When should Epoetin alfa (Epogen) be taken?

From the Guidelines

Epoetin alfa (Epogen) should be taken as prescribed by your healthcare provider, typically administered as an injection either subcutaneously (under the skin) or intravenously (into a vein), with the most common dosing schedule being three times a week, and the dosage should be titrated to maintain a hemoglobin level of 12 g/dL or restarted when the level falls to near 10 g/dL 1.

Dosing Schedule

The dosing schedule for Epoetin alfa (Epogen) may vary depending on the patient's condition and response to treatment. Some patients may be prescribed a once-weekly or once-every-two-weeks regimen.

• The FDA-approved starting dose of epoetin is 150 U/kg three times a week or 40,000 U weekly subcutaneously 1.
• Dose escalation should follow FDA-approved labeling, and no convincing evidence exists to suggest that differences in dose-escalation schedules are associated with different effectiveness 1.

Storage and Administration

• The medication should be stored in a refrigerator (36°F to 46°F) and protected from light, but never frozen 1.
• Before administration, allow the medication to reach room temperature (do not warm artificially) and inspect for particles or discoloration.

Monitoring and Titration

• Baseline and periodic monitoring of iron, total iron-binding capacity, transferrin saturation, or ferritin levels and instituting iron repletion when indicated may help to reduce the need for ESAs, maximize symptomatic improvement for patients, and determine the reason for failure to respond adequately to ESA therapy 1.
• Hb can be increased to the lowest concentration needed to avoid transfusions, which may vary by patient and condition, and modification to reduce the ESA dose is appropriate when Hb reaches a level sufficient to avoid transfusion or the increase exceeds 1 g/dL in any 2-week period to avoid excessive ESA exposure 1.

Important Considerations

• Continuing epoetin treatment beyond 6 to 8 weeks in the absence of response does not seem to be beneficial, assuming an appropriate dose increase has been attempted in nonresponders as per the FDA-approved label, and ESA therapy should be discontinued 1.
• Patients who do not respond should be investigated for underlying tumor progression, iron deficiency, or other etiologies for anemia 1.

From the FDA Drug Label

For correction of anemia in hemodialysis patients, a greater biologic response is not observed at doses exceeding 300 Units/kg 3 times weekly. In clinical studies of patients with CKD on dialysis, epoetin alfa increased hemoglobin levels and decreased the need for RBC transfusion. In clinical studies at starting doses of 50 to 150 Units/kg 3 times weekly, adult patients responded with an average rate of hemoglobin rise The median maintenance dose necessary to maintain the hemoglobin between 10 to 12 g/dL was approximately 75 Units/kg 3 times weekly.

The dosing frequency of Epoetin alfa (Epogen) is 3 times weekly.

• The typical dose is between 50 to 150 Units/kg.
• The median maintenance dose is approximately 75 Units/kg. 2

From the Research

Administration of Epoetin Alfa (Epogen)

• Epoetin alfa (Epogen) should be administered when the hemoglobin (Hb) level is below 11-12 g/dL 3.
• The target Hb concentration to be attained is 11 g/dL, with an upper limit established individually on a clinical basis 3.
• The dosage of epoetin is individual, with more than tenfold variability among individuals, and should be adjusted to achieve the target Hb concentration 3.
• Epoetin can be administered subcutaneously, which has been shown to be effective and convenient, with a lower dosing frequency and reduced cost compared to intravenous administration 4.

Dosing Frequency and Route of Administration

• The dosing frequency of epoetin can be reduced to once every 2 weeks in some patients, without compromising efficacy, when administered subcutaneously 4.
• Subcutaneous administration of epoetin has been shown to have a higher efficacy and lower cost compared to intravenous administration 4.
• The route of administration should be chosen based on individual patient needs and preferences, with subcutaneous administration being the preferred route in many cases 4.

Monitoring and Adjustment of Epoetin Dose

• The Hb concentration and reticulocyte count should be checked weekly following initiation of epoetin treatment and monthly during maintenance 3.
• The epoetin dose should be adjusted as needed to achieve and maintain the target Hb concentration, with a therapeutic range of up to 100,000 IU/week 3.
• Patients with a stable dose-response during conservative therapy may require less frequent monitoring (every 2-3 months) 3.

Special Considerations

• Patients with cardiovascular disease, diabetes, and graft access should have their Hb levels maintained below 12 g/dL 3.
• Patients with CKD and cancer should receive the lowest ESA doses possible that achieve a maximum Hb level of 10 g/dL 5.
• Iron supplements should be used in conjunction with epoetin to maintain adequate iron stores and prevent iron deficiency anemia 3, 6, 7.