Summary of recommendations
| 1. The use of epoetin is recommended as a treatment option for patients with chemotherapy-associated anemia and a hemoglobin concentration that has declined to a level less than or equal to 10 g/dL. Red blood cell transfusion is also an option depending upon the severity of anemia or clinical circumstances. |
| 2. For patients with declining hemoglobin levels but less severe anemia (those with hemoglobin concentration below 12 g/dL but who have never fallen below 10 g/dL), the decision of whether to use epoetin immediately or to wait until hemoglobin levels fall closer to 10 g/dL should be determined by clinical circumstances. Red blood cell transfusion is also a therapeutic option when warranted by severe clinical conditions. |
| 3. The recommendations are based on evidence from trials in which epoetin was administered subcutaneously thrice weekly. The recommended starting dose is 150 U/kg thrice weekly for a minimum of 4 weeks, with consideration given for dose escalation to 300 U/kg thrice weekly for an additional 4-8 weeks in those who do not respond to the initial dose. Although supported by less strong evidence, an alternative weekly dosing regimen (40 000 U/wk), based on common clinical practice, can be considered. Dose escalation of weekly regimens should be under similar circumstances to thrice-weekly regimens. |
| 4. Continuing epoetin treatment beyond 6-8 weeks in the absence of response (eg, less than 1-2 g/dL rise in hemoglobin), assuming appropriate dose increase has been attempted in nonresponders, does not appear to be beneficial. Patients who do not respond should be investigated for underlying tumor progression or iron deficiency. As with other failed individual therapeutic trials, consideration should be given to discontinuing the medication. |
| 5. Hemoglobin levels can be raised to (or near) a concentration of 12 g/dL, at which time the dosage of epoetin should be titrated to maintain that level or restarted when the level falls to near 10 g/dL. Insufficient evidence to date supports the “normalization” of hemoglobin levels to above 12 g/dL. |
| 6. Baseline and periodic monitoring of iron, total iron-binding capacity (TIBC), transferrin saturation, or ferritin levels and instituting iron repletion when indicated may be valuable in limiting the need for epoetin, maximizing symptomatic improvement for patients, and determining the reason for failure to respond adequately to epoetin. There is inadequate evidence to specify the optimal timing, periodicity, or testing regimen for such monitoring. |
| 7. There is evidence from one well-designed, placebo-controlled randomized trial that supports the use of epoetin in patients with anemia associated with low-risk myelodysplasia, but there are no published high-quality studies to support its use in anemic myeloma, non-Hodgkin lymphoma, or chronic lympocytic leukemia patients in the absence of chemotherapy. Treatment with epoetin for myeloma, non-Hodgkin lymphoma, or chronic lymphocytic leukemia patients experiencing chemotherapy-associated anemia should follow the recommendations outlined above. |
| 8. Physicians caring for patients with myeloma, non-Hodgkin lymphoma, or chronic lymphocytic leukemia are advised to begin treatment with chemotherapy and/or corticosteroids and observe the hematologic outcomes achieved solely through tumor reduction before considering epoetin. If a rise in hemoglobin is not observed following chemotherapy, epoetin should be used in accordance with the criteria outlined above for chemotherapy-associated anemia if clinically indicated. Blood transfusion is also a therapeutic option. |
| 1. The use of epoetin is recommended as a treatment option for patients with chemotherapy-associated anemia and a hemoglobin concentration that has declined to a level less than or equal to 10 g/dL. Red blood cell transfusion is also an option depending upon the severity of anemia or clinical circumstances. |
| 2. For patients with declining hemoglobin levels but less severe anemia (those with hemoglobin concentration below 12 g/dL but who have never fallen below 10 g/dL), the decision of whether to use epoetin immediately or to wait until hemoglobin levels fall closer to 10 g/dL should be determined by clinical circumstances. Red blood cell transfusion is also a therapeutic option when warranted by severe clinical conditions. |
| 3. The recommendations are based on evidence from trials in which epoetin was administered subcutaneously thrice weekly. The recommended starting dose is 150 U/kg thrice weekly for a minimum of 4 weeks, with consideration given for dose escalation to 300 U/kg thrice weekly for an additional 4-8 weeks in those who do not respond to the initial dose. Although supported by less strong evidence, an alternative weekly dosing regimen (40 000 U/wk), based on common clinical practice, can be considered. Dose escalation of weekly regimens should be under similar circumstances to thrice-weekly regimens. |
| 4. Continuing epoetin treatment beyond 6-8 weeks in the absence of response (eg, less than 1-2 g/dL rise in hemoglobin), assuming appropriate dose increase has been attempted in nonresponders, does not appear to be beneficial. Patients who do not respond should be investigated for underlying tumor progression or iron deficiency. As with other failed individual therapeutic trials, consideration should be given to discontinuing the medication. |
| 5. Hemoglobin levels can be raised to (or near) a concentration of 12 g/dL, at which time the dosage of epoetin should be titrated to maintain that level or restarted when the level falls to near 10 g/dL. Insufficient evidence to date supports the “normalization” of hemoglobin levels to above 12 g/dL. |
| 6. Baseline and periodic monitoring of iron, total iron-binding capacity (TIBC), transferrin saturation, or ferritin levels and instituting iron repletion when indicated may be valuable in limiting the need for epoetin, maximizing symptomatic improvement for patients, and determining the reason for failure to respond adequately to epoetin. There is inadequate evidence to specify the optimal timing, periodicity, or testing regimen for such monitoring. |
| 7. There is evidence from one well-designed, placebo-controlled randomized trial that supports the use of epoetin in patients with anemia associated with low-risk myelodysplasia, but there are no published high-quality studies to support its use in anemic myeloma, non-Hodgkin lymphoma, or chronic lympocytic leukemia patients in the absence of chemotherapy. Treatment with epoetin for myeloma, non-Hodgkin lymphoma, or chronic lymphocytic leukemia patients experiencing chemotherapy-associated anemia should follow the recommendations outlined above. |
| 8. Physicians caring for patients with myeloma, non-Hodgkin lymphoma, or chronic lymphocytic leukemia are advised to begin treatment with chemotherapy and/or corticosteroids and observe the hematologic outcomes achieved solely through tumor reduction before considering epoetin. If a rise in hemoglobin is not observed following chemotherapy, epoetin should be used in accordance with the criteria outlined above for chemotherapy-associated anemia if clinically indicated. Blood transfusion is also a therapeutic option. |