What is an example of Erythropoiesis-Stimulating Agent (ESA) injection?

From the Guidelines

Erythropoiesis-stimulating agents (ESAs) should be administered via subcutaneous injection to reduce transfusion requirements in patients with cancer- and chemotherapy-induced anemia, as evidenced by a decreased relative risk for transfusion in patients receiving erythropoietin (RR, 0.64; 95% CI, 0.60–0.68) 1.

Key Considerations for ESA Administration

• The main benefit of ESAs is the avoidance of transfusion, which has been shown to decrease PRBC transfusion requirements in patients with cancer undergoing chemotherapy 1.
• A common example of an ESA is epoetin alfa, which can be given at a starting dose of 50-100 units/kg three times weekly for patients with chronic kidney disease-related anemia.
• Darbepoetin alfa is another ESA option that requires less frequent dosing, typically 0.45 mcg/kg once weekly, as seen in a double-blind, placebo-controlled, randomized phase III study that enrolled 320 patients (Hb level ≤ 11 g/dL) receiving darbepoetin alfa at 2.25 mcg/kg/wk versus placebo 1.

Administration and Monitoring

• For administration, clean the injection site (typically abdomen, thigh, or upper arm) with an alcohol swab, pinch the skin, insert the needle at a 45-degree angle, inject the medication, and dispose of the needle in a sharps container.
• Patients should be monitored for hemoglobin levels, as the target is typically 10-11 g/dL, and doses should be adjusted accordingly to avoid cardiovascular risks associated with excessive hemoglobin levels.
• Common side effects include hypertension, headache, and injection site reactions, and iron supplementation is often necessary alongside ESA therapy to ensure adequate iron stores for effective red blood cell production.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION • Patients with CKD: Initial dose: 50 to 100 Units/kg 3 times weekly (adults) and 50 Units/kg 3 times weekly (pediatric patients). • Patients on Zidovudine due to HIV Infection: 100 Units/kg 3 times weekly ( 2. 3). • Patients with Cancer on Chemotherapy: 40,000 Units weekly or 150 Units/kg 3 times weekly (adults); 600 Units/kg intravenously weekly (pediatric patients ≥ 5 years) ( 2.4). • Surgery Patients: 300 Units/kg per day daily for 15 days or 600 Units/kg weekly ( 2. 5)

The initial dose of epoetin alfa for patients with Chronic Kidney Disease (CKD) is 50 to 100 Units/kg administered 3 times weekly for both adults and pediatric patients.

• For patients with HIV infection on zidovudine, the dose is 100 Units/kg 3 times weekly.
• For patients with cancer on chemotherapy, the dose can be either 40,000 Units weekly or 150 Units/kg 3 times weekly for adults, and 600 Units/kg intravenously weekly for pediatric patients aged 5 years or older.
• For surgery patients, the dose is 300 Units/kg per day for 15 days or 600 Units/kg weekly. These dosages are based on information from 2.

From the Research

ESA Injection Overview

• Erythropoiesis-stimulating agents (ESAs) are used to prevent transfusions among chemotherapy-associated anemia patients and chronic kidney disease (CKD) patients 3.
• ESAs can be administered both intravenously and subcutaneously, with the subcutaneous route allowing for optimal hemoglobin levels with reduced doses and costs 4.

Administration Routes

• In hemodialysis, the intravenous route was initially preferred, but subsequent studies have shown that the subcutaneous route is more effective 4.
• For predialysis CKD and peritoneal dialysis, the subcutaneous route is necessary 4.
• The route of administration can affect the risk of pure red cell aplasia, with subcutaneous administration potentially increasing this risk 5.

Dosing Intervals

• The approved dosing interval for epoetin alfa is 2-3 times weekly, while darbepoetin alfa can be administered every 1-2 weeks 6.
• However, clinicians may use less frequent dosing intervals, such as every 2-4 weeks, to improve convenience and reduce costs 6.
• The dosing interval can affect hemoglobin control, with more frequent dosing intervals resulting in better control 6.

Specific ESA Examples

• Epoetin alfa is typically administered 1-3 times weekly, with extended-interval dosing up to every 4 weeks also effective in some patients 5.
• Darbepoetin alfa has an extended administration interval of every 2 weeks, while peginesatide has an interval of every 4 weeks 5.
• The initial dosage of epoetin alfa is typically 50-100 IU/kg three times weekly, with adjustments made based on patient response 7.