Treatment
➤ Rec. 5: The Expert Panel considers epoetin beta and alfa, darbepoetin, and
biosimilar epoetin alfa to be equivalent with respect to effectiveness and
safety. (Moderate recommendation; IC-I)
➤ Rec. 6: ESAs increase the risk of thromboembolism, and clinicians should
carefully weigh the risks of thromboembolism and use caution and clinical
judgment when considering use of these agents. (Strong recommendation;
EB-H)
➤ Rec. 7: It is recommended that starting and modifying doses of ESAs follow
FDA guidelines (see Table 2 for specific dosing information). (Moderate
recommendation; IC-I)
➤ Rec. 8: Hb may be increased to the lowest concentration needed to avoid or
reduce the need for red blood cell transfusions, which may vary by patient
and condition. (Moderate recommendation; IC-I)
➤ Rec. 9: ESAs should be discontinued in patients who do not respond within
6 to 8 weeks. Patients who do not respond to ESA treatment should be
re-evaluated for underlying tumor progression, iron deficiency, or other
etiologies for anemia. (Strong recommendation; IC-I)
➤ Rec. 10: Iron replacement may be used to improve hemoglobin response
and reduce red blood cell transfusions for patients receiving ESA with or
without iron deficiency. Baseline and periodic monitoring of iron, total iron
binding capacity, transferrin saturation, or ferritin levels is recommended.
(Weak recommendation; EB-I)
Table 1. Suggested Baseline Investigations for Anemia in Cancer
Patients Receiving Chemotherapy
a
orough drug exposure history
Review of a peripheral-blood smear
b
Analyses, where indicated, for iron, total iron-binding capacity, transferrin saturation, ferritin,
folate, vitamin B12, or hemoglobinopathy screening,
Assessment of reticulocyte count, occult blood loss and renal insufficiency
Baseline erythropoietin level
Testing of serum thyroid-stimulating hormone level where indicated
Investigations may also include direct antiglobulin testing (e.g. Coombs' test) for patients with
chronic lymphocytic leukemia, non-Hodgkin's lymphoma, or a history of autoimmune disease.
a
Based on the consensus of the Expert Panel. is is not intended to be a comprehensive list of
investigations.
b
And, in some cases, a bone marrow examination.
