What is the treatment for anemia of chronic disease?

From the Guidelines

The treatment for anemia of chronic disease should prioritize addressing the underlying condition causing the anemia, with iron supplementation and erythropoiesis-stimulating agents (ESAs) used as adjunctive therapies to manage anemia, as recommended by the most recent guidelines 1. When managing anemia of chronic disease, it is essential to consider the following key points:

• Addressing the underlying condition causing the anemia is crucial, as it may involve treating chronic infections, inflammation, or malignancies.
• Iron supplementation is often necessary, especially if iron deficiency coexists with anemia, and should be given intravenously, such as iron sucrose 200mg or ferric carboxymaltose 500-1000mg, due to poor absorption of oral iron in inflammatory states.
• ESAs, like epoetin alfa or darbepoetin alfa, can be used to stimulate erythropoiesis, but their use should be titrated to maintain hemoglobin levels between 10-12 g/dL, avoiding higher levels that may increase cardiovascular risks, as noted in studies 1.
• Blood transfusions are typically reserved for patients with severe symptoms or hemoglobin levels below 7-8 g/dL. The pathophysiology of anemia of chronic disease involves inflammatory cytokines increasing hepcidin production, which blocks iron release from storage sites, reduces iron availability for red blood cell production, and directly suppresses erythropoiesis, leading to a decrease in red blood cell survival. Recent guidelines and conferences, such as the Kidney Disease: Improving Global Outcomes (KDIGO) conference 1, have emphasized the importance of optimal anemia management, including the use of iron agents, ESAs, and red cell transfusions, while also considering the potential risks and benefits of these therapies.

From the FDA Drug Label

Aranesp is indicated for the treatment of anemia due to chronic kidney disease (CKD), including patients on dialysis and patients not on dialysis. Use the lowest Aranesp dose sufficient to reduce the need for red blood cell (RBC) transfusions Evaluate the iron status in all patients before and during treatment. Administer supplemental iron therapy when serum ferritin is less than 100 mcg/L or when serum transferrin saturation is less than 20%. Individualize dosing and use the lowest dose of Aranesp sufficient to reduce the need for RBC transfusions

The treatment for anemia of chronic disease includes using the lowest dose of darbepoetin alfa sufficient to reduce the need for red blood cell (RBC) transfusions. It is essential to:

• Evaluate iron stores and administer supplemental iron therapy when necessary
• Individualize dosing to minimize risks
• Monitor hemoglobin levels regularly to adjust the dose as needed 2

From the Research

Treatment Recommendations for Anemia of Chronic Disease

The treatment for anemia of chronic disease involves addressing the underlying condition and correcting the anemia. Key aspects of treatment include:

• Supplementation with iron, folic acid, and vitamin B12, as well as a diet rich in these hematopoietic factors 3
• The route of administration (oral, intramuscular, or intravenous) should be carefully considered based on the patient's clinical status and the potential benefits and side effects 3, 4
• Intravenous iron may be considered for patients with chronic diseases, as it can be given safely and has better efficacy compared to oral iron in chronic anemia 4
• Erythropoiesis-stimulating agents (ESAs) may also be beneficial for patients with anemia of chronic disease 4, 5
• New treatment options, such as hypoxia-inducible factor-prolyl hydroxylase (HIF-PH) inhibitors, are being developed and may be particularly useful for difficult-to-treat patients with anemia of chronic kidney disease 6

Treatment Goals and Considerations

The primary goal of treatment is to restore patient functionality and quality of life by restoring effective red cell production. Treatment should be individualized based on the patient's underlying disease, severity of anemia, and response to therapy. Key considerations include:

• Controlling the underlying disease and correcting anemia 5
• Monitoring hemoglobin levels and adjusting treatment as needed to maintain optimal levels 7
• Managing potential side effects and complications of treatment, such as iron overload or adverse reactions to ESAs 4, 6

Emerging Therapies and Future Directions

Research is ongoing to develop new treatments for anemia of chronic disease, including targeted therapies that address the underlying pathophysiology of the condition. These emerging therapies may offer improved efficacy and safety compared to current treatments, and may be particularly beneficial for patients with difficult-to-treat anemia 3, 5, 6