Erythropoiesis-Stimulating Agents (ESAs): Clinical Use and Guidelines

Introduction to ESAs

Erythropoiesis-stimulating agents (ESAs) are medications designed to stimulate red blood cell production in the bone marrow to treat anemia, primarily indicated for chemotherapy-induced anemia in cancer patients and anemia associated with chronic kidney disease, as recommended by the American Society of Clinical Oncology 1, 2

The American Society of Clinical Oncology recommends treatment of chemotherapy-induced anemia in adult patients with non-myeloid malignancies using ESAs, with initial dosing depending on the specific ESA and indication, such as epoetin alfa (150 IU/kg subcutaneously three times weekly) or darbepoetin (2.25 μg/kg subcutaneously weekly) 1, 2
Dose adjustments are made based on hemoglobin response, with an increase in dose if hemoglobin rise is <1 g/dL after 4 weeks, and a reduction in dose by 25-50% if hemoglobin rises >2 g/dL in 4 weeks or exceeds 12 g/dL, as suggested by the National Kidney Foundation 1, 2, 4

ESAs increase hemoglobin levels with an overall weighted mean difference of 1.63 g/dL compared to controls in chemotherapy-induced anemia, and reduce the need for red blood cell transfusions by approximately 36% in cancer patients, according to the American College of Cardiology 2, 4, 5
The relative risk of thromboembolic events is increased by 67% in patients treated with ESAs compared with placebo, and ESAs should be used with caution in patients with uncontrolled hypertension or a history of thromboembolic events, as warned by the Food and Drug Administration 6, 5

Regular monitoring of hemoglobin levels is essential during ESA therapy, with a target hemoglobin of <12 g/dL for cancer patients and 10-12 g/dL for CKD patients, as recommended by the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines 1, 2, 7
Treatment should be discontinued 4 weeks after completion of chemotherapy in cancer patients, and if no response is observed after 8-9 weeks of therapy, treatment should be discontinued, as suggested by the European Society for Medical Oncology 1, 2