What is the treatment for chemotherapy-induced anemia?

Treatment for Chemotherapy-Induced Anemia

Erythropoiesis-stimulating agents (ESAs) are the primary treatment for chemotherapy-induced anemia when hemoglobin levels fall below 10 g/dL, with iron supplementation (preferably intravenous) as an important adjunctive therapy. 1

Initial Assessment Before Treatment

Before initiating treatment for chemotherapy-induced anemia, evaluate for:

• Alternative causes of anemia through:
  • Drug exposure history
  • Peripheral blood smear review
  • Iron studies (ferritin, transferrin saturation)
  • Vitamin B12 and folate levels
  • Assessment for occult blood loss and renal insufficiency
  • Coombs testing (for patients with chronic lymphocytic leukemia, non-Hodgkin lymphoma, or history of autoimmune disease)

Treatment Algorithm

Step 1: Determine Hemoglobin Level and Assess Iron Status

• Hemoglobin ≤ 10 g/dL: Consider ESA therapy with iron supplementation 1
• Hemoglobin 10-12 g/dL: Consider ESA only if symptomatic or to prevent further decline 1
• Check iron status: Assess ferritin and transferrin saturation before starting ESA 1
  • If iron deficient (ferritin <100 ng/mL or TSAT <20%), provide iron supplementation

Step 2: ESA Selection and Dosing

Both epoetin alfa and darbepoetin alfa are considered equivalent in effectiveness and safety 1.

Epoetin alfa options:

• 150 IU/kg subcutaneously three times weekly
• 40,000 units subcutaneously once weekly
• 80,000 units subcutaneously every 2 weeks
• 120,000 units subcutaneously every 3 weeks 1

Darbepoetin alfa options:

• 2.25 μg/kg subcutaneously weekly
• 500 μg subcutaneously every 3 weeks 1

Step 3: Iron Supplementation

• Intravenous iron is preferred over oral iron for patients receiving ESAs 1, 2
• Options include:
  • Iron sucrose: 200 mg IV weekly for 5 doses
  • Ferric carboxymaltose: 1,000 mg IV over 10 minutes
  • Sodium ferric gluconate: 125 mg IV weekly for 8 doses 1

Step 4: Monitoring and Dose Adjustments

• Monitor hemoglobin weekly after initiation and after each dose adjustment until stable 3
• If Hb increase <1 g/dL after 4 weeks: Increase ESA dose according to product guidelines 1
• If Hb increase ≥1 g/dL: Maintain dose or decrease by 25-50% 1
• If Hb rises >2 g/dL in 4 weeks or exceeds 12 g/dL: Reduce dose by 25-50% 1
• If Hb exceeds 13 g/dL: Discontinue until Hb falls below 12 g/dL, then restart at 25% lower dose 1
• If no response after 8-9 weeks: Discontinue ESA therapy 1

Step 5: Duration of Therapy

• Discontinue ESA 4 weeks after completing chemotherapy 1
• Do not continue beyond 6-8 weeks if there is no response (defined as Hb increase <1 g/dL) 1

Special Considerations

Thromboembolism Risk

ESAs increase the risk of thromboembolism by 67% 1. Use with caution in patients with:

• Previous history of thrombosis
• Surgery or prolonged immobilization
• Multiple myeloma patients on thalidomide/lenalidomide plus doxorubicin/corticosteroids 1

Contraindications for ESA Use

• Uncontrolled hypertension
• Pure Red Cell Aplasia following previous ESA treatment
• Cancer patients not receiving chemotherapy
• Cancer patients receiving curative-intent treatment (use with caution) 1, 3

Red Blood Cell Transfusion

Consider RBC transfusion as an alternative to ESA therapy in:

• Patients with severe anemia requiring immediate correction
• Patients who have failed to respond to ESA therapy
• Patients with contraindications to ESA therapy 1

Common Pitfalls to Avoid

1. Targeting hemoglobin >12 g/dL: This increases mortality and thromboembolic risk 1, 3
2. Neglecting iron status: Up to 42% of cancer patients have low iron levels; failure to correct iron deficiency reduces ESA efficacy 1, 4, 2
3. Using ESAs in non-chemotherapy settings: ESAs should only be used for anemia due to concurrent myelosuppressive chemotherapy 3
4. Continuing ineffective ESA therapy: Discontinue if no response after 8-9 weeks 1
5. Overlooking vitamin deficiencies: Check and correct B12 and folate deficiencies before or during ESA therapy 1

By following this structured approach to chemotherapy-induced anemia, you can effectively improve hemoglobin levels, reduce transfusion requirements, and potentially enhance quality of life while minimizing risks associated with ESA therapy.