Is an erythropoiesis-stimulating agent (ESA) injection needed if hemoglobin (Hgb) is 10 grams per deciliter (g/dL)?

From the Guidelines

An erythropoiesis-stimulating agent (ESA) injection is generally recommended when hemoglobin (Hb) approaches or falls below 10 g/dL in patients with chemotherapy-associated anemia, as it can help increase Hb and decrease transfusions 1. When considering the use of ESAs, it's crucial to evaluate the patient's specific condition, including the presence of chemotherapy-associated anemia or low-risk myelodysplasia.

• The decision to initiate ESA treatment should be based on the patient's hemoglobin level, with a threshold of 10 g/dL, as there is no evidence that starting ESAs at higher hemoglobin levels provides additional benefits in terms of transfusion sparing or quality of life improvement 1.
• It's also important to follow the package insert for starting doses and dose modifications, and to discontinue ESA therapy if there is no response after 6 to 8 weeks, assuming appropriate dose increases have been attempted 1.
• Additionally, monitoring iron stores and supplementing iron intake is recommended for ESA-treated patients, and ESAs should be used cautiously in patients with elevated risk for thromboembolic complications 1.
• The use of ESAs in patients with cancer who are not receiving chemotherapy is not recommended due to increased thromboembolic risks and decreased survival reported in recent trials 1.

From the FDA Drug Label

In controlled trials, patients experienced greater risks for death, serious adverse cardiovascular reactions, and stroke when administered erythropoiesis-stimulating agents (ESAs) to target a hemoglobin level of greater than 11 g/dL [see Warnings and Precautions (5.1)]. For adult patients with CKD on dialysis: Initiate Aranesp treatment when the hemoglobin level is less than 10 g/dL. For adult patients with CKD not on dialysis: Consider initiating Aranesp treatment only when the hemoglobin level is less than 10 g/dL

An ESA injection is not needed if the hemoglobin (Hgb) is 10 grams per deciliter (g/dL) because the treatment is typically initiated when the hemoglobin level is less than 10 g/dL 2.

From the Research

Erythropoiesis-Stimulating Agent (ESA) Injection and Hemoglobin (Hgb) Levels

• The decision to administer an ESA injection depends on the patient's hemoglobin (Hgb) level, with various studies suggesting different thresholds for treatment 3, 4, 5.
• According to a study published in 2015, ESA treatment is recommended when the Hb level becomes <11 g/dL in pre-dialysis patients and <10 g/dL in dialysis patients 3.
• Another study from 2012 suggests that ESA treatment should target hemoglobin levels of 10 to 12 g/dL in dialysis CKD patients 4.
• A 2019 study recommends maintaining Hb levels in the 10- to 11-g/dL range and using the lowest ESA doses possible to achieve a maximum Hb level of 10g/dL in patients with CKD and cancer 5.
• In the context of chemotherapy-induced anemia, the FDA has specified that ESA therapy should not be initiated in patients receiving chemotherapy at Hb levels of 10 gm per dL or higher 6.

Considerations for ESA Administration

• The route of administration, with subcutaneous administration being more effective than intravenous administration for short-acting ESAs 7.
• The dosing interval, with extended-interval dosing up to every 4 weeks being effective in a substantial majority of CKD patients, but requiring higher epoetin doses 7.
• The type of ESA used, with different ESAs having varying dosing requirements and administration intervals 7.

Hemoglobin Level of 10 g/dL

• Based on the studies, an ESA injection may not be necessary if the Hgb level is 10 g/dL, as this is within the recommended target range for some patient populations 3, 4, 5.
• However, the decision to administer an ESA injection should be individualized and based on the patient's specific clinical circumstances and medical history 3, 4, 5.