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Chapter 12. Anemia

JM is a 43-year-old man with metastatic small cell lung cancer who is currently receiving chemotherapy. He was recently diagnosed with chemotherapy-induced anemia with a hemoglobin level of 7.7 g/dL and was initiated on erythropoietin therapy. 2 weeks after initiating erythropoietin, his hemoglobin level is 9.5 g/dL. Which of the following represents the most appropriate course of action for JM's erythropoietin?

a. Continue erythropoietin at the same dose.

b. Decrease the dose of erythropoietin by 25%.

c. Increase the dose of erythropoietin by 50%.

d. Discontinue the erythropoietin.

Answer b is correct. This patient had greater than 1 g/dL increase in hemoglobin 2 weeks after initiating therapy with an ESA. The appropriate course of action is a 25% dose reduction.

Answer a is incorrect. This patient has had too rapid of an increase in hemoglobin and needs to have the dose reduced.

Answer c is incorrect. This is the recommendation for dose adjustment in patients who have an inadequate increase in hemoglobin after initiation of ESA therapy.

Answer d is incorrect. The patient has benefitted from the erythropoietin therapy and continuing therapy at a lower dose is the most appropriate course of action.

MG is a 62-year-old woman with a prior medical history of chronic kidney disease (CKD), hypertension, and stage II colon cancer. Her social history is significant for a long-standing history of alcoholism. She underwent surgical resection of her primary cancer 6 months ago and is currently undergoing chemotherapy with the intent to cure her cancer. Routine laboratory monitoring revealed the patient has a hemoglobin level of 8.8 g/dL. MG's nephrologist wants to start her on an erythropoiesis-stimulating agent (ESA). Which of the following is true regarding the use of ESAs in MG?

a. Darbepoetin can be used in MG at a dose of 500 mcg every 3 weeks.

b. Epoetin can be used in MG at a dose of 40,000 units every week.

c. Darbepoetin can be used in MG at a dose of 0.45 mcg/kg every week.

d. ESAs should not be used in MG.

Answer d is correct. MG has active cancer that is being treated with curative intent. The risk-evaluation mitigation strategy for ESAs clearly indicates that these agents should not be used in patients in this setting, regardless of the cause of anemia. The reason for this contraindication is that clinical trial evidence has shown an increased risk of tumor progression in patients receiving ESAs.


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