From the Guidelines
For anemic Jehovah's Witness patients who refuse blood transfusions, I recommend iron supplementation and erythropoiesis-stimulating agents (ESAs) as the primary treatment options. According to the most recent and highest quality study available 1, iron supplementation should be given to patients with absolute iron deficiency, and ESAs can be considered in patients with symptomatic anemia who are receiving chemotherapy. The study recommends that the Hb target range for treatment with an ESA is a stable level of 12 g/dL without RBC transfusions.
Treatment Options
- Iron supplementation: ferrous sulfate 325mg orally three times daily or ferrous gluconate 300mg orally twice daily
- ESAs: epoetin alfa 150-300 units/kg subcutaneously three times weekly
- Vitamin supplements: folate 1mg daily and vitamin B12 1000mcg monthly if deficient
- Intravenous iron: iron sucrose 200mg or ferric carboxymaltose 750-1000mg may be used for faster repletion in severe cases
Considerations
- Minimize blood draws and use pediatric collection tubes to reduce blood loss
- Consider cell salvage techniques during surgery
- A hematology consultation is advisable for severe anemia
- Always document the patient's specific blood product refusals and acceptable alternatives in the medical record
The study also notes that patients who do not respond to ESA therapy within 4-8 weeks should stop ESA therapy, except for patients receiving epoetin theta, who may have their dose doubled after 4 weeks if Hb has not increased by at least 1 g/dL 1. Additionally, the study recommends that iron treatment should be given before the initiation of and/or during ESA therapy in the case of functional iron deficiency 1.
It's worth noting that other studies, such as 1, 1, 1, and 1, also support the use of iron supplementation and ESAs in the treatment of anemia in patients who refuse blood transfusions. However, the most recent and highest quality study available 1 provides the most up-to-date guidance on the use of these treatments.
From the FDA Drug Label
DOSAGE AND ADMINISTRATION Avoid using the intravenous route. Use of this product intravenously will result in almost all of the vitamin being lost in the urine. Pernicious Anemia Parenteral vitamin B12 is the recommended treatment and will be required for the remainder of the patient's life. The oral form is not dependable A dose of 100 mcg daily for 6 or 7 days should be administered by intramuscular or deep subcutaneous injection. If there is clinical improvement and if a reticulocyte response is observed, the same amount may be given on alternate days for seven doses, then every 3 to 4 days for another 2 to 3 weeks. By this time hematologic values should have become normal This regimen should be followed by 100 mcg monthly for life. Folic acid should be administered concomitantly if needed.
For an anemic patient who is a Jehovah's Witness, vitamin B12 can be given as an alternative to blood transfusions. The recommended dose is 100 mcg daily for 6 or 7 days administered by intramuscular or deep subcutaneous injection 2. Folic acid should also be administered concomitantly if needed.
From the Research
Treatment Options for Anemic Jehovah's Witness Patients
- Erythropoietin-stimulating agents and intravenous iron can be used to augment erythropoiesis and restore endogenous hemoglobin levels in Jehovah's Witness patients with life-threatening anemia 3.
- Hemoglobin-based oxygen carriers (HBOCs) can be used to supplement oxygen-carrying capacity in patients with severe anemia (Hb <5 g/dL) 3.
- High-dose recombinant human erythropoietin can be administered to increase hemoglobin levels in anemic patients 4, 5.
- Bovine hemoglobin substitutes can be used as an initial therapy to maintain tissue oxygen delivery while awaiting the maximal effect of recombinant erythropoietin on bone marrow red blood cell production 4.
Pharmacotherapy in Acutely Anemic Jehovah's Witnesses
- High-dose erythropoietin, intravenous iron supplementation, and hemostatic agents have demonstrated good clinical outcomes in case reports 5.
- Erythropoietin doses as high as 40,000 units daily have been advocated by some experts, but pharmacokinetic studies do not support dose-dependent effects 5.
- Hemoglobin-based oxygen carriers (HBOCs) are currently not FDA approved, but may represent a lifesaving modality in the setting of severe anemia 5.
Erythropoietin Treatment in Severely Anaemic Jehovah's Witnesses
- Low-dose erythropoietin treatment (<600 IU/kg/week) is not associated with clinical benefits in severely anaemic Jehovah's Witnesses 6.
- Treatment with low-dose EPO-β was not associated with either shorter duration of severe anaemia or a reduction in mortality 6.
Oral Iron Supplementation
- Oral iron supplementation is usually efficacious in correcting iron-deficiency anemia and replenishing iron stores, but causes gastrointestinal side effects that reduce compliance 7.
- Novel iron formulations, such as ferric maltol or nanoparticle encapsulated sucrosomial® iron, have been developed to improve efficacy and tolerability 7.