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Guideline on epoetin/darbepoetin use in cancer patients stresses lowest dose to avoid transfusions

Reuters Health • The Doctor's Channel Daily Newscast

NEW YORK (Reuters Health) – In order to minimize the risk of potential harms, erythropoiesis-stimulating agents (ESAs) in patients undergoing myelosuppressive chemotherapy should be administered at the lowest dose needed to raise hemoglobin to the minimum necessary level to avoid transfusions, according to updated recommendations from the American Society of Clinical Oncology and American Society of Hematology.

An abridged version of the guideline is published in the Journal of Clinical Oncology, available online October 25.

“It provides updated recommendations collectively for ESAs and reviews currently available information on ESA-associated tumor progression, venous thromboembolism, and/or survival, but does not revisit the effectiveness of ESAs to reduce transfusions or increase Hb in detail because the evidence on these outcomes is robust,” explains the Update Committee, co-chaired by Dr. J. Douglas Rizzo of the Medical College of Wisconsin, Milwaukee and Dr. Melissa Brouwers at McMaster University in Hamilton, Ontario, Canada.

In deciding whether to use ESAs, the “demonstrated risks” of thromboembolism and the possibility of death must be considered, the authors say.

While RBC transfusion is an option in patients with chemotherapy-associated anemia and a hemoglobin level below 10 g/dL, the use of darbepoetin or epoetin is also recommended to decrease transfusions. The optimal Hb level at which to start ESA therapy level “cannot be definitively determined from the available evidence,” the panel states. “Under these circumstances, whether or not to initiate ESA treatment should be determined by clinical judgment, consideration of the risks and benefits of ESAs, and patient preferences.”

Patient involvement in the decision process is another salient feature of the updated guidance. “The Update Committee recommends that clinicians discuss potential harms (eg, thromboembolism, shorter survival) and benefits (eg, decreased transfusions) of ESAs and compare these with potential harms (eg, serious infections, immune-mediated adverse reactions) and benefits (eg, rapid Hb improvement) of RBC transfusions. Individual preferences for assumed risk should contribute to shared decisions on managing chemotherapy-induced anemia.”

Other updated recommendations cover starting doses and modifying the dose, when to discontinue therapy for lack of response, and anemia in patients not currently on chemo. On that point, “It is recommended that ESAs not be used in treatment of anemia associated with malignancy in patients who are not receiving concurrent myelosuppressive chemotherapy,” the committee advises.

The complete guideline, a patient guide, “and other clinical tools and resources to help clinicians implement this guideline” are available at


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

J Clin Oncol 2010;