What are the causes and management of post-operative anemia following total joint arthroplasty (Total Joint Replacement)

From the Guidelines

Post-operative anemia following total arthroplasty should be managed with a combination of iron supplementation and blood transfusions when necessary, with a focus on preoperative optimization and regular monitoring of hemoglobin levels to reduce morbidity, mortality, and improve quality of life. The management of post-operative anemia involves identifying the cause and type of anemia, and correcting it preoperatively 1. For patients with iron deficiency anemia, oral or intravenous iron can be used, with intravenous iron being more effective at restoring hemoglobin concentrations 1.

Key Considerations

• Preoperative optimization with iron supplementation and erythropoietin can reduce post-operative anemia risk 1
• Regular monitoring of hemoglobin levels, typically on post-operative days 1,2, and prior to discharge, helps guide management decisions and ensures appropriate treatment
• Blood transfusions are generally reserved for hemoglobin levels below 7-8 g/dL or for symptomatic patients 1

Treatment Options

• Oral iron supplementation with ferrous sulfate 325 mg three times daily or ferrous gluconate 325 mg twice daily for 4-6 weeks for mild to moderate anemia (hemoglobin 8-10 g/dL)
• Intravenous iron, such as iron sucrose 200 mg IV or ferric carboxymaltose 750-1000 mg as a single dose, for patients with more severe anemia (hemoglobin <8 g/dL) or those with symptoms like dizziness, tachycardia, or hypotension
• Blood transfusions for symptomatic anemia, with a goal of improving hemoglobin levels and reducing symptoms 1 The recent PREVENTT trial showed that the use of intravenous iron in patients with all types of anemia before major open elective abdominal surgery increased hemoglobin concentrations before surgery but did not reduce the frequency of blood transfusion, mortality, in hospital complications, length of stay or quality of life relative to a placebo 1. However, a 2021 systematic review showed that preoperative IV iron supplementation decreased blood transfusion by 16% and was not associated with increased incidence of any adverse effects across the groups 1. Overall, the management of post-operative anemia following total arthroplasty requires a comprehensive approach that includes preoperative optimization, regular monitoring of hemoglobin levels, and appropriate treatment with iron supplementation and blood transfusions when necessary.

From the FDA Drug Label

The safety and efficacy of epoetin alfa were evaluated in a placebo-controlled, double-blind study (S1) enrolling 316 patients scheduled for major, elective orthopedic hip or knee surgery who were expected to require ≥ 2 units of blood and who were not able or willing to participate in an autologous blood donation program Treatment with epoetin alfa 300 Units/kg significantly (p = 0. 024) reduced the risk of allogeneic RBC transfusion in patients with a pretreatment hemoglobin of > 10 to ≤ 13 g/dL; The mean number of units transfused per epoetin alfa-treated patient (0.45 units blood for 300 Units/kg, 0.42 units blood for 100 Units/kg) was less than the mean transfused per placebo-treated patient (1.14 units) (overall p = 0. 028)

Postoperative Anemia Management: Epoetin alfa can be used to reduce the risk of allogeneic red blood cell (RBC) transfusion in patients undergoing major elective orthopedic hip or knee surgery, particularly those with a pretreatment hemoglobin level of > 10 to ≤ 13 g/dL 2.

• The recommended dose is 300 Units/kg subcutaneously for 10 days before surgery, on the day of surgery, and for 4 days after surgery.
• Patients should also receive oral iron and a low-dose, postoperative warfarin regimen.
• The use of epoetin alfa in patients with a pretreatment hemoglobin level of ≤ 10 g/dL is not well established due to limited data 2.

From the Research

Postoperative Anemia in Total Arthroplasty

• Postoperative anemia is a significant concern in total arthroplasty, associated with substantial morbidity and mortality 3.
• Iron supplementation has been investigated as a potential strategy to address postoperative anemia and reduce the need for blood transfusion.

Iron Supplementation

• Intraoperative and postoperative intravenous iron supplementation has been shown to improve postoperative hemoglobin levels and reduce the rates of postoperative anemia 3, 4.
• Oral iron supplementation has not been found to be effective in improving postoperative hemoglobin levels or reducing the rates of postoperative anemia 3, 5.
• High-dose intravenous iron supplementation has been found to be more effective than low-dose iron supplementation in reducing postoperative hemoglobin drop and blood transfusion rate 4.

Timing and Dose of Iron Supplementation

• The optimal timing and dose of iron supplementation are not clearly established, but high-dose intravenous iron supplementation has been found to be effective in reducing postoperative hemoglobin drop and blood transfusion rate 4.
• Preoperative iron supplementation has been found to reduce the burden of perioperative anemia and reduce the utilization of other blood-conserving therapies 6.

Combination Therapy

• The combination of iron supplementation with erythropoiesis-stimulating agents (ESAs) has been found to be effective in reducing red blood cell utilization in patients with preoperative anemia undergoing elective surgery 7.
• Oral iron supplementation with ESAs has been found to probably result in a reduced number of patients transfused and number of units transfused, while intravenous iron supplementation with ESAs may result in a reduced number of patients transfused 7.