Updated guidelines suggest caution with chemo-induced anemia

Physicians need to use caution when giving erythropoiesis-stimulating agents (ESAs) to cancer patients who have chemotherapy-induced anemia, according to new guidelines.

With rare exceptions, ESAs should not be given to cancer patients who are not receiving chemotherapy, according to joint guidelines issued by the American Society of Hematology and the American Society of Clinical Oncology.

Clinicians should discuss potential harms and benefits of ESAs and of red blood cell transfusions with patients undergoing myelosuppressive chemotherapy who have hemoglobin of 10 g/dL or less. Individual preferences for assumed risk should contribute to shared decisions on managing chemotherapy-induced anemia. Risks include mortality, venous thromboembolism, tumor progression and stroke.

If used, ESAs should be administered at the lowest dose possible and should raise hemoglobin levels to the lowest concentration possible to avoid transfusions. Available evidence does not validate hemoglobin levels between 10 g/dL and 12 g/dL either as thresholds for starting treatment or as therapy targets for ESA.

Starting doses and dose modifications after response or nonresponse should follow Food and Drug Administration-approved labeling. The FDA-approved starting dose of epoetin is 150 U/kg three times a week or 40,000 U weekly subcutaneously. The FDA-approved starting dose of darbepoetin is 2.25 µg/kg weekly or 500 µg every 3 weeks subcutaneously.

ESAs should be discontinued after six to eight weeks in nonresponders. The committee cautioned against ESA use under other circumstances. ESAs should be avoided in cancer patients not receiving chemotherapy, except for those with lower-risk myelodysplastic syndromes.

The updated guidelines appeared online Oct. 25 ahead of print in the Nov. 18 issue of Blood and the Nov. 20 issue of the Journal of Clinical Oncology.