Erythropoiesis-stimulating agents, ESA in CKD anemia. How long does it take for EPO to work?
A 69-year-old man with CKD G4A2 from hypertension is evaluated at the nephrology and hypertension clinic for fatigue. His hemoglobin is 8.9 g/dL. He is iron replete. He does not have a history of cancer.
He started on EPO 4 weeks ago. His hemoglobin was 8.2 g/dl. The patient is frustrated that the hemoglobin is not better and he is still fatigued.
We are observing a response. The goal is to elevate the hemoglobin to the lowest concentration necessary to reduce the need, or avoid the need for a blood transfusion, especially in the setting of a possible kidney transplant in the future.
We should continue the current protocol, noting that it can take 6 to 8 weeks to see the maximal response to erythropoietin, and we do not want to overshoot.
With respect to ESA in CKD anemia, patients have higher morbidity and mortality if a patient’s hemoglobin falls below 10 g/dL, based on a 2014 analysis.
ESAs are drugs that cause the bone marrow to generate additional red blood cells. They are used in the treatment of anemia resulting from various conditions, including chronic kidney disease and chemotherapy-associated anemia.
Erythropoietin (EPO) has been approved for the treatment of anemia associated with chronic kidney disease. When prescribing erythropoiesis-stimulating agents (ESAs), healthcare providers should follow specific guidelines to ensure effective management of anemia while minimizing risks.
When starting ESA in CKD anemia and cancer, the primary goal is to elevate hemoglobin levels to the lowest concentration necessary to avoid or reduce the need for red blood cell transfusions and side-effects associated with hemoglobin levels that are too high because of ESA therapy.
It is crucial to monitor the patient’s response to treatment. This is usually done via protocols which safely raise a patient’s hemoglobin concentration:
* Patients with chronic kidney disease have higher mortality and morbidity from cardiovascular-related events when the patient’s hemoglobin falls below 10 g/dL. EPO is usually started when the hemoglobin falls below 10 g/dL. * The ideal range is usually between 11 and 12 g/dL, but it’s important to be cautious about higher doses of ESAs since they can raise the risk of thrombotic events. * If no response is observed within 6 to 8 weeks, ESA in CKD anemia therapy should be discontinued. * The patient should be reevaluated for potential underlying causes, such as tumor progression or iron deficiency.
In cases of chemotherapy-associated anemia, ESAs may be prescribed under certain conditions: * They can be considered for patients when cancer treatment is not expected to be curative and the hemoglobin level is less than 10 g/dL. *However, ESAs should not be prescribed to patients whose cancer treatment is expected to be curative.
The American Society of Clinical Oncology (ASCO) has stated that epoetin (EPO), darbepoetin, and biosimilars, such as Mircera, are equally effective and safe for treating anemia. Biosimilars of epoetin alfa are safe and effective compared with their progenitor, ensuring that patients have access to reliable treatment options.
