Erythropoiesis-Stimulating Agents for Persistent Anemia

Initial ESA Selection and Dosing

The American Society of Clinical Oncology recommends epoetin alfa (40,000 U SC weekly or 150 U/kg SC three times weekly) or darbepoetin alfa (2.25 μg/kg SC weekly or 500 μg SC every 3 weeks) for persistent anemia, with dose adjustments based on hemoglobin response 1, 2
Epoetin alfa can be administered as either 150 U/kg subcutaneously three times weekly or 40,000 U subcutaneously weekly, according to the American Society of Clinical Oncology and the European Society for Medical Oncology 1, 3
Darbepoetin alfa can be administered as either 2.25 μg/kg subcutaneously weekly or 500 μg subcutaneously every 3 weeks, as recommended by the American Society of Clinical Oncology 1, 2
ESA therapy should only be initiated when hemoglobin is <10 g/dL and there is a minimum of two additional months of planned chemotherapy for cancer patients, as stated by the American Society of Clinical Oncology 1

If hemoglobin increases by <1 g/dL after 4 weeks of therapy, increase epoetin alfa dose to 300 U/kg three times weekly or increase darbepoetin alfa dose to 4.5 μg/kg weekly, according to the American Society of Clinical Oncology 1, 2
If hemoglobin increases by ≥1 g/dL after 4 weeks, maintain the current dose or consider decreasing by 25-50%, as recommended by the European Society for Medical Oncology 3, 5
Decrease epoetin alfa dose by 25% or darbepoetin alfa dose by 40% when hemoglobin reaches a level needed to avoid transfusion or if hemoglobin increases >1 g/dL in any 2-week period, as stated by the American Society of Clinical Oncology 1, 2

Discontinue ESA therapy if no response (defined as <1 g/dL increase in hemoglobin) after 6-8 weeks of appropriate dosing, according to the American Society of Clinical Oncology and the European Society for Medical Oncology 1, 6
For patients who respond, discontinue ESA therapy 4 weeks after completion of chemotherapy, as recommended by the European Society for Medical Oncology 6, 3

Consider iron supplementation to improve hemoglobin response and reduce red blood cell transfusions in patients receiving ESAs, as stated by the American Society of Clinical Oncology 1, 2
Baseline and periodic monitoring of iron, total iron-binding capacity, transferrin saturation, or ferritin levels is recommended by the American Society of Clinical Oncology 1

ESAs should not be used in patients with uncontrolled hypertension or known hypersensitivity to ESAs, according to the European Society for Medical Oncology 6
Use ESAs with caution in patients with a high risk of thromboembolic events, as the relative risk is increased by 67% compared to placebo, as stated by the European Society for Medical Oncology 6
Target hemoglobin should not exceed 12 g/dL due to increased risk of cardiovascular events, as recommended by the European Society for Medical Oncology 6, 3

Continuing ESA treatment beyond 6-8 weeks in non-responders increases exposure to potential harms without benefit, according to the American Society of Clinical Oncology and the European Society for Medical Oncology 1, 6
Failure to evaluate and correct iron deficiency before or during ESA therapy may result in poor response, as stated by the American Society of Clinical Oncology 1, 2
Not monitoring hemoglobin levels regularly to guide dose adjustments can lead to excessive rises in hemoglobin and increased risk of adverse events, according to the European Society for Medical Oncology 3