Can I give Retacrit (epoetin alfa) to a non-dialysis patient with anemia and thrombocytopenia?

Using Retacrit (Epoetin Alfa) in Non-Dialysis Patients with Anemia and Thrombocytopenia

Retacrit (epoetin alfa) should not be used in non-dialysis patients with anemia and thrombocytopenia due to increased risk of thromboembolism and lack of mortality benefit. 1

Risk Assessment and Contraindications

Erythropoiesis-stimulating agents (ESAs) like Retacrit significantly increase the risk of thromboembolism, which is particularly concerning in patients with pre-existing thrombocytopenia:

• ESAs increase thromboembolism risk by 50-75% in clinical trials 1
• Thrombocytopenia is a risk factor that may exacerbate bleeding complications if thromboembolism occurs
• The combination of increased clotting risk with decreased platelet function creates a dangerous clinical scenario

Evidence Against Use in Non-Dialysis Patients

The 2017 ACC/AHA/HFSA guideline explicitly states that "erythropoietin-stimulating agents should not be used to improve morbidity and mortality" in patients with heart failure and anemia (Class III: No Benefit recommendation) 1. This recommendation extends to other non-dialysis patients with anemia.

The ASCO/ASH clinical practice guidelines (2019) recommend:

1. ESAs should not be offered to most patients with non-chemotherapy-associated anemia 1
2. ESAs may only be considered for lower-risk myelodysplastic syndromes with serum erythropoietin levels ≤500 IU/L 1

Alternative Management Approaches

For non-dialysis patients with anemia and thrombocytopenia, consider:

1. Red blood cell transfusions for severe symptomatic anemia
2. Treat underlying causes of anemia and thrombocytopenia:
   • Iron, B12, or folate deficiency
   • Occult blood loss
   • Bone marrow disorders
   • Medication effects
   • Renal insufficiency

Diagnostic Workup Before Considering Any ESA

If ESA therapy is still being considered despite the risks, a thorough workup is mandatory:

• Complete blood count with differential
• Peripheral blood smear examination
• Iron studies (ferritin, transferrin saturation)
• Vitamin B12 and folate levels
• Reticulocyte count
• Renal function tests
• Occult blood loss assessment
• Consider bone marrow examination in selected cases 1

Special Considerations

In patients with cancer and chemotherapy-induced anemia:

• ESAs may be considered only when cancer treatment is not curative in intent
• Hemoglobin should have fallen below 10 g/dL
• Thrombocytopenia remains a significant risk factor that may contraindicate ESA use 1

Conclusion

The combination of anemia and thrombocytopenia in a non-dialysis patient represents a significant contraindication to ESA therapy due to the increased risk of thromboembolism without clear mortality benefit. Red blood cell transfusion and addressing underlying causes remain the safest approach for these patients.