What is the treatment for anemia of chronic disease?

From the Guidelines

The treatment for anemia of chronic disease should primarily focus on addressing the underlying condition causing the anemia, and when specific treatment is needed for the anemia itself, intravenous iron therapy is recommended, as it has been shown to increase hemoglobin levels and improve morbidity and survival in patients with chronic kidney disease 1. The most effective approach is to treat the primary disease process, such as infection, inflammation, or malignancy. When specific treatment is needed for the anemia itself, recombinant human erythropoietin (EPO) therapy is often used, typically at doses of 50-300 units/kg three times weekly subcutaneously, adjusted based on hemoglobin response.

• Iron supplementation may be beneficial in cases of absolute iron deficiency, but is generally less effective in anemia of chronic disease due to the functional iron deficiency caused by hepcidin-mediated iron sequestration.
• Intravenous iron (such as iron sucrose 200mg or ferric carboxymaltose 500-1000mg) is preferred over oral formulations when supplementation is needed, as it can provide a more rapid and effective increase in iron stores 1. The pathophysiology involves inflammatory cytokines disrupting normal iron metabolism and reducing erythropoietin production and effectiveness, which explains why simply providing iron supplements often fails to resolve the anemia. Regular monitoring of hemoglobin levels and iron studies is essential to assess treatment response and adjust therapy accordingly. In some cases, erythropoietic therapy may be considered when anemia does not improve with intravenous iron therapy and control of inflammation, and treatment with erythropoiesis-stimulating agents (ESA) can be a valid option, especially when combined with intravenous iron supplementation 1.

From the FDA Drug Label

1.1 Anemia Due to Chronic Kidney Disease Aranesp is indicated for the treatment of anemia due to chronic kidney disease (CKD), including patients on dialysis and patients not on dialysis.

1.1 Anemia Due to Chronic Kidney Disease Epogen is indicated for the treatment of anemia due to chronic kidney disease (CKD), including patients on dialysis and not on dialysis to decrease the need for red blood cell (RBC) transfusion.

The treatment for anemia of chronic disease is not directly addressed in the provided drug labels. However, the labels do discuss the treatment of anemia due to chronic kidney disease (CKD), which can be a cause of anemia of chronic disease.

• Darbepoetin alfa (PO) and epoetin alfa (PO) are indicated for the treatment of anemia due to CKD, including patients on dialysis and not on dialysis.
• The goal of treatment is to decrease the need for red blood cell (RBC) transfusions.
• It is essential to individualize dosing and use the lowest dose sufficient to reduce the need for RBC transfusions 2.
• Supplemental iron therapy should be administered when serum ferritin is less than 100 mcg/L or when serum transferrin saturation is less than 20% 2.
• Hemoglobin levels should be monitored at least weekly until stable, then at least monthly 2.

From the Research

Treatment Options

• The basic form of treatment for anemia of chronic diseases remains 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) requires careful consideration of the benefits and possible side effects, and assessment of the patient's clinical status 3.
• New methods of treating both the underlying disease and anemia are raising hopes, including the administration of drugs molecularly targeted to specific proteins or receptors involved in the development of anemia of chronic diseases 3.

Targeted Therapies

• Hypoxia-inducible factor-prolyl hydroxylase (HIF-PH) inhibitors may be particularly useful for difficult-to-treat patients with anemia of chronic kidney disease, providing increased hemoglobin levels and improved iron utilization 4.
• HIF-PH inhibitors may be equally effective in patients with or without underlying inflammation 4.

Iron Therapy

• Iron therapy is essential when using erythropoietin to maximize erythropoiesis by avoiding absolute and functional iron deficiency 5.
• Body iron stores are best maintained by providing 800-1200 mg of iron intravenously in a year, or more if blood loss is significant 5.
• Iron gluconate and iron sucrose are the safest intravenous medications 5.

Treatment of Underlying Conditions

• The recommended approach is the treatment of the underlying disease, which can lead to a major improvement or even resolution of anemia of chronic disease 6.
• Currently available treatments (transfusion, iron, and erythropoiesis-stimulating agents) can ameliorate anemia, but a considerable percentage of non-responders exist 6.
• Anemia in the setting of inflammatory bowel disease should be aggressively diagnosed, investigated, and treated, with a focus on iron deficiency and anemia of chronic disease 7.