Treatment options for managing anemia of cancer or chemotherapy
| . | Dosage . | Cancer indication . | Comments . |
|---|---|---|---|
| IV iron products | |||
| Ferric gluconate | 125 mg over 60 minutes | No | Associated with serious infusion reactions |
| Repeat doses over 2 to 3 weeks to achieve 1000-mg total dose | |||
| Ferric carboxymaltose | 750 mg over 7.5 minutes as slow IV push or over ≥15 minutes as infusion | No | Broad indication for iron deficiency |
| May consider a repeat dose in ≥7 days | Transient hypophosphatemia is a common adverse reaction | ||
| Ferumoxytol | 510 mg over ≥15 minutes | No | Broad indication for iron deficiency |
| Repeat dose in ≥3 days | Affects MRI interpretation | ||
| Black-box warning for hypersensitivity | |||
| Ferric derisomaltose (also known as iron isomaltoside) | For patients ≥50 kg give 1000 mg over ≥20 minutes. For patients weighing <50 kg give 20 mg/kg using actual body weight over ≥20 minutes | No | Broad indication for iron deficiency |
| Up to 1500 mg in divided doses (eg, 1000 mg + 500 mg). A dose of 500 mg can be given over ~2 minutes ≥7 days after initial dose | Approved in the United States in early 2020 | ||
| Iron sucrose | 200 mg over 5 minutes or 300 mg over 90 minutes | No | Most commonly used IV iron product in the United States |
| Repeat dosing over 3 to 5 weeks to achieve 900- to 1000-mg total dose target | |||
| LMW iron dextran | 1000 mg over 1 to 2 hours most common | No | Broad indication for iron deficiency |
| Dosing range, 100 to 2000 mg | Black-box warning for hypersensitivity | ||
| Doses exceeding 100 mg are not FDA-approved but have been the generally accepted practice for more than 3 decades | Test dose (25 mg/0.5 mL) required before the first infusion | ||
| Doses up to 100 mg may be infused undiluted, rate not to exceed 50 mg/minute | |||
| Total dose infusion (up to 2000 mg per dose) possible | |||
| Oral iron products | |||
| Oral iron salts may vary. | Ferrous sulfate 325 mg (65 mg elemental) orally once per day to 3 times per day, as tolerated. | No | May use up to 195 mg elemental iron daily; dose and frequency vary per patient tolerance. Preparations containing less elemental iron per dose may cause less gastrointestinal upset |
| ESAs | |||
| Epoetin alfa (and biosimilars) | Practice-based fixed dosing: 40 000 units SC once per week or 80 000 units SC once every 2 weeks or 120 000 units SC once every 3 weeks | Yes | ESAs indicated for chemotherapy-induced anemia, not anemia from cancer alone |
| FDA-approved dosing: 150 units/kg SC 3 times per week or 40 000 units SC once per week | Use the lowest dose for patients with chronic kidney disease–induced anemia and consider risk of tumor progression in this population | ||
| Darbepoetin alfa | Practice-based fixed dosing: 200 μg SC once every 2 weeks or 300 μg SC once every 3 weeks or 500 μg SC once every 3 weeks | Yes | ESAs indicated for chemotherapy-induced anemia, not anemia from cancer alone |
| FDA-approved dosing: 2.25 μg/kg SC once every week or 500 μg SC once every 3 weeks | Use the lowest dose for patients with chronic kidney disease–induced anemia and consider risk of tumor progression in this population | ||
| B vitamins | |||
| Folic acid (vitamin B9) | 1 mg orally once per day | No | May use over-the-counter preparations |
| Cyanocobalamin (vitamin B12) | 1000 μg SC (deep) or intramuscular injection on days 1,3,7,10, 14, 21, 30, and every 30 days thereafter or 2000 μg orally once per day | No | Schedule of parenteral cyanocobalamin is variable.31 Intramuscular/SC vitamin B12 can be self-administered at home |
| Androgens | |||
| Testosterone | Dosage variable and based upon formulation; available as oral, buccal, topical (gel, solution, or patch), intranasal, subcutaneous pellet, and intramuscular preparations | No | Used in myeloproliferative neoplasm and bone marrow transplant patients. Consider topical route in patients with thrombocytopenia. Response typically seen within 3 months |
| Danazol | 200 mg orally 3 times per day or 400 mg orally twice per day | No | Used in patients with myeloproliferative neoplasms; response typically seen within 3 months |
| . | Dosage . | Cancer indication . | Comments . |
|---|---|---|---|
| IV iron products | |||
| Ferric gluconate | 125 mg over 60 minutes | No | Associated with serious infusion reactions |
| Repeat doses over 2 to 3 weeks to achieve 1000-mg total dose | |||
| Ferric carboxymaltose | 750 mg over 7.5 minutes as slow IV push or over ≥15 minutes as infusion | No | Broad indication for iron deficiency |
| May consider a repeat dose in ≥7 days | Transient hypophosphatemia is a common adverse reaction | ||
| Ferumoxytol | 510 mg over ≥15 minutes | No | Broad indication for iron deficiency |
| Repeat dose in ≥3 days | Affects MRI interpretation | ||
| Black-box warning for hypersensitivity | |||
| Ferric derisomaltose (also known as iron isomaltoside) | For patients ≥50 kg give 1000 mg over ≥20 minutes. For patients weighing <50 kg give 20 mg/kg using actual body weight over ≥20 minutes | No | Broad indication for iron deficiency |
| Up to 1500 mg in divided doses (eg, 1000 mg + 500 mg). A dose of 500 mg can be given over ~2 minutes ≥7 days after initial dose | Approved in the United States in early 2020 | ||
| Iron sucrose | 200 mg over 5 minutes or 300 mg over 90 minutes | No | Most commonly used IV iron product in the United States |
| Repeat dosing over 3 to 5 weeks to achieve 900- to 1000-mg total dose target | |||
| LMW iron dextran | 1000 mg over 1 to 2 hours most common | No | Broad indication for iron deficiency |
| Dosing range, 100 to 2000 mg | Black-box warning for hypersensitivity | ||
| Doses exceeding 100 mg are not FDA-approved but have been the generally accepted practice for more than 3 decades | Test dose (25 mg/0.5 mL) required before the first infusion | ||
| Doses up to 100 mg may be infused undiluted, rate not to exceed 50 mg/minute | |||
| Total dose infusion (up to 2000 mg per dose) possible | |||
| Oral iron products | |||
| Oral iron salts may vary. | Ferrous sulfate 325 mg (65 mg elemental) orally once per day to 3 times per day, as tolerated. | No | May use up to 195 mg elemental iron daily; dose and frequency vary per patient tolerance. Preparations containing less elemental iron per dose may cause less gastrointestinal upset |
| ESAs | |||
| Epoetin alfa (and biosimilars) | Practice-based fixed dosing: 40 000 units SC once per week or 80 000 units SC once every 2 weeks or 120 000 units SC once every 3 weeks | Yes | ESAs indicated for chemotherapy-induced anemia, not anemia from cancer alone |
| FDA-approved dosing: 150 units/kg SC 3 times per week or 40 000 units SC once per week | Use the lowest dose for patients with chronic kidney disease–induced anemia and consider risk of tumor progression in this population | ||
| Darbepoetin alfa | Practice-based fixed dosing: 200 μg SC once every 2 weeks or 300 μg SC once every 3 weeks or 500 μg SC once every 3 weeks | Yes | ESAs indicated for chemotherapy-induced anemia, not anemia from cancer alone |
| FDA-approved dosing: 2.25 μg/kg SC once every week or 500 μg SC once every 3 weeks | Use the lowest dose for patients with chronic kidney disease–induced anemia and consider risk of tumor progression in this population | ||
| B vitamins | |||
| Folic acid (vitamin B9) | 1 mg orally once per day | No | May use over-the-counter preparations |
| Cyanocobalamin (vitamin B12) | 1000 μg SC (deep) or intramuscular injection on days 1,3,7,10, 14, 21, 30, and every 30 days thereafter or 2000 μg orally once per day | No | Schedule of parenteral cyanocobalamin is variable.31 Intramuscular/SC vitamin B12 can be self-administered at home |
| Androgens | |||
| Testosterone | Dosage variable and based upon formulation; available as oral, buccal, topical (gel, solution, or patch), intranasal, subcutaneous pellet, and intramuscular preparations | No | Used in myeloproliferative neoplasm and bone marrow transplant patients. Consider topical route in patients with thrombocytopenia. Response typically seen within 3 months |
| Danazol | 200 mg orally 3 times per day or 400 mg orally twice per day | No | Used in patients with myeloproliferative neoplasms; response typically seen within 3 months |
FDA, US Food and Drug Administration; MRI, magnetic resonance imaging; SC, subcutaneously.