanisms and management of retinopathy of prematurity”, Hartnett and Penn (2012) stated that “Very-low-birth-weight infants are at high risk not only for retinopathy of prematurity but also for subsequent neurodevelopmental impairment. Interest in erythropoietin as a neuroprotective agent is increasing. When administered in preterm infants, erythropoietin was associated with improved cognition in childhood. Laboratory studies have shown that early administration of erythropoietin reduced phase 1 avascularization in both mouse and rat models of oxygen-induced retinopathy. However, retrospective studies have shown an association between erythropoietin and severe oxygen-induced retinopathy in preterm infants. Erythropoietin was also found to promote intravitreal angiogenesis in a transgenic mouse model of oxygen-induced retinopathy. Some investigators have proposed administering erythropoietin early in preterm infants to promote physiologic retinal vascular development and attempt to reduce the risk of development of stage 3 retinopathy of prematurity, but additional studies are needed to determine the window of time for relatively safe administration”. The authors concluded that current therapies for severe retinopathy of prematurity focuses on laser therapy as well as visual rehabilitation, and potential new treatment strategies include targets within oxidative pathways, erythropoietin, and anti-vascular endothelial growth factor agents.
Moebus et al (2013) noted that the AGO-ETC trial compared 5-year relapse-free survival of intense dose-dense (IDD) sequential chemotherapy with epirubicin (E), paclitaxel (T), and cyclophosphamide (C) (IDD-ETC) every 2 weeks versus conventional scheduled epirubicin/cyclophosphamide followed by paclitaxel (EC→T) (every 3 weeks) as adjuvant treatment in high-risk breast cancer patients. These researchers evaluated the safety and effectiveness of epoetin alfa in a second randomization of the IDD arm. A total of 1,284 patients were enrolled; 658 patients were randomly assigned to the IDD-ETC treatment group. Within the IDD-ETC group, 324 patients were further randomly assigned to the epoetin alfa group, and 319 were randomly assigned to the non- ESA control group. Primary efficacy end-points included change in Hb level from baseline to Cycle 9 and the percentage of subjects requiring red blood cell transfusion. Relapse-free survival, overall survival, and intra-mammary relapse were secondary end-points estimated with Kaplan-Meier and Cox regression methods. Except for the primary hypothesis, all statistical tests were 2-sided. Epoetin alfa avoided the decrease in Hb level (no decrease in the epoetin alfa group versus -2.20 g/dL change for the control group; p < 0.001) and statistically significantly reduced the percentage of subjects requiring red blood cell transfusion (12.8 % versus 28.1 %; p < 0.0001). The incidence of thrombotic events was 7 % in the epoetin alfa arm versus 3 % in the control arm. After a median follow-up of 62 months, epoetin alfa treatment did not affect overall survival, relapse-free survival, or intra-mammary relapse. The authors concluded that epoetin alfa resulted in improved Hb levels and decreased transfusions without an impact on relapse-free or overall survival. However, epoetin alfa had an adverse effect, resulting in increased thrombosis.
In a Cochrane review, Marti-Carvajal et al (2013) evaluated the clinical benefits and harms of ESAs for anemia in rheumatoid arthritis. These investigators searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (issue 7 2012), Ovid MEDLINE and Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations (1948 to August 7, 2012), OVID EMBASE (1980 to August 7, 2012), LILACS (1982 to August 7, 2012), the Clinical Trials Search Portal of the World Health Organization, reference lists of the retrieved publications and review articles. They did not apply any language restrictions. These researchers included RCTs in patients aged 16 years or over, with a diagnosis of rheumatoid arthritis affected by anemia. They considered health-related quality of life, fatigue and safety as the primary outcomes. Two authors independently performed trial selection, risk of bias assessment, and data extraction. They estimated difference in means with 95 % CIs for continuous outcomes. They estimated risk ratios with 95 % CIs for binary outcomes. These investigators included 3 RCTs with a total of 133 participants. All trials compared human recombinant erythropoietin (EPO), for different durations (8, 12 and 52 weeks), versus placebo. All RCTs assessed health-related quality of life. All trials had high or unclear risk of bias for most domains, and were sponsored by the pharmaceutical industry. Two trials administered EPO by a subcutaneous route while the other used an intravenous route. These researchers decided not to pool results from trials, due to inconsistencies in the reporting of results. Health-related quality of life: subcutaneous EPO -- 1 trial with 70 patients at 52 weeks showed a statistically significant difference in improvement of patient global assessment (median and interquartile range 3.5 (1.0 to 6.0) compared with placebo 4.5 (2.0 to 7.5) (p = 0.027) on a visual analog scale (VAS) scale (0 to 10)). The other shorter-term trials (12 weeks with subcutaneous EPO and 8 weeks with intravenous administration) did not find statistically significant differences between treatment and control groups in health-related quality of life outcomes. Change in Hb: both trials of subcutaneous EPO showed a statistically significant difference in increasing Hb levels;
- at 52 weeks (1 trial, 70 patients), intervention Hb level (median of 134, interquartile range 110 to 158 g/L) compared with the placebo group level (median of 112, interquartile range; 86 to 128 g/L) (p = 0.0001);
- at 12 weeks (1 trial, 24 patients) compared with placebo (difference in means of 8.00, 95 % CI: 7.43 to 8.57).
Intravenous EPO at 8 weeks showed no statistically significant difference in increasing hematocrit level for EPO versus placebo (difference in means of 4.69, 95 % CI: -0.17 to 9.55; p = 0.06). Information on withdrawals due to adverse events was not reported in 2 trials, and 1 trial found no serious adverse events leading to withdrawals. None of the trials reported withdrawals due to high blood pressure, or to lack of efficacy or to fatigue. The authors concluded that there are conflicting data for ESAs to increase quality of life and Hb level by treating anemia in patients with rheumatoid arthritis. However, this conclusion was based on RCTs with a high-risk of bias, and relies on trials assessing EPO. They stated that the safety profile of EPO is unclear; and future trials assessing ESAs for anemia in rheumatoid arthritis should be conducted by independent researchers and reported according to the CONSORT statements.
Tran et al (2014) noted that ESAs are widely used in treating anemia associated with renal failure. They are also now used peri-operatively to reduce the use of allogeneic blood transfusions (ABTs) in patients undergoing surgery with anticipated high blood loss. Although they can reduce the risks associated with ABT and improve quality of life, the use of ESAs is still associated with adverse effects. These investigators performed a systematic review to examine the current evidence for the safety and effectiveness of peri-operative ESAs use. A search of PubMed and Medline databases has been performed using a combination of search terms including erythropoietin, peri-operative, surgical, safety and efficacy. The authors concluded that current evidence supported the use of peri-operative ESAs to reduce the need for ABT. However, large studies assessing safety in anemic patients with chronic renal disease have found adverse effects including cardiovascular, stroke and thromboembolic events. However, whether these concerns can be conferred onto the surgical population remains to be seen as the peri-operative dosing strategies have been more variable in timing, dose and duration in comparison with those used for chronic diseases. Moreover, they stated that future research needs to address the questions of optimal dosing strategies in order to maximize the positive effects and minimize adverse events.
Lai et al (2014) noted that ESAs to treat anemia in breast cancer patients who are treated with chemotherapy is a matter of ongoing debate. Several recent randomized trials challenged conventional wisdom, which holds that ESAs are contraindicated for breast cancer patients undergoing curative treatment. These investigators performed the first large national population-based study to analyze the association between ESA use and breast cancer patient outcomes. Cytotoxic chemotherapy-treated invasive breast cancer patients were identified from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Non-ESA users were sequentially 1:1 matched to 2,000 randomly sampled ESA users on demographics (age, diagnosis year, race, marital status, and socioeconomic status), tumor presentation (stage, grade, and status of hormone receptors), and treatments (surgery, radiation, and sub-types of chemotherapy) using a minimum distant strategy. Breast cancer-specific survival of ESA and matched non-ESA users was compared using Fine and Gray competing risk model. Compared to ESA users, non-ESA users exhibited dramatically different baseline characteristics such as less advanced tumor, and fewer co-morbidities. Non-ESA users had a significantly more favorable breast cancer-specific survival (subdistribution hazard ratio [sHR] = 0.75, p < 0.0001). This survival disparity was progressively diminished in the sequential matching of demographics (sHR = 0.74, p = 0.0004), presentation (sHR = 0.86, p = 0.06), and treatment (sHR = 0.89, p = 0.17) variables. Stratified analyses identified subgroups of patients whose breast cancer-specific survival were not different between ESA and non-ESA users. In the SEER-Medicare database, ESA usage did not appear to be associated with unfavorable breast cancer-specific survival in breast cancer patients receiving cytotoxic chemotherapy. The authors concluded that the ESA-breast cancer prognosis association is complex and requires more intensive investigations.
Kelada and Marignol (2014) stated that ESAs are used in breast cancer patients with chemotherapy-induced anemia to alleviate anemia and in turn, reduce fatigue. These drugs may also decrease overall survival and increase the incidence of serious adverse effects such as thrombo-vascular events (TVEs). These investigators evaluated the evidence to-date on administering ESAs to breast cancer patients with chemotherapy-induced anemia. The authors concluded that these findings suggested a clear need for well-designed clinical trials that follow current FDA ESA label changes to guide clinical practice in an effort to reduce harm to these patients.
Fokkema et al (2014) stated that ESAs have been investigated in small studies in patients with STEMI undergoing PCI. Erythropoiesis-stimulating agents did not show a clear effect on left ventricular function or clinical outcome, but some studies suggested an increased risk of thromboembolic events. These researchers performed a systematic literature search in MEDLINE, until December 2012. They included randomized clinical trials investigating the effect of ESAs in STEMI patients undergoing primary PCI, with greater than or equal to 30 days of follow-up. The primary end-point was a composite of all-cause mortality, MI, and stent thrombosis after PCI; secondary end-point was all-cause mortality. Individual patient data were obtained from 10 of 11 trials, including 97.3 % (1,242/1,277) of all patients randomized to control (n = 600) or to ESAs (n = 642). Baseline characteristics were well-balanced between the treatment allocations. Mean follow-up time was 248 (±131) days. The primary end-point occurred in 3.5 % (20/577) in the control group and in 2.1 % (13/610) in the ESA group (hazard ratio [HR] for ESAs, 0.63; 95 % CI: 0.31 to 1.27]; p = 0.20). Mortality occurred in 13 (2.3 %) in the control group and 5 (0.8 %) in the ESA group (HR for ESAs, 0.38; 95 % CI: 0.13 to 1.06]; p = 0.06). The authors concluded that ESA administration did not result in an increased risk of adverse cardiac events in STEMI patients undergoing primary PCI. They stated that results of ongoing studies may provide further insight to the potential beneficial clinical effects of ESAs in STEMI patients.
Robertson et al (2014) compared the effects of erythropoietin and 2 Hb transfusion thresholds (7 and 10 g/dL) on neurological recovery after TBI. Randomized clinical trial of 200 patients (erythropoietin, n = 102; placebo, n = 98) with closed head injury who were unable to follow commands and were enrolled within 6 hours of injury at neurosurgical intensive care units in 2 U.S. level I trauma centers between May 2006 and August 2012 were included in this study, which used a factorial design to test whether erythropoietin would fail to improve favorable outcomes by 20 % and whether a Hb transfusion threshold of greater than 10 g/dL would increase favorable outcomes without increasing complications. Erythropoietin or placebo was initially dosed daily for 3 days and then weekly for 2 more weeks (n = 74) and then the 24- and 48-hour doses were stopped for the remainder of the patients (n = 126). There were 99 patients assigned to a Hb transfusion threshold of 7 g/dL and 101 patients assigned to 10 g/dL. Interventions included intravenous erythropoietin (500 IU/kg per dose) or saline; transfusion threshold was maintained with packed red blood cells. Main outcome measure was Glasgow Outcome Scale score dichotomized as favorable (good recovery and moderate disability) or unfavorable (severe disability, vegetative, or dead) at 6 months post-injury. There was no interaction between erythropoietin and Hb transfusion threshold. Compared with placebo (favorable outcome rate: 34/89 [38.2 %; 95 % CI: 28.1 % to 49.1 %]), both erythropoietin groups were futile (first dosing regimen: 17/35 [48.6 %; 95 % CI: 31.4 % to 66.0 %], p = 0.13; second dosing regimen: 17/57 [29.8 %; 95 % CI: 18.4 % to 43.4 %], p < 0.001). Favorable outcome rates were 37/87 (42.5 %) for the Hb transfusion threshold of 7 g/dL and 31/94 (33.0 %) for 10 g/dL (95 % CI: for the difference, -0.06 to 0.25, p = 0.28). There was a higher incidence of thromboembolic events for the transfusion threshold of 10 g/dL (22/101 [21.8 %] versus 8/99 [8.1 %] for the threshold of 7 g/dL, OR, 0.32 [95 % CI: 0.12 to 0.79], p = 0.009). The authors concluded that in patients with closed head injury, neither the administration of erythropoietin nor maintaining Hb concentration of greater than 10 g/dL resulted in improved neurological outcome at 6 months. The transfusion threshold of 10 g/dL was associated with a higher incidence of adverse events. They stated that these findings did not support either approach in this setting.
Anemia in Chronic Obstructive Pulmonary Disease (COPD)
Silverberg et al (2014) noted that little is known about iron deficiency (ID) and anemia in chronic obstructive pulmonary disease (COPD). The purposes of this study were:
- to study the prevalence and treatment of anemia and ID in patients hospitalized with an exacerbation of COPD, and
- to study the hematological responses and degree of dyspnea before and after correction of anemia with subcutaneous ESAs and intravenous (IV) iron therapy, in ambulatory anemic patients with both COPD and CKD.
These investigators examined the hospital records of all patients with an acute exacerbation of COPD (AECOPD) to assess the investigation, prevalence, and treatment of anemia and ID. They treated 12 anemic COPD outpatients with the combination of ESAs and IV-iron, given once-weekly for 5 weeks. One week later they measured the hematological response and the severity of dyspnea by VAS. Of 107 consecutive patients hospitalized with an AECOPD, 47 (43.9 %) were found to be anemic on admission. Two (3.3 %) of the 60 non-anemic patients and 18 (38.3 %) of the 47 anemic patients had serum iron, percent transferrin saturation (%Tsat) and serum ferritin measured. All 18 (100 %) anemic patients had ID, yet none had oral or IV iron subscribed before or during hospitalization, or at discharge. Iron deficiency was found in 11 (91.7 %) of the 12 anemic ambulatory patients. Hemoglobin, hematocrit (Hct) and the VAS scores increased significantly with the ESAs and IV-iron treatment. There was a highly significant correlation between the ∆Hb and ∆VAS; rs = 0.71 p = 0.009 and between the ∆Hct and ∆VAS; rs = 0.8 p = 0.0014. The authors concluded that ID is common in COPD patients but is rarely looked for or treated. Yet correction of the ID in COPD patients with ESAs and IV iron can improve the anemia, the ID, and may improve the dyspnea. These findings need to be validated by well-designed studies.
Furthermore, current COPD guidelines (GOLD, 2015; NICE, 2010; Qaseem, et al., 2011) do not mention the use of erythropoietin/erythropoesis stimulating agents as management tools. UpToDate reviews on “Management of stable chronic obstructive pulmonary disease” (Ferguson and Make, 2014) and “Management of exacerbations of chronic obstructive pulmonary disease” (Stoller, 2014) do not mention the use of erythropoietin/erythropoiesis stimulating agents as therapeutic options.
Anemia in Heart Failure
Lindquist et al (2015) determined the safety and effectiveness of ESAs for the treatment of anemia in patients with systolic heart failure. A search of MEDLINE (1946 to January 2014) and EMBASE (1947 to January 2014) was conducted using the search terms erythropoietin and systolic heart failure. In addition, bibliographies of relevant articles were reviewed for additional citations. All English language RCTs evaluating clinical outcomes or adverse events when using ESAs in the setting of systolic heart failure were included. A total of 9 studies were reviewed. All studies examining hematological parameters found a statistically significant increase in Hb levels with active treatment versus placebo. Of the 7 trials evaluating exercise tolerance or capacity, only 4 demonstrated statistically significant improvement in these measures in patients receiving ESAs, whereas the remainder showed no clinical benefit. Four studies examined quality-of-life measures. Although numerical improvements were observed in most trials, statistical significance was reached in only 2 trials. A non-significant trend for decreased mortality in patients treated with darbepoetin with a similar adverse event profile compared to placebo was shown in 1 study; however, the largest trial to-date showed no benefit in all-cause mortality or heart failure-related hospitalizations with the use of ESAs. Additionally, a statistically significant increase in the number of cerebrovascular events and thrombotic events was found. The authors concluded that there was inconclusive evidence to suggest that the use of ESAs in treating anemia in patients with heart failure is beneficial. They noted that although ESAs demonstrated a clear ability for increasing Hb levels, the data regarding clinical outcomes such as exercise parameters, quality of life, and hospitalizations are conflicting. In addition, a mortality benefit has not been shown; therefore, the potential for improved symptomatology must be weighed against the potential for adverse events.
Anemia Treatment in Cancer Patients
The Spanish Society of Medical Oncology (SEOM)’s clinical guidelines for anemia treatment in cancer patients (Alvarez et al, 2021) provided the following information:
- Indications: Patients with solid tumors and symptomatic anemia under treatment with chemotherapy (level of evidence I, grade of recommendation A) or chemoradiotherapy (level of evidence II, grade of recommendation B) who present Hgb levels of less than 10 g/dL or asymptomatic anemia with Hgb levels of less than 8 g/dL, after correction of iron levels or other underlying causes (level of evidence I, grade of recommendation A).
- ESAs should not be used in patients who are not receiving chemotherapy (level of evidence I, grade of recommendation A).
Adams et al 92022) noted that anemia is common among cancer patients; and they may require RBC transfusions; ESAs and iron might aid in lowering the need for RBC transfusions. However, it remains unclear if the combination of both drugs is preferable compared to using just 1 drug. In a Cochrane review, these investigators examined the effect of IV iron, oral iron or no iron in combination with or without ESAs to prevent or alleviate anemia in cancer patients and generated treatment rankings using network meta-analyses (NMAs). They identified studies by searching bibliographic databases (CENTRAL, Medline, Embase; until June 2021). These investigators also searched various registries, conference proceedings and reference lists of identified trials. They included RCTs comparing IV, oral or no iron, with or without ESAs for the prevention or alleviation of anemia resulting from chemotherapy, radiotherapy, combination therapy or the underlying malignancy in cancer patients. Two review authors independently extracted data and assessed risk of bias. Outcomes were on-study mortality, number of patients receiving RBC transfusions, number of RBC units, hematological response, overall mortality and AEs. These researchers conducted NMAs and generated treatment rankings; and assessed the certainty of the evidence using the GRADE approach.
A total of 96 trials (25,157 participants) met the inclusion criteria; 62 trials (24,603 participants) could be considered in the NMA (12 different therapeutic options). These investigators presented the comparisons of ESA with or without iron and iron alone versus no treatment. On-study mortality: The authors estimated that 92 of 1,000 participants without treatment for anemia died up to 30 days after the active study period. Evidence from NMA (55 trials; 15,074 participants) suggested that treatment with ESA and IV iron (12 of 1,000; RR 0.13, 95 % CI: 0.01 to 2.29; low certainty) or oral iron (34 of 1,000; RR 0.37, 95 % CI: 0.01 to 27.38; low certainty) may decrease or increase and ESA alone (103 of 1,000; RR 1.12, 95 % CI: 0.92 to 1.35; moderate certainty) probably slightly increased on-study mortality. Furthermore, treatment with IV iron alone (271 of 1,000; RR 2.95, 95 % CI: 0.71 to 12.34; low certainty) may increase and oral iron alone (24 of 1,000; RR 0.26, 95 % CI: 0.00 to 19.73; low certainty) may increase or decrease on-study mortality. Hematological response: The authors estimated that 90 of 1,000 participants without treatment for anemia had a hematological response. Evidence from NMA (31 trials; 6,985 participants) suggested that treatment with ESA and IV iron (604 of 1,000; RR 6.71, 95 % CI: 4.93 to 9.14; moderate certainty), ESA and oral iron (527 of 1,000; RR 5.85, 95 % CI: 4.06 to 8.42; moderate certainty), and ESA alone (467 of 1,000; RR 5.19, 95 % CI: 4.02 to 6.71; moderate certainty) probably increased hematological response. Furthermore, treatment with oral iron alone may increase hematological response (153 of 1,000; RR 1.70, 95 % CI: 0.69 to 4.20; low certainty). RBC transfusions: The authors estimated that 360 of 1,000 participants without treatment for anemia needed at least 1 transfusion. Evidence from NMA (69 trials; 18,684 participants) suggested that treatment with ESA and IV iron (158 of 1,000; RR 0.44, 95 % CI: 0.31 to 0.63; moderate certainty), ESA and oral iron (144 of 1,000; RR 0.40, 95 % CI: 0.24 to 0.66; moderate certainty) and ESA alone (212 of 1,000; RR 0.59, 95 % CI: 0.51 to 0.69; moderate certainty) probably decreased the need for transfusions. Furthermore, treatment with IV iron alone (268 of 1,000; RR 0.74, 95 % CI: 0.43 to 1.28; low certainty) and with oral iron alone (333 of 1,000; RR 0.92, 95 % CI: 0.54 to 1.57; low certainty) may decrease or increase the need for transfusions. Overall mortality: The authors estimated that 347 of 1,000 participants without treatment for anemia died overall. Low-certainty evidence from NMA (71 trials; 21,576 participants) suggested that treatment with ESA and IV iron (507 of 1,000; RR 1.46, 95 % CI: 0.87 to 2.43) or oral iron (482 of 1,000; RR 1.39, 95 % CI: 0.60 to 3.22) and IV iron alone (521 of 1,000; RR 1.50, 95 % CI: 0.63 to 3.56) or oral iron alone (534 of 1,000; RR 1.54, 95 % CI: 0.66 to 3.56) may decrease or increase overall mortality. Treatment with ESA alone may lead to little or no difference in overall mortality (357 of 1,000; RR 1.03, 95 % CI: 0.97 to 1.10; low certainty). Thromboembolic events: The authors estimated that 36 of 1,000 participants without treatment for anemia developed thromboembolic events. Evidence from NMA (50 trials; 15,408 participants) suggested that treatment with ESA and IV iron (66 of 1,000; RR 1.82, 95 % CI: 0.98 to 3.41; moderate certainty) probably slightly increased and with ESA alone (66 of 1,000; RR 1.82, 95 % CI: 1.34 to 2.47; high certainty) slightly increased the number of thromboembolic events. None of the trials reported results on the other comparisons. Thrombocytopenia or hemorrhage: The authors estimated that 76 of 1,000 participants without treatment for anemia developed thrombocytopenia/hemorrhage. Evidence from NMA (13 trials, 2,744 participants) suggested that treatment with ESA alone probably led to little or no difference in thrombocytopenia/hemorrhage (76 of 1,000; RR 1.00, 95 % CI: 0.67 to 1.48; moderate certainty). None of the trials reported results on other comparisons. Hypertension: The authors estimated that 10 of 1,000 participants without treatment for anemia developed hypertension. Evidence from NMA (24 trials; 8,383 participants) suggested that treatment with ESA alone probably increased the number of hypertensions (29 of 1,000; RR 2.93, 95 % CI: 1.19 to 7.25; moderate certainty). None of the trials reported results on the other comparisons.
The authors concluded that when considering ESAs with iron as prevention for anemia, one has to balance between safety and effectiveness. Results suggested that treatment with ESA and iron probably decreased number of RBC transfusions; but may increase mortality and the number of thromboembolic events. For most outcomes the different comparisons within the network were not fully connected; thus, ranking of all treatments together was not possible. These researchers stated that more head-to-head comparisons including all evaluated treatment combinations are needed to fill the gaps and prove results of this review.
Before Surgery for Craniosynostosis Correction
Fearon and Weinthal (2002) noted that the majority of infants and children undergoing craniosynostosis correction receive a blood transfusion. The risks of blood transfusion include, but are not limited to, acute hemolytic reactions (about 1 in 250,000), human immunodeficiency virus (HIV; about 1 in 200,000), hepatitis B and C (about 1 in 30,000 each), and transfusion-related lung injuries (about 1 in 5,000). In a prospective, single-blinded, randomized study, these researchers examined the safety and efficacy of preoperative single weekly dosing with EPO (epoetin alfa [Procrit]) in reducing the rate of transfusion in infants and small children undergoing craniosynostosis repair. A total of 29 patients (less than 8 years) undergoing craniosynostosis repair were randomized into 2 groups: one received preoperative EPO (600 U/kg) weekly for 3 weeks, and the other served as a control. All care-givers responsible for blood transfusions were blinded, and strict criteria for transfusion were established. A pediatric hematologist monitored both groups, and all patients received supplemental iron (4 mg/kg); 14 patients were randomized to receive EPO, and 8 of these 14 patients (57 %) needed transfusion (mean age of 17 months; mean weight of 10.1 kg). Of the 6 patients not requiring transfusion, 3 were younger than 12 months old (mean of 6 months); 14 of 15 patients (93 %) in the control group (mean age of 13 months; mean weight of 9.3 kg) needed a blood transfusion during the study. The only control patient not requiring transfusion was the eldest (5-year-old). The difference between the 2 groups was statistically significant (Fisher's exact test = 0.03). The control group showed no change in Hb levels from baseline to preoperative levels, but the EPO group increased their average Hb levels from 12.1 to 13.1 g/dL. There were no adverse effects noted among children receiving EPO, nor were there any surgical complications. The authors concluded that the preoperative administration of EPO significantly raised Hb levels and reduced the need for a blood transfusion with craniosynostosis correction. They stated that more suggestions were made that may further reduce the need for blood transfusions, and a cost-benefit analysis was discussed.
Krajewski et al (2008) stated that craniosynostotic correction typically performed around infant physiologic nadir of Hb (about 3 to 6 months of age) is associated with high transfusion rates of packed RBCs and other blood products. As a blood conserving strategy, these investigators studied the use of the following: First, recombinant human EPO or Procrit (to optimize pre-operative Hct). Second, Cell Saver (CS; to recycle the slow, constant ooze of blood during the prolonged case). UCLA patients with craniosynostosis from 2003 to 2005 were divided into the study group (Procrit and CS) or the control group (n = 79). The study group first received recombinant human EPO at 3 weeks, 2 weeks, and 1 week pre-operatively and then used CS intra-operatively. Outcomes were based on morbidities and transfusion rate comparisons. The 2 groups were comparable with regards to age (5.66 and 5.71 months), and operative times (3.11 versus 2.59 hours). In the study group there was a marked increase in pre-operative Hct (56.2 %). The study group had significantly lower transfusions rates (5 % versus 100 % control group) and lower volumes transfused than in the control group (0.05 pediatric units versus 1.74 pediatric units). Furthermore, of the 80 % of patients in the study group who received CS blood at the end of the case, about 31 % would have needed a transfusion if the recycled blood were unavailable. The authors concluded that these findings showed that for elective craniosynostotic correction, successful blood conserving dual therapy with Procrit and CS might be used to decrease transfusion rates and the need for any blood products.
Vega et al (2014) stated that children with craniosynostosis may require cranial vault re-modeling to prevent or relieve elevated intra-cranial pressure (ICP) and to correct the underlying craniofacial abnormalities. The procedure is typically associated with significant blood loss and high transfusion rates. The risks associated with transfusions are well documented and include transmission of infectious agents, bacterial contamination, acute hemolytic reactions, transfusion-related lung injury, and transfusion-related immune modulation. These investigators presented the Children's Hospital of Richmond (CHoR) protocol, which was developed to reduce the rate of blood transfusion in infants undergoing primary craniosynostosis repair. They performed a retrospective chart review of pediatric patients treated between January 2003 and February 2012. The CHoR protocol was instituted in November 2008, with the following 3 components: First, the use of pre-operative EPO and iron therapy. Second, the use of an intra-operative blood recycling device. Third, acceptance of a lower level of Hb as a trigger for transfusion (less than 7 g/dL). Patients who underwent surgery before the protocol implementation served as controls. A total of 60 children were included in the study, 32 of whom were treated with the CHoR protocol. The control (C) and protocol (P) groups were comparable with respect to patient age (7 versus 8.4 months, p = 0.145). Recombinant EPO effectively raised the mean pre-operative Hb level in the P group (12 versus 9.7 g/dL, p < 0.001). Although adoption of more aggressive surgical vault re-modeling in 2008 resulted in a higher estimated blood loss (EBL; 212 versus 114.5 ml, p = 0.004) and length of surgery (4 versus 2.8 hours, p < 0.001), transfusion was carried out in significantly fewer cases in the P group (56 % versus 96 %, p < 0.001). The mean length of stay (LOS) in the hospital was shorter for the P group (2.6 versus 3.4 days, p < 0.001). The authors concluded that a protocol that included pre-operative administration of recombinant EPO, intra-operative autologous blood recycling, and accepting a lower transfusion trigger significantly decreased transfusion utilization (p < 0.001). A decreased LOS (p < 0.001) was observed, although the authors did not examine if composite transfusion complication reductions led to better outcomes. These findings were confounded by the combined use of pre-operative administration of recombinant EPO, intra-operative autologous blood recycling, and accepting a lower transfusion trigger.
White et al (2015) noted that surgery for craniosynostosis is associated with the potential for significant blood loss. Multiple technologies have been introduced to reduce the volume of blood transfused. These are pre-operative autologous donation; pre-operative EPO; intra-operative CS; acute normo-volemic hemodilution; anti-fibrinolytic drugs such as tranexamic acid, ε-aminocaproic acid, and aprotinin; fibrin sealants or fibrin glue; and post-operative drain re-infusion. All comparative studies with a treatment group and a control group were considered. There was a range of different study types from RCTs to case series with historic controls. These were intervention versus no intervention or a comparison of 2 interventions. Studies were identified by searching Cochrane CENTRAL, Medline, and Embase; manufacturer's Web sites; and bibliographies of relevant published articles. The primary outcome measures were the number of allogeneic blood donor exposures, the volume of allogeneic blood transfused, and the post-operative Hb or Hct levels; a total of 696 studies were identified. After removal of duplicates and after exclusion criteria were applied, there were 18 studies to be included; 14 were case series with controls and 4 were RCTs. The authors concluded that the production of high-quality evidence on the interventions to minimize blood loss and transfusion in children undergoing surgery for craniosynostosis was difficult. Most of the literature was non-randomized and non-comparative. Several areas remained unaddressed; EPO and tranexamic acid were comparatively well studied; CS, acute normo-volemic hemodilution, and aprotinin were less so. There was only 1 comparative study on the use of fibrin glue and drain re-infusion, with no studies on pre-operative autologous donation and ε-aminocaproic acid. Tranexamic acid was clinically effective in reducing allogeneic blood transfusion. There was some evidence that CS and EPO may be clinically effective; however, none of the interventions studied was shown to be cost-effective because of lack of evidence.
Aljaaly et al (2017) stated that pediatric craniosynostosis surgery is associated with significant blood loss often requiring ABT. These researchers examined the clinical effectiveness of pre-operative EPO administration in pediatric craniosynostosis surgery in reducing transfusion requirements. They carried out a systematic review and meta-analysis of the literature for studies published in English language between 1946 and 2015. Inclusion criteria included original studies in the pediatric population (0 to 8 years of age) involving pre-operative use of EPO in craniofacial procedures with quantitative reporting of peri-operative blood transfusion. Extracted data included demographics, Hct, Hb, EBL, number of patients transfused, and amount of ABT. A total of 4 studies met the inclusion criteria with a total of 117 patients. Patients were divided into 2 groups: EPO versus control. No statistical differences were found in the demographics between the 2 groups. Mean pre-operative Hct level was higher in the EPO group compared with control (43 % versus 35 %). The percentage of patients who required ABT and the volume of transfused blood were less in the EPO group (54 % versus 98 %; and 84 ml versus 283 ml, respectively). Meta-analysis of 3 comparable studies showed a lower proportion of patients who needed blood transfusion in the EPO group. The authors concluded that the present meta-analysis demonstrated that pre-operative administration of EPO in pediatric craniosynostosis surgery decreased the proportion of patients requiring ABT. Furthermore, the volume of transfusion was reduced in patients who received EPO. Moreover, these investigators stated that future randomized studies are needed to establish the cost-effectiveness of routine pre-operative EPO administration in craniosynostosis surgery.
Beta Thalassemia
An UpToDate review on “Treatment of beta thalassemia” (Benz, 2016) states that “Addition of erythropoietin -- The myelosuppressive effect of HU [hydroxyurea] may compromise its therapeutic efficacy, suggesting the use of erythropoietin to support red cell production when HU is used in the treatment of beta thalassemia. This was tested in a randomized trial in 80 transfusion-dependent subjects ≤ 18 years of age with thalassemia intermedia (TI). All received HU (25 mg/kg per day by mouth) and were randomly assigned to receive (Group A) or not receive (Group B) recombinant human erythropoietin (EPO, total dose of 1,000 international units/kg per week subcutaneously, divided into 3 doses per week). After a mean follow-up period of 1 year, the following results were obtained:
- Subjects receiving both HU and EPO (Group A) had significantly greater increases in hemoglobin (1.6 versus 0.7 g/dL) and HbF (17.0 versus 10.8 %) over baseline than those receiving HU alone (Group B).
- While all 80 subjects were initially transfusion-dependent, 15 of 40 in Group A (37.5 %) became transfusion-independent, whereas only 6 of 40 in Group B (15 %) reached this status.
- No serious adverse events necessitating discontinuation of therapy were seen in either group.
While this proof-of-principle study reported better responses to HU plus EPO in patients with lower initial blood EPO levels, HbF levels > 40 %, or prior splenectomy, larger clinical trials with longer follow-up are needed. Questions to be addressed before recommending use of this regimen include determining those who are most likely to respond as well as overall costs and safety of long-term treatment, such as the side effects of high-dose EPO (e.g., thrombosis, reduced survival, bone remodeling) and the development of complications (e.g., myelodysplasia, acute leukemia) when HU is given in concert with EPO.
Cognitive Deficits Associated with Bipolar Disorder, Depression and Schizophrenia
Li and associates (2018) reviewed the safety and efficacy of adjunctive EPO in treating cognitive deficits associated with schizophrenia, bipolar disorder, and major depression based on RCTs. Two evaluators independently and systematically searched and selected studies, extracted data, and conducted quality assessment. A total of 4 RCTs with 144 patients (71 in the EPO group and 73 in the placebo group) met the study entry criteria. Adjunctive EPO could improve schizophrenia-related cognitive performance. In patients with bipolar disorder, EPO could also enhance sustained attention, recognition of happy faces, and speed of complex information processing across learning, attention, and executive function when compared with placebo. In addition, EPO could enhance verbal recall, recognition, and memory in patients with major depression. The authors concluded that this preliminary study found that adjunctive EPO appeared to be effective in treating cognitive deficits associated with schizophrenia, bipolar disorder, and major depression without major AEs observed. Moreover, these researchers stated that further higher quality RCTs with larger samples are needed to confirm these findings.
COVID-19 Pandemic and Anemia in Malignancy
In 2020, the NCCN panel announced short-term recommendations specific to issues with the COVID-19 (SARS-CoV-2) virus pandemic. Per NCCN, "We have encountered unique issues related to caring for cancer patients in the current COVID-19 pandemic and have realized that our current standard-of-care NCCN Guidelines do not adequately address some of these issues, such as the limited blood supply, possible impact on those with active infection, and measures that might shorten or prevent hospitalization. These issues may wax and wane, and may require continuous communication with local Blood Bank directors to optimize treatment." Therefore, the recommendation are for broadening the use of ESA therapy +/- IV iron supplementation to manage anemia in patients with malignancy requiring blood transfusion support. Cautionary statement: An increased risk of thrombosis has been observed with ESAs. Therefore, use the lowest dose of ESA sufficient to avoid transfusion. For example, hold ESA for Hgb ≥10.
In October 2021, NCCN webstie no longer includes the above recommendation.
Erythropoietin for Hypoxic-Ischemic Encephalopathy
Nair and Kumar (2018) noted that clinical trials evaluating erythropoietin in infants with hypoxic ischemic encephalopathy (HIE) have shown promising results. The authors commented that, since hypothermia has become standard of care therapy for HIE, larger trials are currently on going evaluating erythropoietin as a complement to cooling therapy. The authors stated that a phase III trial evaluating the effect of erythropoeitin with hypothermia on the combined outcome of death or neurodevelopmental disability is currently underway. They also reported that a large multicenter randomized controlled trial evaluating use of darbepoetin in mild HIE is currently underway (MEND study).
In an open-label pilot study, Nonomura and colleagues (2019) examined the safety and feasibility of the combination therapy with erythropoietin (Epo), magnesium sulfate and hypothermia in neonates with hypoxic-ischemic encephalopathy (HIE). A combination therapy with Epo (300 U/kg every other day for 2 weeks), magnesium sulfate (250 mg/kg for 3 days) and hypothermia was started within 6 hours of birth in neonates who met the institutional criteria for hypothermia therapy was carried out. All patients received continuous infusion of dopamine. Vital signs and AEs were recorded during the therapy. Short-term and long-term developmental outcomes were also evaluated. A total of 9 patients were included in the study. The mean age at first intervention was 3.9 hours (SD, 0.5). Death, serious AEs or changes in vital signs likely due to intervention were not observed during hospital care. All 9 patients completed the therapy. At the time of hospital discharge, 8 patients had established oral feeding and did not require ventilation support; 2 patients had abnormal MRI findings. At 18 months of age, 8 patients received a follow-up evaluation, and 3 of them showed signs of severe neurodevelopmental disability. The authors concluded that the this pilot study showed that combination therapy with 300 U/kg Epo every other day for 2 weeks, 250 mg/kg magnesium sulphate for 3 days and therapeutic hypothermia was feasible in newborn patients with HIE. Moreover, these researchers stated that to demonstrate the long-term neuroprotective safety and efficacy of this therapy, phase-II and phase-III clinical trials with an adequate sample size are needed.
The authors stated that this study had several limitations. First, it was conducted in a small number of patients (n = 9) without a control treatment and was not designed to evaluate efficacy. However, all 9 patients included in the study completed the therapy without developing AEs. Death or serious AEs were not observed. Second, these investigators chose the low-dose of EPO. Thus, the safety data would not be applicable to future studies using higher doses.
Erythropoietin for Nephron-Protection in Persons Undergoing Kidney Transplantation
Vlachopanos and associates (2015) stated that DGF due to ischemia-reperfusion injury is a major early complication of KTx. Recombinant human erythropoietin (rHuEPO) has been shown to exert nephron-protective action in animal models. In a meta-analysis, these investigators examined the impact of rHuEPO on DGF in KTx. Eligible studies comparing peri-operative high-dose rHuEPO with placebo or no therapy for prevention of DGF were identified through Medline, CENTRAL, and Transplant Library. Their design and data were assessed by 2 independent reviewers. Among 737 examined studies, 4 RCTs involving 356 recipients of kidney allografts from deceased donors, fulfilled inclusion criteria. Statistical heterogeneity across studies was not significant (p = 0.98, I(2) = 0 %). In a random effects model, no significant difference was found in the occurrence of DGF (OR: 0,74, 95 % CI: 0.47 to 1.18, p = 0.21). At 4 weeks after KTx, the rHuEPO group exhibited higher systolic blood pressure (SBP) (mean difference [MD]: 6.47 mmHg, 95 % CI: 1.25 to 11.68, p = 0.02). The authors concluded that peri-operative, high-dose rHuEPO administration did not prevent DGF in deceased donor KTx. Furthermore, it was associated with higher SBP leading to safety concerns. These researchers stated that non-erythropoietic rHuEPO derivatives, designed for nephron-protective action without increasing cardiovascular risk, might prove an alternative but still are at early stages of development.
Zhou and colleagues (2020) noted that the protective effect of rHuEPO on KTx has not been established. In a systematic review and meta-analysis, these researchers examined the potential influence of rHuEPO on transplanted kidneys. They identified relevant studies, searched electronic databases (PubMed, Medline, Embase, Ovid, the Cochrane Library, and major nephrology journals) from inception until June 15, 2018; 2 independent reviewers assessed study quality. The systematic review and meta-analysis were performed with fixed- or random-effects models according to heterogeneity, and results were expressed as RR or weighted MD (WMD). A total of 6 RCTs with 435 patients met the inclusion criteria. Compared with placebo, rHuEPO had no statistically significant effect on DGF (RR = 0.89, 95 % CI: 0.73 to 1.07; p = 0.22) and slow graft function (RR = 0.93, 95 % CI: 0.60 to 1.43; p = 0.73). The rHuEPO and control groups did not differ in thrombo-embolic events, mortality, AR, and blood transfusion. A significant difference was found in long-term eGFR (RR = 3.65, 95 % CI: -4.45 to 11.75; p = 0.003). The authors concluded that these findings suggested that rHuEPO had a limited nephron-protective effect in patients undergoing KTx and did not increase the susceptibility to AEs.
Erythropoietin for the Treatment of Diabetic Neuropathy
Suarez-Mendez and colleagues (2018) noted that EPO is needed for promoting the progress of erythroid differentiation. However, the discovery of EPO and the EPO receptor (EPOR) in the nervous system may contribute to new treatment strategies for the use of EPO in neurodegenerative disorders. Diabetic neuropathy (DN) is a neurodegenerative disease that affects a large proportion of diabetic patients and results in alterations in functionality, mood and sleep. The pathogenic mechanisms generating DN involve: Schwannopathy, polyol pathway activity, advanced glycation end-products (AGEs) accumulation, protein kinase C (PKC) activity, increased hexosamine pathway flux, oxidative stress, nitric oxide and inflammation. In this sense, evidence from both clinical and experimental studies indicated that EPO may reverse DN via an anti-oxidant action by decreasing pro-inflammatory cytokines, restoring Na+/K+-ATPase activity, and blocking the generation of pro-apoptotic proteins. In this review, the authors discussed the potential neuro-protective effect of EPO on the pathogenesis of DN; and suggested a possible therapeutic use of EPO for DN.
Erythropoietin for the Treatment of Oral Mucositis
Rezazadeh and colleagues (2018) noted that oral mucositis (OM) represents a therapeutic challenge frequently encountered in cancer patients undergoing chemotherapy or radiotherapy; and EPO has anti-inflammatory, anti-oxidant, and wound-healing properties and thus has important roles in the prevention and treatment of OM. In the current study, these researchers developed a thermally sensitive muco-adhesive gel based on tri-methyl chitosan (TMC) containing EPO for the treatment of OM. TMCs with various degrees of substitution (DS) were synthesized and mixed with β-glycero-phosphate (GP) and characterized for gelation properties by means of rheological analysis. The effects of DS of TMCs and different concentrations of GP on gelation temperature and time were examined. The muco-adhesive property of the mixtures was also assessed using cattle buccal mucosa. The optimized mixture was loaded with EPO and subjected to in-vitro drug release, wash-away, in-vitro anti-microbial, and wound-healing tests. The effect of EPO-loaded formulation was also examined in-vivo in Sprague-Dawley rats with chemotherapy-induced mucositis. The best properties were obtained with the blend of TMC of 9.8 % DS (5 %) and GP (20 %). EPO was released from the hydrogel during 8 hours, and more than 30 % of the drug still remained on the mucosa after 3 hours of washing the buccal mucosa with phosphate buffer. TMC/GP mixture was characterized by anti-microbial properties. The authors concluded that the EPO hydrogel demonstrated in-vitro/in-vivo wound-healing properties; thus, EPO-loaded hydrogel has the potential to be used in the treatment of OM and other oral or subcutaneous wounds.
ESAs in Hematopoietic Stem Cell Transplants
Martino et al (2015) stated that ESAs are used in treating cancer- and chemotherapy-induced anemia with the aim of accelerating the recovery of RBCs, reduce the risks associated with RBC transfusions and improve quality of life. These researchers performed a systematic review to examine the current evidence for the safety and effectiveness of using ESAs in hematopoietic stem cell transplants (HSCTs). These investigators noted that despite the international recommendations for the use of ESAs in treating different malignancies, there is a lack of guidelines for their use in patients undergoing HSCT. An evaluation of published clinical trials showed that there are no available powerful studies concerning the use of ESAs in this setting, with only heterogeneous and small numbers of patients reported so far. Nevertheless, the more robust and intriguing of these data suggested that the ESA's administration at an appropriate time after the infusion of stem cells may be effective both in autologous and allogeneic HSCTs. The authors concluded that new guidelines are needed, overseen by an expert in the in the field of stem cell transplantation.
Friedreich's Ataxia
Sacca and colleagues (2016) stated that Friedreich's ataxia (FRDA) is an autosomal recessive disease with no available therapy. Clinical trials with EPO in FRDA patients have yielded conflicting results, and the long-term effect of the drug remains unknown. These researchers designed a double-blind, placebo-controlled, multi-center study to examine the effectiveness of epoetin alfa on 56 patients with FRDA. The primary end-point of the study was the effect of epoetin alfa on peak oxygen uptake (VO2 max) at the cardiopulmonary exercise test. Secondary end-points were frataxin levels in peripheral blood mononuclear cells, improvement in echocardiography findings, vascular reactivity, neurological progression, upper limb dexterity, safety, and quality of life. Epoetin alfa or placebo (1:1 ratio) was administered subcutaneously at a dose of 1,200 IU/Kg of body weight every 12 weeks for 48 weeks. A total of 56 patients were randomized; 27 completed the study in the active treatment group, and 26 completed the study in the placebo group [KG1]; VO2 max was not modified after treatment (0.01 [-0.04 to 0.05]; p = 0.749), as well as most of the secondary end-point measures, including frataxin. The 9-hole peg test showed a significant amelioration in the treatment group (-17.24 sec. [-31.5 to -3.0]; p = 0.018). The treatment was safe and well-tolerated. The authors concluded that although results were not in favor of an effect of epoetin alfa in FRDA, this was the largest study examining its effect. These investigators stated that it is still possible that epoetin alfa may show some symptomatic effect on upper-limb performance. This study provided class I evidence that EPO did not ameliorate VO2 max in patients with FRDA.
Aranca and associates (2016) noted that FRDA is an inherited, progressive neurodegenerative disease that typically affects teenagers and young adults. Therapeutic strategies and disease insight have expanded rapidly over recent years, leading to hope for the FRDA population. There is currently no FDA-approved treatment for FRDA, but advances in research of its pathogenesis have led to clinical trials of potential treatments. The authors reviewed emerging therapies and discussed future perspectives, including the need for more precise measures for detecting changes in neurologic symptoms as well as a disease-modifying agent; and EPO is one of the keywords listed in this review.
Hairy Cell Leukemia
Naika and Saven (2012) stated that neutrophil growth factors have been applied to reduce complications from cladribine-induced severe neutropenia because it occurs in 30 % to 40 % of patients. At Scripps Clinic, the authors performed a phase-II clinical trial investigating filgrastim at a dose of 5 μg/kg per day subcutaneously for 3 consecutive days before cladribine administration, then daily after cladribine was finished until resolution of neutropenia. These researchers treated 35 patients with hairy cell leukemia and compared them with historical controls. The median nadir neutrophil count was roughly 0.5 × 109/L compared with 0.3 × 109/L in patients not receiving filgrastim (p = 0.04). After a median of 10 days of filgrastim, the time for neutrophils to recover to greater than 1.0 × 109/L was shortened from 22 days in the historical control arm to 9 days. However, these investigators noted no differences with regard to the number of febrile days or hospitalization rates. The authors concluded that routine use of filgrastim is not recommended. Because the rates of severe anemia from cladribine are low, these investigators similarly do not recommend prophylactic erythropoietin-stimulating agents, although this has never been prospectively studied.
Maevis et al. (2014) conducted a short review of current recommendations for hairy cell leukemia. Their review did not recommend epoetin as a therapeutic option. The authors referenced Saven et al. who neither recommend a routine use of granulocyte-colony-stimulating factor based on their findings in a phase II study investigating the influence of filgrastim on cladribine-induced severe neutropenia nor prophylactic erythropoietin-stimulating agents because of the rareness of severe cladribine-induced anemia.
An UpToDate review on “Treatment of hairy cell leukemia” (Tallman, 2017) does not mention epoetin as a therapeutic option.
Hemolysis Anemia Associated with Prosthetic Valve
Shapira et al (2009) stated that hemolysis is one of the potentially serious complications of prosthetic heart valves. It is usually associated with either structural deterioration or para-valvular leak. Mild, compensated hemolysis associated with mechanical heart valves is not uncommon even in the current era. Severe hemolysis is rare, however, and usually reflects para-valvular leak. The use of trans-esophageal echocardiography (TEE)-guided operative techniques may help prevent or minimize early post-operative para-valvular leakage. There is a gamut of available therapeutic approaches -- medical, transcatheter, and surgical -- to this complication and therapy should be tailored to the individual patient. Novel pharmacological agents include EPO and pentoxifylline. Several reports described the feasibility of transcatheter closure of paravalvular leak with coils or devices; however, their effect on hemolysis is unpredictable. Surgery remains the treatment of choice in severe cases.
Hemolytic Anemia
Zuppa et al (2012) investigated a cohort of 14 neonates to compare the effectiveness of recombinant human erythropoietin (rHuEPO) in two care protocols that differ for doses of rHuEPO administrated and for timing of administration. Protocol A: a dose of 200 U/kg/day of rHuEpo administered subcutaneously starting from the end of the second week of life; Protocol B: a dose of 400 U/kg/day of rHuEpo administered subcutaneously starting from the end of the first week of life. The hematocrit values in the protocol A group decreased during treatment (32,5% vs 25,2%), whereas the hematocrit value in protocol B group remained almost stable (38,7% vs 42,8%). The mean numbers of platelets remained stable in both groups while neutrophils increased in protocol A group and decreased in protocol B (p<0,05). Reticulocyte count increased during treatment in both groups, although only in protocol B group it was statistically significative (p<0,05). The authors concluded that their results suggest similar efficacy between the two treatment protocols. Increasing doses of rHuEPO does not seem to enhance their effectiveness.
Donato et al. (2009) discussed recombinant erythropoietin as treatment for hyporegenerative anemia following hemolytic disease of the newborn. The authors study consisted of a case series report on 50 neonates with hemolytic disease of the newborn (HDN) due to Rh, ABO or KpA antigens. The neonates were 7 days or older. Treatment with erythropoietin was started when hematocrit dropped to levels requiring a transfusion, and inappropriate reticulocyte response Reticulocyte Production Index <1). At start of treatment mean age was 24.3 +/- 12.0 days (range 8-65 days), hematocrit 24.1 +/- 2.8% (range 18-30%), and Reticulocyte Production Index 0.34 +/- 0.25 (range 0.05-0.98). The authors stated that the Hematocrit and Reticulocyte Production Index showed significant increases after 7 and 14 days of treatment (p <0.001). No difference was observed either between infants with Rh-HDN and ABO-HDN or between Rh-HDN patients with or without intrauterine transfusions. Seven infants (14%) required one packed RBC transfusion during erythropoietin therapy, 2 of them within 72 hours from starting treatment. The percentage of transfused infants showed no difference either between ABO-HDN and Rh-HDN or between Rh-HDN with and without intrauterine transfusions. Moderate, short-lasting neutropenia, not associated to infections, was observed in 11 patients. No other adverse effect was observed. They concluded that the administration of erythropoietin appears to be a safe and useful therapy; however, Its efficacy should be confirmed by randomized studies.
Dominquez et al (2010) conducted an observational study in 13 newborns with late anemia due to a hemolytic disease caused by Rh isoimmunization (9 cases), ABO isoimmunication (2 cases), glucose-6-P-dehydrogenase deficiency (1 case) or idiopathic (1 case). The newborns began EPO treatment when they reached the haematocrit level for a blood transfusion. EPO treatment was started at 26±7 days of life (15-46), with a haematocrit value of 21.7±3% (18-27) and a reticulocyte count of 3.8±2.2%. Blood transfusion was not necessary in 11 newborns (haematocrit of 30.7±4.4% and reticulocytes of 5.9±1.4%), and only 2 newborns were admitted for a blood transfusion (haematocrit 18±4.4% and reticulocytes 0.6%). Significant increases in haemoglobin and reticulocyte figures were seen after EPO treatment. Although the authors concluded that EPO administration proved useful to avoid blood transfusion in 84% of treated newborns, sample size was small.
Rath et al. (2011) discussed hematological morbidity and management in neonates with hemolytic disease due to red cell alloimmunization. The authors state that treatment of severe anemia with intrauterine red cell transfusions in fetuses with red cell alloimmunization, has led to an increase in perinatal survival, creating a shift towards improving postnatal treatment options. They state that postnatal treatment of anemia consists of top-up transfusions and supplements to support erythropoiesis such as folic acid and iron, and occasionally erythropoietin treatment.
An American Society for Hematology education module (2015) uses the reference to Zuppa et al. (2010) to support the point that low erythropoietin levels may contribute to anemia; however, there is no recommendation for administration of erythropoietin for hemolytic anemia due to Rh sensitization in newborn (Delaney and Matthews, 2015).
Hereditary Hemochromatosis
Bruckl and colleagues (2017) examined retrospectively the effectiveness of combined therapy using EPO and erythrocytapheresis (EA) in patients with hereditary hemochromatosis (HH) who did not tolerate phlebotomy. A total of 20 patients (age range of 43 to 74 years) with genetically confirmed HH had received low-dose EPO (4,000 IU) in accordance to the patient's hemoglobin levels between each EA session. Laboratory parameters including hemoglobin, ferritin, transferrin, and iron were measured at regular intervals. Anemia did not occur in a single patient and no serious adverse events (AEs) were observed. Combined treatment with EPO and EA was well-tolerated, and all 18 patients who suffered from fatigue prior to therapy recovered. Median ferritin values were 678.5 ng/L before treatment and 145 ng/L after treatment. The authors concluded that EA in combination with EPO is safe and effective in treating patients with HH. Moreover, they stated that prospective studies comparing this therapeutic option to phlebotomy are needed.
Myelodysplastic Syndromes (MDS)
The British Committee for Standards in Haematology’s guidelines on “The diagnosis and management of adult myelodysplastic syndromes” (Killick et al, 2014) provided the following recommendations:
- Patients with International Prognostic Scoring System (IPSS) low and intermediate-1 (INT-1) MDS, symptomatic anemia and who fulfil the criteria for a high or intermediate predictive score for response should be considered for a trial of therapy with an ESA (Grade 1B).
- Patients with non-sideroblastic phenotypes should be offered a trial of therapy with an ESA (Grade 1B).
- Patients with sideroblastic phenotypes should be offered a trial of therapy with an ESA plus G-CSF (Grade 1B).
- Patients should receive a maximum trial period of 16 weeks of therapy. This should comprise 8 weeks at the starting dose of ESA ± G-CSF and a further 8 weeks at the higher doses, if required (Grade 2B).
- Patients achieving a complete or partial erythroid response by accepted criteria should continue on long-term therapy until the response is lost and at the minimum dose of ESAs required to maintain the response.
Seastone and Gerds (2015) stated that MDS are characterized by refractory cytopenias that lead to symptomatic anemia, bleeding, and increased risk for infections. For the past 20 years, the use of darbepoetin and other ESAs to treat symptomatic anemia in lower-risk MDS has been a standard of care. This practice is supported by numerous phase I/II studies and 1 phase III study demonstrating the benefit of using ESAs alone, or in combination with G-CSF, for treatment of symptomatic anemia with the goal of decreasing RBC transfusion requirements. The authors summarized the published experience regarding the use of ESAs, with a special focus on darbepoetin, in patients with MDS and symptomatic anemia.
Myelofibrosis
Huang et al (2008) conducted a retrospective study to examine the risk factors for leukemic transformation in patients with primary myelofibrosis. The study that examined clinical variables at the time of diagnosis and specific treatment modalities for their effect on leukemic transformation in 311 patients with primary myelofibrosis (PMF) who were seen at the Mayo Clinic. Analysis of parameters at the time of diagnosis revealed a significant association between inferior leukemia-free survival and a peripheral blood blast percentage>or=3 (P<.0001), a platelet count<100x10(9)/L (P=.004), a monocyte count>or=1x10(9)/L (P=.02), the presence of hypercatabolic symptoms (P=.03), a low hemoglobin level (P=.04), and a high leukocyte count (P=.04). Neither leukemia-free nor overall survival was found to be affected by the presence of <3% peripheral blood blasts or JAK2V617F mutation. The evaluation of treatment effect on leukemic transformation unexpectedly revealed a significant and independent association with previous therapy with either erythropoiesis-stimulating agents (ESA) (P=.004) or danazol (P=.007), even when the aforementioned prognostic indicators at the time of diagnosis were added as covariates to the multivariate model. In contrast, leukemia-free survival was not found to be affected by a treatment history with hydroxyurea, thalidomide, or other drugs. The authors concluded that peripheral blood blast percentage>or=3 and/or a platelet count<100x10(9)/L at the time of diagnosis were found to be strong and independent predictors of leukemic transformation in patients with PMF. The unexpected association between leukemic transformation and a history of treatment with ESA or danazol requires validation by prospective studies.
Huang et al (2009) discussed ESA having limited therapeutic activity in transfusion-dependent patients with primary myelofibrosis (PMF) regardless of serum erythropoietin level. The authors reviewed a master database of patients diagnosed with PMF from 1976 through 2006, and seen at the Mayo Clinic. They identified 43 patients (median age 67 yrs old) treated with ESA. Study inclusion required documentation of a complete blood count prior to therapy and follow-up that was adequate enough to assess response. They excluded patients who were receiving other anemia-improving agents concomitantly with an ESA, such as prednisone, androgens, danazol, or thalidomide. Response was defined as a minimum 2.0 g ⁄dL increase in hemoglobin level or becoming transfusion-independent over a minimum of 1-month period. ESA was administered for a median of 4.3 months (range 0.5–54.0). Prior to ESA treatment, 16 (37%) patients were red blood cell transfusion-dependent and the median hemoglobin level in transfusion-independent patients at start of therapy was 9.4 g/dL. Pretreatment serum Epo level was documented in 25 patients (median 34 U⁄ L range 2-323). Overall response rate to ESA was 23% among transfusion-dependent patients, and 37% (10 out of 27) among transfusion-independent patients (p = 0.007). ESA response was not correlated with baseline serum Epo level in all 43 study patients (P = 0.68) or the subset of 27 transfusion-independent patients (P = 0.39), PMF-specific treatment history, use of concurrent cytoreductive therapy, cytogenetic findings, or JAK2V617F presence. The authors concluded that ESA, if at all used in PMF, should be avoided in those patients who are either transfusion-dependent or have a baseline hemoglobin of ≥ 10 g/dL.
Based on the experience and knowledge of experts in the field, Barbui and colleagues (2011) presented a review of critical concepts and developed recommendations on the management of Philadelphia-negative classical myeloproliferative neoplasms. Key questions were selected according the criterion of clinical relevance. Statements were produced using a Delphi process, and two consensus conferences involving a panel of 21 experts appointed by the European LeukemiaNet (ELN) were convened. The authors noted a consensus on primary myelofibrosis (PMF) in that corticosteroids, androgens, erythropoiesis-stimulating agents, and immunomodulators are recommended to treat anemia of PMF; however, all of these agents have limitations, and there are no comparative trials, whereas hydroxyurea is the first-line treatment of PMF-associated splenomegaly.
Hernandez-Boluda et al (2017) discussed predictive factors for anemia response to erythropoiesis-stimulating agents (ESA) in myelofibrosis. The authors analyzed ESA therapy in 163 myelofibrosis patients with severe anemia, of which, most of had inadequate EPO levels (< 125 U/L) at start of treatment. The revised criteria of the International Working Group for Myelofibrosis Treatment and Research were used in evaluating anemia response. The authors noted that 86 patients (53%) achieved an anemia response. Median response duration was 19.3 months. In multivariate analysis, baseline factors associated with a higher response rate were female sex (P=.007), leukocyte count ≥10×109 /L (P=.033), and serum ferritin <200 ng/mL (P=.002). Patients with 2 or 3 of the above features had a significantly higher response rate than the remainder (73% vs 28%, respectively; P<.001). Over the 373 patient-years of follow-up on ESA treatment, nine patients developed thrombotic complications (six arterial, three venous), accounting for 2.41 events per 100 patient-years. Survival time from ESA start was longer in anemia responders than in non-responders (P=.011). Hernandez-Boluda and colleagues concluded that the data obtained can help to identify which myelofibrosis patients are more likely to benefit from ESA treatment.
An UpToDate review on “Management of primary myelofibrosis” (Tefferi, 2017), states that “erythropoietin or darbepoetin have generally not been successful in alleviating the anemia associated with PMF, although others have reported responses, most often in patients not requiring transfusional support and/or those with inappropriately low serum erythropoietin levels.”
Neonatal Encephalopathy
Rogers and colleagues (2014) stated that EPO is neuro-protective in animal models of neonatal hypoxic-ischemic encephalopathy (HIE). These researchers previously reported a phase I safety and pharmacokinetic study of EPO in neonates. This article presented the neurodevelopmental follow-up of infants who were enrolled in the phase I clinical trial. These investigators enrolled 24 newborns with HIE in a dose-escalation study. Patients received up to 6 doses of EPO in addition to therapeutic hypothermia (TH). All infants underwent neonatal brain magnetic resonance imaging (MRI) reviewed by a single neuro-radiologist. Moderate-to-severe neurodevelopmental disability was defined as cerebral palsy (CP) with Gross Motor Function Classification System levels III to V or cognitive impairment based on Bayley Scales of Infant Development II mental developmental index or Bayley III cognitive composite score. Outcomes were available for 22 of 24 infants, at mean age of 22 months (range of 8 to 34). There were no deaths; 8 (36 %) had moderate-to-severe brain injury on neonatal MRI. Moderate-to-severe disability occurred in 1 child (4.5 %), in the setting of moderate-to-severe basal ganglia and/or thalamic injury; 7 infants with moderate-to-severe watershed injury exhibited the following outcomes: normal (n = 3), mild language delay (n = 2), mild hemiplegic CP (n = 1), and epilepsy (n = 1). All 11 patients with a normal brain MRI had a normal outcome. The authors concluded that this study was the first to describe neurodevelopmental outcomes in infants who received high doses of EPO and TH during the neonatal period. The findings suggested that future studies are needed to evaluate the effectiveness of this new potential neuro-protective therapy.
McAdams and Juul (2016) stated that neonatal encephalopathy (NE) is a major cause of neonatal mortality and morbidity; and TH is standard treatment for newborns at 36 weeks of gestation or greater with intra-partum hypoxia-related NE. Term and late preterm infants with moderate to severe NE show improved survival and neurodevelopmental outcomes at 18 months of age after TH. Therapeutic hypothermia can increase survival without increasing major disability, rates of an IQ less than 70, or CP. Neonates with severe NE remain at risk of death or severe neurodevelopmental impairment. The authors discussed the evidence supporting TH and other novel therapeutics for term or near term neonates with NE; EPO is one of the keywords listed in this review.
Juul and colleagues (2018) noted that HIE remains an important cause of neonatal death and frequently leads to significant long-term disability in survivors. Therapeutic hypothermia, while beneficial, still leaves many treated infants with lifelong disabilities. Adjunctive therapies are needed, and EPO has the potential to provide additional neuroprotection. These investigators reviewed the current incidence, mechanism of injury, and sequelae of HIE, and described a new phase-III randomized, placebo-controlled clinical trial of EPO neuro-protection in term and near-term infants with moderate-to-severe HIE treated with therapeutic hypothermia. They presented an overview of HIE, neuro-protective functions of EPO, and the design of a double-blind, placebo-controlled, multi-center clinical trial of high-dose EPO administration, enrolling 500 neonates of greater than or equal to 36 weeks of gestation with moderate or severe HIE diagnosed by clinical criteria. The authors stated that EPO has robust neuro-protective effects in pre-clinical studies, and phase-I/phase-II clinical trials suggesting that multiple high-doses of EPO may provide neuro-protection against brain injury in term infants. The High Dose Erythropoietin for Asphyxia and Encephalopathy (HEAL) Trial will examine if high-dose EPO reduces the combined outcome of death or neuro-developmental disability when given in conjunction with hypothermia to newborns with moderate/severe HIE.
Optic Neuritis
Diem and associates (2016) stated that optic neuritis leads to degeneration of retinal ganglion cells whose axons form the optic nerve. The standard treatment is a methylprednisolone pulse therapy. This treatment slightly shortens the time of recovery but does not prevent neurodegeneration and persistent visual impairment. In a phase II clinical trial performed in preparation of this study, these researchers have shown that EPO protects global retinal nerve fiber layer thickness (RNFLT-G) in acute optic neuritis; however, the preparatory trial was not powered to show effects on visual function. These researchers noted that “Treatment of Optic Neuritis with Erythropoietin (TONE)” is a national, randomized, double-blind, placebo-controlled, multi-center trial with 2 parallel arms. The primary objective is to determine the effectiveness of EPO compared to placebo given add-on to methylprednisolone as assessed by measurements of RNFLT-G and low-contrast visual acuity in the affected eye 6 months after randomization. Inclusion criteria were a first episode of optic neuritis with decreased visual acuity to less than or equal to 0.5 (decimal system) and an onset of symptoms within 10 days prior to inclusion. The most important exclusion criteria were history of optic neuritis or multiple sclerosis or any ocular disease (affected or non-affected eye), significant hyperopia, myopia or astigmatism, elevated blood pressure, thrombotic events or malignancy. After randomization, patients either receive 33,000 IU rhEPO intravenously for 3 consecutive days or placebo (0.9 % saline) administered intravenously. With an estimated power of 80 %, the calculated sample size is 1,00 patients. The authors noted that the trial started in September 2014 with a planned recruitment period of 30 months.
Out-of-Hospital Cardiac Arrest
Cariou and colleagues (2016) stated that preliminary data suggested a clinical benefit in treating out-of-hospital cardiac arrest (OHCA) patients with a high dose of EPO analogs. These researchers evaluated the effectiveness of epoetin alfa treatment on the outcome of OHCA patients in a phase III clinical trial. These researchers performed a multi-center, single-blind, RCT. Patients still comatose after a witnessed OHCA of presumed cardiac origin were eligible. In the intervention group, patients received 5 intravenous injections spaced 12 hours apart during the first 48 hours (40,000 units each, resulting in a maximal dose of 200,000 total units), started as soon as possible after resuscitation. In the control group, patients received standard care without EPO. The main end-point was the proportion of patients in each group reaching level 1 on the Cerebral Performance Category (CPC) scale (survival with no or minor neurological sequelae) at day 60. Secondary end-points included all-cause mortality rate, distribution of patients in CPC levels at different time-points, and side effects. In total, 476 patients were included in the primary analysis. Baseline characteristics were similar in the 2 groups. At day 60, 32.4 % of patients (76 of 234) in the intervention group reached a CPC 1 level, as compared with 32.1 % of patients (78 of 242) in the control group (OR: 1.01; 95 % CI: 0.68 to 1.48). The mortality rate and proportion of patients in each CPC level did not differ at any time points. Serious AEs were more frequent in EPO-treated patients as compared with controls (22.6 % versus 14.9 %; p = 0.03), particularly thrombotic complications (12.4 % versus 5.8 %; p = 0.01). The authors concluded that in patients resuscitated from an OHCA of presumed cardiac cause, early administration of EPO plus standard therapy did not confer a benefit, and was associated with a higher complication rate.
Preoperative Erythropoiesis-Stimulating Agents in Anemic, Elective Surgery Patients
Kaufner et al (2020) stated that approximately 30 % of adults undergoing non-cardiac surgery suffer from preoperative anemia. Preoperative anemia is a risk factor for mortality and adverse outcomes in different surgical specialties and is frequently the reason for blood transfusion. The most common causes are renal, chronic diseases, and iron deficiency. International guidelines recommend that the cause of anemia guide preoperative anemia treatment. Recombinant human erythropoietin (rHuEPO) with iron supplementation has frequently been used to increase preoperative Hb concentrations in patients in order to avoid the need for peri-operative allogeneic RBC transfusion. In a Cochrane review, these investigators examined the effectiveness of preoperative rHuEPO therapy (subcutaneous or parenteral) with iron (enteral or parenteral) in reducing the need for allogeneic RBC transfusions in preoperatively anemic adults undergoing non-cardiac surgery. They searched CENTRAL, Ovid Medline(R), Ovid Embase, ISI Web of Science: SCI-EXPANDED and CPCI-S, and clinical trial registries WHO ICTRP and ClinicalTrials.gov on August 29, 2019. These researchers included all RCTs that compared pre-operative rHuEPO + iron therapy to control treatment (placebo, no treatment, or standard of care [SOC] with or without iron) for preoperatively anemic adults undergoing non-cardiac surgery. They used the World Health Organization (WHO) definition of anemia: Hb concentration (g/dL) less than 13 g/dL for males, and 12 g/dL for non-pregnant females (decision of inclusion based on mean Hb concentration). These investigators defined 2 subgroups of rHuEPO dosage: ”low” for 150 to 300 IU/kg body weight, and “high” for 500 to 600 IU/kg body weight. Two review authors collected data from the included studies. The primary outcome was the need for RBC transfusion (no autologous transfusion, fresh frozen plasma or platelets), measured in transfused participants during surgery (intra-operative) and up to 5 days after surgery. Secondary outcomes of interest included Hb concentration (directly before surgery), number of RBC units (where 1 unit contains 250 to 450 ml) transfused per participant (intra-operative and up to 5 days after surgery), mortality (within 30 days after surgery), hospital LOS, and AEs (e.g., renal dysfunction, thromboembolism, hypertension, allergic reaction, headache, fever, constipation). Most of the included trials were in orthopedic, gastro-intestinal (GI), and gynecological surgery and included participants with mild and moderate preoperative anemia (Hb from 10 to 12 g/dL). The duration of pre-operative rHuEPO treatment varied across the trials, ranging from once-weekly to daily or a 5- to 10-day period, and in 1 trial preoperative rHuEPO was given on the morning of surgery and for 5 days post-operatively. These researchers included 12 trials (participants = 1,880) in the quantitative analysis of the need for RBC transfusion following preoperative treatment with rHuEPO + iron to correct pre-operative anemia in non-cardiac surgery; 2 studies were multi-armed trials with 2 different dose regimens. Preoperative rHuEPO + iron given to anemic adults reduced the need RBC transfusion (RR 0.55, 95 % CI: 0.38 to 0.80; participants = 1,880; studies = 12; I2 = 84 %; moderate-quality evidence due to inconsistency). This analysis suggested that on average, the combined administration of rHuEPO + iron will mean 231 fewer individuals will need transfusion for every 1,000 individuals compared to the control group. Preoperative high-dose rHuEPO + iron given to anemic adults increased the HB concentration (mean difference (MD) 1.87 g/dL, 95 % CI: 1.26 to 2.49; participants = 852; studies = 3; I2 = 89 %; low-quality evidence due to inconsistency and risk of bias) but not low-dose rHuEPO + iron (MD 0.11 g/dL, 95 % CI: -0.46 to 0.69; participants = 334; studies = 4; I2 = 69 %; low-quality evidence due to inconsistency and risk of bias). There was probably little or no difference in the number of RBC units when rHuEPO + iron was given preoperatively (MD -0.09, 95 % CI: -0.23 to 0.05; participants = 1,420; studies = 6; I2 = 2 %; moderate-quality evidence due to imprecision). There was probably little or no difference in the risk of mortality within 30 days of surgery (RR 1.19, 95 % CI: 0.39 to 3.63; participants = 230; studies = 2; I2 = 0 %; moderate-quality evidence due to imprecision) or of AEs including local rash, fever, constipation, or transient hypertension (RR 0.93, 95 % CI: 0.68 to 1.28; participants = 1,722; studies = 10; I2 = 0 %; moderate-quality evidence due to imprecision). The administration of rHuEPO + iron before non-cardiac surgery did not clearly reduce the hospital LOS of preoperative anemic adults (MD -1.07, 95 % CI: -4.12 to 1.98; participants = 293; studies = 3; I2 = 87 %; low-quality evidence due to inconsistency and imprecision). The authors concluded that moderate-quality evidence suggested that preoperative rHuEPO + iron therapy for anemic adults before non-cardiac surgery reduced the need for RBC transfusion and, when given at higher doses, increased the Hb concentration preoperatively. The administration of rHuEPO + iron treatment did not decrease the mean number of units of RBC transfused per patient; and there were no important differences in the risk of AEs or mortality within 30 days, nor in hospital LOS. These researchers stated that further, well-designed, adequately powered RCTs are needed to estimate the impact of this combined treatment more precisely.
Avau et al (2021) noted that for anemic elective surgery patients, current clinical practice guidelines weakly recommend the routine use of iron, but not ESAs, except for short-acting ESAs in major orthopedic surgery. This recommendation is, however, not based on any cost-effectiveness studies. In a systematic review, these researchers examined the evidence on the cost-effectiveness of pre-operative iron and/or ESAs in anemic, elective surgery patients and updated existing economic evaluations (EEs) with recent data. A total of 8 databases and registries were searched for EEs and RCTs reporting cost-effectiveness data on November 11, 2020. Data were extracted, narratively synthesized and appraised using the Philips reporting checklist. Pre-existing full EEs were updated with effectiveness data from a recent systematic review and current cost data. Incremental cost-effectiveness ratios were expressed as cost per (quality-adjusted) life-year [(QA)LY] gained. Only 5 studies (4 EEs and 1 RCT) were included, 1 on IV iron and 4 on ESAs + oral iron. The EE on IV iron only had an in-hospital time horizon; thus, cost-effectiveness of pre-operative iron remains uncertain. The 3 EEs on ESAs had a lifetime time horizon; but reported cost per (QA)LY gained of 20 to 65 million (GBP or CAD). Updating these analyses with current data confirmed ESAs to have a cost per (QA)LY gained of 3.5 to 120 million (GBP or CAD). The authors concluded that the cost-effectiveness of pre-operative iron is unproven, whereas routine pre-operative ESA therapy could not be considered cost-effective in elective surgery, based on the limited available data. Moreover, these investigators stated that future guidelines should reflect these findings.
The authors stated that this study had several drawbacks. The identified body of evidence was sparse, especially regarding cost-effectiveness of iron therapy, where only 1 study on IV therapy was identified; thus, any conclusion regarding the cost-effectiveness of oral or IV iron therapy remains speculative. The cost-effectiveness of EPO together with oral iron therapy was examined by 4 studies, which were, however, mostly outdated. Despite the additional sensitivity analyses conducted by these investigators, this remains a source of uncertainty. In addition, these studies only focused on orthopedic or cardiac surgery. The cost-effectiveness of EPO in other high-risk surgical procedures (e.g., abdominal surgery) remains unproven. Furthermore, the evaluations were limited to transfusion avoidance, and AEs associated with this. Including other clinically important outcomes with a large impact on cost (e.g., return to operating room due to bleeding) would have added value. A full health technology assessment with a long-term time horizon on the cost-effectiveness of pre-operative EPO and/or iron therapy in anemic elective surgery patients, addressing the current clinical and economical context, is needed for a more precise incremental cost-effectiveness ratio (ICER) estimate.
Bath et al (2022) stated that anemia is present in up to 2/3 of patients undergoing colorectal surgery mainly caused by iron deficiency and inflammation. As anemia is associated with increased risk of peri-operative death, diagnosis and treatment of pre-operative anemia according to etiology have been recommended. In a retrospective, cohort study, these researchers examined if the association between anemia and survival in patients undergoing colorectal surgery was determined by the severity of anemia alone or also by anemia etiology. To determine the prevalence of anemia and etiology, pre-operative hematological parameters, C-reactive protein (CRP), ferritin and transferrin saturation were retrospectively assessed and correlated with outcome in a cohort of patients undergoing colorectal surgery between 2005 and 2019 at the University Hospital of Innsbruck. Anemia was defined as Hb 120 g/L or less in females and less than 130 g/L in males. The etiology of anemia was classified on the basis of serum iron parameters, as iron deficiency anemia, anemia of inflammation or other anemia etiologies. Pre-operative anemia was present in 54 % (1,316/2,458) of all patients. Anemia was associated with iron deficiency in 45 % (134/299) and classified as anemia of inflammation in 32 % (97/299) of patients with available serum iron parameters. The etiology of anemia was a strong and independent predictor of survival, where iron deficiency and anemia of inflammation were associated with better post-operative survival than other anemia etiologies. One year survival rates were 84.3 %, 77.3 % and 69.1 % for patients with iron deficiency anemia, anemia of inflammation and other anemia types. Inflammation indicated by high CRP was a strong negative predictor of OS. The authors concluded that anemia had a high prevalence among patients undergoing colorectal surgery and rational treatment required early assessment of serum iron parameters and CRP. Moreover, these investigators stated that the 3 pillars of patient blood management (PBM) include optimization of erythropoiesis, minimization of blood loss and hemostasis, as well as the optimization of the physiological reserve of anemia. In the peri-operative setting, optimization of erythropoiesis is mainly based on IV iron supplementation and treatment of the underlying cause of iron deficiency; erythropoiesis-stimulating agents are not mentioned as a management option.
Preterm Infants or Low Birth-Weight Infants
Messier and Ohls (2014) noted that the use of ESAs such as erythropoietin and darbepoetin in preterm and term infants has been studied for over 20 years. Recent investigations have explored the potential neuroprotective effects of ESAs. These investigators reviewed the recent clinical trials and experimental animal models that provide evidence in support of using ESA to improve the neurodevelopmental outcomes in term and preterm infants. Continued work using animal models have confirmed the neuroprotective properties of ESAs, including promotion of oligodendrocyte development in the face of neuronal injury. Clinical studies in term and preterm infants have reported the neuroprotective effects following ESA administration, and improved neurodevelopmental outcomes have been reported in the studies of preterm infants. The authors concluded that ESAs show great promise in preventing and treating brain injury in term and preterm infants.
Also, an UpToDate review on “Late preterm infants” (Barfield and Lee, 2014) does not mention the use of erythropoietin/erythropoiesis stimulating agents as management tools.
Natalucci and colleagues (2016) examined if prophylactic early high-dose recombinant human erythropoietin (rhEPO) in preterm infants improves neurodevelopmental outcome at 2 years' corrected age. Preterm infants born between 26 weeks 0 days' and 31 weeks 6 days' gestation were enrolled in a randomized, double-blind, placebo-controlled, multi-center trial in Switzerland between 2005 and 2012. Neurodevelopmental assessments at age 2 years were completed in 2014. Participants were randomly assigned to receive either rhEPO (3,000 IU/kg) or placebo (isotonic saline, 0.9 %) intravenously within 3 hours, at 12 to 18 hours, and at 36 to 42 hours after birth. Primary outcome was cognitive development assessed with the Mental Development Index (MDI; norm, 100 [SD, 15]; higher values indicate better function) of the Bayley Scales of Infant Development, second edition (BSID-II) at 2 years corrected age. The minimal clinically important difference between groups was 5 points (0.3 SD). Secondary outcomes were motor development (assessed with the Psychomotor Development Index), cerebral palsy, hearing or visual impairment, and anthropometric growth parameters. Among 448 preterm infants randomized (mean gestational age of 29.0 [range of 26.0 to 30.9] weeks; 264 [59 %] female; mean birth weight of 1,210 [range of 490 to 2,290] g), 228 were randomized to rhEPO and 220 to placebo. Neurodevelopmental outcome data were available for 365 (81 %) at a mean age of 23.6 months. In an intention-to-treat analysis, mean MDI was not statistically significantly different between the rhEPO group (93.5 [SD, 16.0] [95 % CI: 91.2 to 95.8]) and the placebo group (94.5 [SD, 17.8] [95 % CI, 90.8 to 98.5]) (difference, -1.0 [95 % CI: -4.5 to 2.5]; p = 0.56). No differences were found between groups in the secondary outcomes. The authors concluded that among very preterm infants who received prophylactic early high-dose rhEPO for neuroprotection, compared with infants who received placebo, there were no statistically significant differences in neurodevelopmental outcomes at 2 years. Moreover, they stated that follow-up for cognitive and physical problems that may not become evident until later in life is required.
Ohlsson and Aher (2020) noted that pre-term infants have low plasma levels of EPO, providing a rationale for the use of ESAs for the prevention or treatment of anemia as well as neuroprotection and protection against necrotizing enterocolitis (NEC). In a Cochrane review, these researchers examined the safety and effectiveness of ESAs (EPO and/or darbepoetin [Darbe]) initiated early (before 8 days after birth) compared with placebo or no intervention in reducing RBC transfusions, adverse neurological outcomes, and feeding intolerance including NEC in pre-term and/or low birth-weight infants. Primary objective was to examine the safety and effectiveness of ESAs administered early in reducing RBC transfusions: To examine the effectiveness and safety of ESAs initiated early in reducing RBC transfusions in pre-term infants. Secondary objectives: Review authors performed subgroup analyses of low (less than or equal to 500 IU/kg/week) and high (greater than 500 IU/kg/week) doses of EPO and the amount of iron supplementation provided: none, low (less than or equal to 5 mg/kg/day), and high (greater than 5 mg/kg/day). Primary objective for studies that primarily examine the neuro-protective effectiveness of ESAs: To assess the safety and effectiveness of ESAs initiated early in reducing adverse neurological outcomes in pre-term infants. Primary objective for studies that primarily examine the effectiveness of EPO or Darbe administered early in reducing feeding intolerance: To assess the safety and effectiveness of ESAs administered early in reducing feeding intolerance (and NEC) in pre-term infants. Other secondary objectives: To compare the effectiveness of ESAs in reducing the incidence of AEs and improving long-term neuro-developmental outcomes. These investigators used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 2), Medline via PubMed (1966 to March 10, 2017), Embase (1980 to March 10, 2017), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to March 10, 2017). They searched clinical trials databases, conference proceedings, and reference lists of retrieved articles for randomized and quasi-randomized controlled trials. Randomized and quasi-randomized controlled trials of early initiation of EAS treatment versus placebo or no intervention in pre-term or low birth-weight infants were selected for analysis. They used the methods described in the Cochrane Handbook for Systematic Reviews of Interventions and the GRADE approach to evaluate the quality of evidence. This updated review includes 34 studies enrolling 3,643 infants. All analyses compared ESAs versus a control consisting of placebo or no treatment. Early ESAs reduced the risk of “use of 1 or more RBC transfusions” (typical RR 0.79, 95 % CI: 0.74 to 0.85; typical risk difference (RD) -0.14, 95 % CI: -0.18 to -0.10; I2 = 69 % for RR and 62 % for RD (moderate heterogeneity); number needed to treat for an additional beneficial outcome (NNTB) 7, 95 % CI: 6 to 10; 19 studies, 1,750 infants). The quality of the evidence was low; NCE was significantly reduced in the ESA group compared with the placebo group (typical RR 0.69, 95 % CI: 0.52 to 0.91; typical RD -0.03, 95 % CI: -0.05 to -0.01; I2 = 0 % for RR and 22 % for RD (low heterogeneity); NNTB 33, 95 % CI: 20 to 100; 15 studies, 2,639 infants). The quality of the evidence was moderate. Data showed a reduction in “any neurodevelopmental impairment at 18 to 22 months” corrected age in the ESA group (typical RR 0.62, 95 % CI: 0.48 to 0.80; typical RD -0.08, 95 % CI: -0.12 to -0.04; NNTB 13, 95 % CI: 8 to 25; I2 = 76 % for RR (high heterogeneity) and 66 % for RD (moderate); 4 studies, 1,130 infants). The quality of the evidence was low. Results revealed increased scores on the Bayley-II Mental Development Index (MDI) at 18 to 24 months in the ESA group (weighted MD (WMD) 8.22, 95 % CI: 6.52 to 9.92; I2 = 97 % (high heterogeneity); 3 studies, 981 children). The quality of the evidence was low. The total volume of RBCs transfused per infant was reduced by 7 ml/kg. The number of RBC transfusions per infant was minimally reduced, but the number of donors to whom infants who were transfused were exposed was not significantly reduced. Data showed no significant difference in risk of stage greater than or equal to stage III retinopathy of prematurity (ROP) with early EPO (typical RR 1.24, 95 % CI: 0.81 to 1.90; typical RD 0.01, 95 % CI: -0.02 to 0.04; I2 = 0 % (no heterogeneity) for RR; I2 = 34 % (low heterogeneity) for RD; 8 studies, 1,283 infants). Mortality was not affected, but results showed significant reductions in the incidence of intra-ventricular hemorrhage (IVH) and peri-ventricular leukomalacia (PVL). The authors concluded that early administration of ESAs reduces the use of RBC transfusions, the volume of RBCs transfused, and donor exposure after study entry. Small reductions were likely to be of limited clinical importance. Donor exposure probably was not avoided, given that all but 1 study included infants who had received RBC transfusions before trial entry. This update found no significant difference in the rate of ROP (stage III or higher) for studies that initiated EPO treatment at less than 8 days of age, which has been a topic of concern in earlier versions of this review. Early EPO treatment significantly decreased rates of IVH, PVL, and NEC. Neurodevelopmental outcomes at 18 to 22 months and later varied in published studies. Ongoing research should examine current clinical practices that will limit donor exposure. Promising but conflicting results related to the neuro-protective effect of early EPO require further study. Very different results from the 2 largest published trials and high heterogeneity in the analyses indicated that researchers should wait for the results of 2 ongoing large trials before drawing firm conclusions. Administration of EPO is not currently recommended because limited benefits have been identified to date; and the use of darbepoetin requires further study.
In a Cochrane review, Aher and Ohlsson (2020) examined the safety and effectiveness of late initiation of ESAs, between 8 and 28 days after birth, in reducing the use of RBC transfusions in pre-term or low birth-weight infants. They used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2018, Issue 5), Medline via PubMed (1966 to June 5, 2018), Embase (1980 to June 5, 2018), and CINAHL (1982 to June 5, 2018). These investigators searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for RCTs and quasi-randomized trials. Randomized or quasi-randomized controlled trials of late initiation of EPO treatment (started at greater than or equal to 8 days of age) versus placebo or no intervention in pre-term (less than 37 weeks) or low birth-weight infants (less than 2,500 g) were selected for analysis. They carried out data collection and analyses in accordance with the methods of the Cochrane Neonatal Review Group; and used the GRADE approach to assess the quality of the evidence. These researchers included 31 studies (32 comparisons) randomizing 1,651 pre-term infants. Literature searches in 2018 identified 1 new study for inclusion. No new on-going trials were identified; and no studies used darbepoetin. Most included trials were of small sample size. The meta-analysis showed a significant effect on the use of 1 or more RBC transfusions (21 studies (n = 1,202); typical RR of 0.72, 9 5% CI: 0.65 to 0.79; typical RD -0.17, 95 % CI: -0.22 to -0.12; typical NNTB 6, 95 % CI: 5 to 8). There was moderate heterogeneity for this outcome (RR I² = 66 %; RD I² = 58 %). The quality of the evidence was very low. These investigators obtained similar results in secondary analyses based on different combinations of high/low doses of EPO and iron supplementation. There was no significant reduction in the total volume (ml/kg) of blood transfused per infant (typical MD -1.6 ml/kg, 95 % CI: -5.8 to 2.6); 5 studies, 197 infants). There was high heterogeneity for this outcome (I² = 92 %). There was a significant reduction in the number of transfusions per infant (11 studies enrolling 817 infants, typical MD -0.22, 95 % CI: -0.38 to -0.06). There was high heterogeneity for this outcome (I² = 94 %); 3 studies including 404 infants reported on ROP (all stages or stage not reported), with a typical RR 1.27 (95 % CI: 0.99 to 1.64) and a typical RD of 0.09 (95 % CI: -0.00 to 0.18) . There was high heterogeneity for this outcome for both RR (I² = 83 %) and RD (I² = 82 %). The quality of the evidence was very low; 3 trials enrolling 442 infants reported on ROP (stage greater than or equal to 3). The typical RR was 1.73 (95 % CI: 0.92 to 3.24) and the typical RD was 0.05 (95 % CI: -0.01 to 0.10). There was no heterogeneity for this outcome for RR (I² = 18 %) but high heterogeneity for RD (I² = 79 %). The quality of the evidence was very low. There were no significant differences in other clinical outcomes including mortality and necrotizing enterocolitis. For the outcomes of mortality and necrotizing enterocolitis, the quality of the evidence was moderate. Long-term neurodevelopmental outcomes were not reported. The authors concluded that late administration of EPO reduce the use of 1 or more RBC transfusions, the number of RBC transfusions per infant (less than 1 transfusion per infant) but not the total volume (ml/kg) of RBCs transfused per infant. Any donor exposure was likely not avoided as most studies included infants who had received RBC transfusions prior to trial entry. Late EPO did not significantly reduce or increase any clinically important adverse outcomes except for a trend in increased risk for ROP. These researchers stated that further research of the use of late EPO treatment, to prevent donor exposure, is not indicated. Research efforts should focus on limiting donor exposure during the first few days of life in sick neonates, when RBC requirements are most likely to be required and cannot be prevented by late EPO treatment. The use of satellite packs (dividing 1 unit of donor blood into many smaller aliquots) may reduce donor exposure.
These researchers stated that the use of late EPO was not associated with any short‐term serious AEs except for a possible association with ROP stage III or higher. A large proportion of pre-term/extremely low birth-wight infants require RBC transfusions during the first few days of life, when neither early nor late EPO administration could possibly have an impact. The decision to use late EPO will depend on the baseline rate of RBC transfusions in this population in a specific neonatal ICU, the costs, the associated pain, and the values assigned to the clinical outcomes. Other means of reducing the need RBC transfusions should be considered, including reduced blood sampling, and the use of “satellite packs” from directed or universal donors.
Sickle Cell Disease
Chou and colleagues (2020) stated that red cell transfusions remain a mainstay of therapy for patients with sickle cell disease (SCD); but pose significant clinical challenges. Guidance for specific indications and administration of transfusion, as well as screening, prevention, and management of alloimmunization, delayed hemolytic transfusion reactions (DHTRs), and iron-overload may improve outcomes. These investigators developed evidence-based guidelines to support patients, clinicians, and other healthcare professionals in their decisions regarding transfusion support for SCD and the management of transfusion-related complications. The American Society of Hematology (ASH) formed a multi-disciplinary panel that was balanced to minimize bias from conflicts of interest and that included a patient representative. The panel prioritized clinical questions and outcomes. The Mayo Clinic Evidence-Based Practice Research Program supported the guideline development process. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to form recommendations, which were subject to public comment. The panel developed 10 recommendations that focused on red cell antigen typing and matching, indications, and mode of administration (simple versus red cell exchange), as well as screening, prevention, and management of alloimmunization, DHTRs, and iron-overload. The authors concluded that the majority of panel recommendations were conditional due to the paucity of direct, high-certainty evidence for outcomes of interest. Research priorities were identified, including prospective studies to understand the role of serologic versus genotypic red cell matching, the mechanism of HTRs resulting from specific allo-antigens to inform therapy, the role and timing of regular transfusions during pregnancy for women, and the optimal treatment of transfusional iron-overload in SCD.
The panel noted that a DHTR is defined as a significant drop in hemoglobin within 21 days post-transfusion associated with 1 or more of the following: new red cell alloantibody, hemoglobinuria, accelerated increase in percentage hemoglobin S (HbS%) with a concomitant fall in HbA post-transfusion, relative reticulocytopenia or reticulocytosis from baseline, significant lactate dehydrogenase (LDH) rise from baseline, and exclusion of an alternative cause. The panel also noted that supportive care for severe hemolytic transfusion reactions with hyper-hemolysis should be initiated in all patients, including EPO with or without IV iron.
Traumatic Brain Injury
In a matched case control study, Talving and co-workers (2010) examined if administration of ESA would improve survival following severe traumatic brain injury (sTBI). Patients with sTBI [head Abbreviated Injury Scale (AIS), greater than or equal to 3] receiving ESA while in the surgical intensive care unit (n = 89) were matched 1 to 2 (n = 178) by age, gender, mechanism of injury, Glasgow Coma Scale, presence of hypotension on admission, Injury Severity Score, AIS for all body regions, and presence of anemia with patients who did not receive the agent. Each case's controls were chosen to have surgical intensive care unit length of stay more than or equal to the time from admission to first dose of ESA. The primary outcome measure in this study was mortality. Cases and controls had similar age, gender, mechanisms of injury, incidence of hypotension, Glasgow Coma Scale on admission, Injury Severity Score, and AIS for all body regions. Although the ESA-treated patients experienced protracted hospital length of stay and comparable surgical intensive care unit free days, they demonstrated a significantly lower in-hospital mortality in comparison to controls at 7.9 % versus 24.2 %, respectively (OR: 0.27; 95 % CI: 0.12 to 0.62; p = 0.001). The authors concluded that administration of ESA in sTBI is associated with a significant in-hospital survival advantage without increase in morbidity. They stated that prospective, large, randomized controlled trials are needed to validate these findings.
In a systematic review and meta-analysis, Lee and colleagues (2019) examined the effects of EPO on mortality and neurological outcomes in patients with TBI. Electronic databases of studies published up to January 5, 2017 were searched to retrieve relevant investigations comparing the outcomes of EPO-treated patients and untreated patients following TBI. These investigators calculated the relative risk (RR) of mortality, neurologic outcomes, and DVT with corresponding 95 % CI using meta-analysis. A total of 6 RCTs (1,041 patients) met the eligibility criteria; EPO was found to significantly reduce the occurrence of mortality (RR 0.68 [95 % CI: 0.50 to 0.95]; p = 0.02), but did not significantly reduce poor functional outcome (RR 1.22 [95 %: CI 0.82 to 1.81]; p = 0.33). There were no significant differences in the occurrence of complications, such as DVT, between the treatment groups (RR -0.02 [95 % CI: -0.06 to 0.02]; p = 0.81). The authors concluded that findings of this meta-analysis suggest that the use of EPO may prevent death following TBI without causing AEs, such as DVT. However, these researchers stated that the role of EPO in improving neurological outcome(s) remains unclear, and further well-designed RCTs using modified protocols and involving specific patient populations are needed to clarify this issue, and to verify the findings.
Appendix
Appendix A: FDA-Approved Indications and Brands of Erythropoiesis-Stimulating Agents
Note: There is a lack of evidence that one brand of erythropoietin alpha (i.e., Procrit, Epogen, Retacrit) is more effective than another brand. In addition, there is a lack of reliable evidence that darbepoetin is more effective than erythropoietin alpha or Mircera for darbepoetin's labeled indications.
| FDA-Approved Indications | Brands of ESAs |
|---|---|
| Treatment of anemia of chronic kidney disease (CKD) | Epogen, Procrit, Aranesp, Retacrit, Mircera |
| Treatment of anemia in zidovudine-treated HIV-infected patients | Epogen, Procrit, Retacrit |
| Treatment of anemia in cancer patients on chemotherapy | Epogen, Procrit, Aranesp, Retacrit |
| Reduction of allogeneic blood transfusion in surgery patients | Epogen, Procrit, Retacrit |
Appendix B: Normal Reference Range of Serum Iron and Serum Ferritin
-
Serum Iron
- Children: 50 to 120 mcg/dL
- Men: 80-180 mcg/dL
- Newborns: 100 to 250 mcg/dL
- Women: 60-160 mcg/dL
Source: Devkota, 2019
-
Serum Ferritin
- Female: 12 to 150 ng/mL
- Male: 12 to 300 ng/mL
Source: UCSF, 2018
Appendix C: Conversion of Epoetin alpha to Darbepoetin
For persons already receiving either IV or SQ epoetin alfa, the manufacturer recommends the conversion in the following table:
| Previous weekly epoetin alfa dose (Units/week) | Weekly darbepoetin alfa dose (micrograms/week) |
|---|---|
| less than 1500 | Adult:6.25 Pediatric: insuffienct data available |
| 1500 to 2499 | Adult: 6.25 Pediatric: 6.25 |
| 2500 to 4999 | Adult: 12.5 Pediatric: 10 |
| 5000 to 10,999 | Adult: 25 Pediatric: 20 |
| 11,000 to 17,999 | Adult: 40 Pediatric: 40 |
| 18,000 to 33,999 | Adult: 60 Pediatric: 60 |
| 34,000 to 89,999 | Adult: 100 Pediatric: 100 |
| 90,000 or greater | Adult: 200 Pediatric: 200 |
Source: Amgen, 2019
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