Treatment options of Fe deficiency anemia
- Oral iron supplements (approx. 200 mg/day elemental iron)
- Diet (meat, fish, poultry)
- Parenteral iron
When is parenteral iron used in treatment of Fe deficiency anemia?
- Iron malabsorption
- Intolerance of oral therapy
- Chronic non-compliance
Types of oral iron supplements and how much is elemental
- Ferrous gluconate 300 mg (12% elemental)
- Ferrous sulfate 300 mg (20%)
- Ferrous fumarate 100 mg (33%)
- Polysacch iron complex 150 mg (100%)
Types of parenteral iron
- Iron dextran
- Sodium ferric gluconate
- Iron sucrose
- Ferumoxytol
Which parenteral iron is more likely to cause anaphylaxis?
Iron dextran
Approximately how much elemental iron should be given each day in Fe deficiency anemia?
200 mg/day
1st line treatment of Vit B12 deficiency anemia?
PO cyanocobalamin (B12)
2nd line treatment of Vit B12 deficiency anemia?
- IM/SC Canocobalamin DAILY until acute symptoms reside
- Then weekly until Hgb/HCT normal
- Then monthly indefinitely
What is Nascobal?
- Nasal spray of B12
- MAINTENANCE treatment of Vit B12 deficiency anemia
- Expensive
- 1 hr before or after ingestion of hot foods or beverages
Rare ADRs of Vit B12 therapy
- Hyperuricemia
- Hypokalemia
- Sodium retention
Treatment of folic acid anemia
- Oral folic acid IV/PO daily for about 4 months
- Long term therapy sometimes indicated
- Maintenance dose used in some patients
How is Nascobal dosed?
- 1 spray in 1 nostril weekly
- 1 hr before or after ingestion of hot foods or beverages
- Each spray is 500 mcg
Treatment options for anemia of chronic disease?
- RBC transfusions
- Erythropoiesis stimulating agents
When are RBC transfusions typically considered in pts with anemia from chronic disease?
Hgb 8-10 g/dL (or less)
Drawbacks of RBC transfusions in chronic anemia
- Limited, expensive
- Short term (doesn’t fix cause)
- Infection risk
Describe erythropoiesis stimulating agents
Mimic body’s own EPO produced by kidneys
What agents are erythropoiesis stimulating agents?
Darbepoetin (Aranesp)
Epoetin alfa (Epogen, Procrit)
*Recombinant DNA available IV or SC (preferred)
What route is preferred when using erythropoiesis stimulating agents?
SC (but they are available IV too)
When are erythropoiesis stimulating agents indicated? What are the preferred agents for each indication?
Anemia secondary to:
- Cancer (APE: Aranesp, Procrit, Epogen)
- Renal disease (AEP)
- Drug induced (AEP)
What should be given along with erythropoiesis stimulating agents?
Iron supplements to prevent deficiency (ESAs trigger rapid use of iron stores)
MOA of ESAs
- Mimic EPO, circulate through vasculature and into BM
- In BM, bind receptors on hematopoietic stem cells
- Stimulus results in increased erythrogenesis
Efficacy difference between Darbepoetin (Aranesp) and Epoetin alfa (Epogen, Procrit)?
NONE
How does dosing of Darbepoetin (Aranesp) compare to Epoetin alfa?
Darbepoetin: longer half life allows less frequent dosing (once a week or less)
How should ESAs be dosed in chemo patients?
Lowest effective dose to maintain lowest Hgb to prevent RBC transfusion (and don’t exceed Hgb of 11)
How should ESAs be dose adjusted in chemo pts if Hgb response is less than 1 and remains under 10 after 4 weeks?
- Epoetin: INCREASE to 60,000 units
- Darbepoetin: STAY at 500 mcg
How should ESAs be dose adjusted in chemo pts if Hgb increases by more than 1 within 2 weeks?
- Epoetin: reduce by 25% to 30,000 units
- Darbepoetin: reduce by 40% to 300 mcg
When should ESAs be d/c in chemo pts?
No response in Hgb or still requiring RBC transfusion after:
- 8 weeks of epoetin
- 9 weeks of darbepoetin
Max epoetin dose in renal patients?
Up to 20,000 units tiw
Max epoetin dose in oncology pts?
60,000 units q week
Max darbepoetin dose in oncology pts?
500 mcg q 3 weeks
Warnings a/w ESA use
- Increased mortality
- Serious CV and thromboembolic events
- Increased risk of tumor progression or recurrence
In general, how should ESAs be dosed?
Individualized - use LOWEST dose to avoid RBC transfusion
When are ESAs contraindicated?
Patients receiving myelosuppressive therapy when the anticipated outcome is CURE (bc ESAs may shorten overall survival and increase risk of tumor progression/recurrence)
What is the ESA Apprise program?
- Assisting Providers and cancer Patients with Risk Information for Safe use of ESAs
- Prescribers/hospital designees must enroll to dispense Aranesp or Procrit to oncology pts
Who needs to be enrolled in the ESA Apprise program?
Prescribers/hospital designees
Patients do NOT need to enroll
In oncology patients, what are ESAs used for?
ONLY treatment of anemia due to concomitant myelosuppressive chemo (discontinue after completion of the chemo)
What should be monitored routinely during ESA treatment?
Iron (monthly)
How long could it take renal pts to see ESA treatment response in HCT/Hgb?
2-6 weeks
How long could it take oncology pts to see ESA treatment response in HCT/Hgb?
4-8 weeks
Response rate of oncology pts to ESAs?
Only about 60% oncology pts respond to ESA therapy
Types of sickle cell crises
- Vaso-occlusive (MC)
- Aplastic
- Hemolytic
- Splenic sequestration (significant cause of mortality)
Supportive and preventive treatment of sickle cell disease
- Folic acid (prevents deficiency due to hyper-erythropoiesis)
- Vaccines (HIB, pneumococcal)
- Proph penicillin up to 5 yo
- Hydroxyurea (increases Hgb-F)
Treatment of sickle cell complications
- RBC transfusions (in life threatening situations)
- HSCT
What is the only potentially curative treatment of sickle cell disease?
HSCT (limited success, risk of treatment related toxicity, limited by availability of donors)
Drawbacks of HSCT for sickle cell disease
- Limited success
- Risk of treatment related toxicity
- Limited by availability of donors
Drawbacks of RBC transfusions in sickle cell disease
May increase risk of transfusion reactions and iron overload
Management of sickle cell crisis
- Hydration w/saline based fluid (3-4 L/day, avoid overhydration)
- Pain management (individualized)
How do RBC transfusions work in sickle cell disease?
Dilutes concentration of RBCs containing Hgb-S
When is splenectomy recommended in sickle cell disease?
Cases of severe splenic sequestration
What should patients on hydroxyurea be monitored for?
Myelosuppression
