Management of Anemia in Patients on Hormone Therapy

Initial Assessment and Management

For a patient with low hemoglobin levels on hormone therapy, erythropoiesis-stimulating agent (ESA) therapy is recommended after correction of iron deficiency and other underlying causes of anemia, according to the European Society for Medical Oncology 1, 2, 3
Evaluate for iron deficiency and other correctable causes of anemia before initiating ESA therapy, as recommended by the European Society for Medical Oncology 1, 2
Check iron studies including serum ferritin and transferrin saturation (TSAT) to diagnose absolute or functional iron deficiency 3
Absolute iron deficiency is defined as serum ferritin < 100 ng/mL, while functional iron deficiency is defined as TSAT < 20% and serum ferritin > 100 ng/mL 2, 3
The American Society of Clinical Oncology recommends that patients with hemoglobin levels < 8 g/dL in the absence of symptoms may be considered for ESA therapy 1, 3

If iron deficiency is identified, administer intravenous iron before initiating ESA therapy, as recommended by the European Society for Medical Oncology 1, 3
For absolute iron deficiency, administer IV iron according to approved product labels until correction of deficiency 3
For functional iron deficiency, administer 1000 mg iron as single or multiple doses according to available IV iron formulations 3
Oral iron is less effective and may not be adequate to support erythropoiesis during ESA therapy, according to the European Society for Medical Oncology 3

The recommended ESA dosing is approximately 450 IU/week/kg body weight for epoetin alpha, beta, or zeta, as recommended by the European Society for Medical Oncology 1, 2, 3
Darbepoetin alpha dosing is 6.75 mg/kg body weight every 3 weeks or 2.25 mg/kg body weight weekly 1
Epoetin theta dosing is 20,000 IU once weekly 1
The target hemoglobin level should be a stable 12 g/dL without requiring red blood cell transfusions, as recommended by the European Society for Medical Oncology 1, 3
Avoid hemoglobin rise of > 2 g/dL over a 4-week period, as recommended by the American Society of Clinical Oncology 4

For patients with low hemoglobin levels or severe anemia-related symptoms, red blood cell transfusions are justified, according to the American Society of Clinical Oncology 3, 5
Transfuse only the minimum number of RBC units necessary to relieve symptoms or return to a safe hemoglobin range (7-8 g/dL) 5

Monitor hemoglobin levels regularly during therapy, at least every three months while on hormone therapy, as recommended by the National Kidney Foundation 6
Check hemoglobin at least every three months while on hormone therapy, and more frequently during initial ESA therapy 3, 6
Evaluate for symptoms of anemia at each visit, including fatigue, weakness, decreased exercise tolerance, and dyspnea, as recommended by the European Society for Medical Oncology 7

ESA therapy should be used cautiously as it may affect mortality in cancer patients if target hemoglobin levels exceed 12 g/dL, according to the European Society for Medical Oncology 4, 7
Avoid ESA therapy in patients with active malignancy who are not receiving chemotherapy, as recommended by the European Society for Medical Oncology 1, 3