DOCSLIB.ORG

Chronic Anemia and the Role of the Infusion Therapy Nurse

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Chronic Anemia and the Role of the Infusion Therapy Nurse VOLUME 38 | NUMBER 5 | SEPTEMBER/OCTOBER 2015 The Art and Science of Infusion Nursing Jeffrey Betcher, RPh, BCOP Velvet Van Ryan, BSN, RN, OCN® Joseph Mikhael, MD Chronic Anemia and the Role of the Infusion Therapy Nurse destruction of erythrocytes. They encompass a broad ABSTRACT range of anemias that develop acutely or chronically Chronic anemia develops over a course of weeks and may persist for several months if left untreated. to months and is usually mild to moderate in Formally, anemia of chronic disease is a specific catego- nature. It is important to understand the etiology ry of anemia associated with underlying infection, of the reduced number of circulating red blood inflammation, or malignancy. For the purpose of this cells to treat the anemia appropriately. Diagnosis publication, the term chronic anemia will be used to is dependent on patient history and laboratory encompass anemia of chronic disease; anemia of chron- findings, such as complete blood counts, iron ic kidney disease (CKD); anemia of cancer; and vitamin studies, a peripheral smear, and occasionally, a B12, folate, and iron deficiency anemias. On diagnosis, the infusion therapy nurse may be involved with treat- bone marrow biopsy. Treatment modalities fre- ment strategies ranging from treatment of an underlying quently administered by infusion therapy nurses chronic disease, replacement of deficiencies (iron, vita- include treatment of the underlying chronic dis- min B12, folate, or erythropoietin), or transfusion of ease, replacement of deficiencies (iron, vitamin red blood cells (RBCs) in symptomatic patients or those B12, folate, or erythropoietin), or transfusion of with cardiovascular instability. Normal erythropoiesis, red blood cells. Infusion therapy nurses play a clinical and laboratory findings, etiology, medications vital role in the assessment and delivery of medi- used for treatment of chronic anemia, and the role of cation therapy to patients with chronic anemia. the infusion therapy nurse in the delivery of care to Key words: anemia, chronic, ESA, iron, infusion patients will be reviewed. nemia is defined as a reduction below nor- ERYTHROPOIESIS mal of the number of erythrocytes, quan- tity of hemoglobin (Hgb), or volume of RBCs are unable to divide into new cells and live on red cells in the blood. Anemia occurs by 1 average about 120 days. To replenish themselves, aged or more of 3 mechanisms: blood loss, and ruptured cells must be replaced by new cells. The Adecreased production of erythrocytes, and increased body replaces approximately 1% of its total RBCs on a 1 destruction of erythrocytes. Chronic anemias result daily basis. This process is called erythropoiesis. When primarily from a decreased production of erythrocytes, the body has an increased need for RBC production with or without accompanying blood loss or increased secondary to anemia, the kidneys sense tissue hypoxia and increase secretion of the hormone erythropoietin. Author Affiliation: Mayo Clinic, Phoenix, Arizona. Jeffrey Betcher, RPh, BCOP, is a clinical pharmacy specialist at the Erythropoietin travels to the bone marrow by means of Mayo Clinic in Phoenix. the circulatory system and stimulates differentiation of Velvet Van Ryan, BSN, RN, OCN®, is a unit-based educator at hematopoietic stem cells. As the differentiated cells, the Mayo Clinic in Phoenix. known as erythroblasts, mature, they fill with Hgb and Joseph Mikhael, MD, is an associate professor of medicine at the release their nucleus. Vitamin B12 and folate are critical Mayo Clinic College of Medicine and a consultant at the Mayo to DNA synthesis within the nucleus.2 The release of the Clinic in Phoenix. The authors have no conflicts of interest to disclose. nucleus causes the cell to collapse on itself, creating a Corresponding Author: Joseph Mikhael, MD, 13400 East Shea disk-like formation. This formation allows for increased Boulevard, Scottsdale, AZ 85259 ([email protected]). cell surface so Hgb can attract more oxygen molecules. DOI: 10.1097/NAN.0000000000000122 Hgb is responsible for the red color of the RBC. The VOLUME 38 | NUMBER 5 | SEPTEMBER/OCTOBER 2015 Copyright © 2015 Infusion Nurses Society 341 Copyright © 2015 Infusion Nurses Society. Unauthorized reproduction of this article is prohibited. JIN-D-14-00056.indd 341 28/08/15 9:22 PM mature RBC is then released into the bloodstream. Near This is important in early diagnoses of iron deficiency the end of RBC life, macrophages engulf the RBC, and anemia. Tsat measures the absorption and transporta- iron is recycled for a new generation of RBCs. Large tion of dietary iron. Transferrin is a protein that binds amounts of iron, which is stored in ferritin, are required iron. TIBC measures the blood’s capacity to bind iron for Hgb production. and transferrin. Ferritin and transferrin levels are used to calculate the TIBC. Figure 1 illustrates a classifica- tion algorithm for the chronic anemias. CLINICAL AND LABORATORY FINDINGS ETIOLOGY A thorough patient history is critical to the evaluation The 3 major mechanisms of anemia are: and management of patients with anemia. Classic pres- 1. Blood loss (acute or chronic) entation may include pale appearance, fatigue, weak- 2. Decreased RBC production ness, anorexia, insomnia, shortness of breath, dizziness, a. Defect in stem cells (aplastic anemia, pure red headache, decreased mental and physical performance, cell aplasia) pica, and palpitations. However, it is important to rec- b. Defect in heme production (iron deficiency, ognize that not all patients with anemia present with thalassemias) these classic symptoms; an underlying chronic illness c. Defective DNA production (vitamin B12 and may frequently mask the symptoms of anemia. folic acid deficiencies) The provider’s physical examination of the patient d. Destruction of bone marrow (solid tumor with suspected anemia should include inspection of gen- metastasis, inherent marrow malignancy, or eral appearance, vital signs, assessment for skin pallor, a other marrow invasion) cardiac exam, and evaluation for splenomegaly. 3. Increased red cell destruction Laboratory studies remain the mainstay of diagnosis a. Caused by external factors and determining etiology of the anemia. This includes a b. Caused by hereditary internal factors complete blood count (CBC), iron studies, and a periph- c. Caused by an acquired defect1 eral smear. Important components of the CBC are Hgb, hematocrit (Hct), reticulocytes, mean corpuscular vol- The chronic anemias generally develop as a result of ume (MCV), and RBC distribution. Leukocytes and an underlying cause that decreases RBC production and platelets are also a part of the CBC and are less relevant may or may not have an associated blood loss or to the diagnosis of anemia but may have utility in ruling increase in red cell destruction. out other hematological causes such as leukemia. Suspicion of iron deficiency anemia warrants iron stud- Anemia of Chronic Disease ies (ie, serum iron, ferritin, total iron binding capacity [TIBC], and transferrin saturation [Tsat]). Vitamin B12 The pale appearance of patients with chronic infections and folate levels are important for diagnosis and differ- such as tuberculosis was recognized hundreds of years entiation of megaloblastic anemias. Erythropoietin lev- ago. The pallor was eventually attributed to an anemia els should be considered with a diagnosis of anemia of of chronic disease, which occurs when an inflammatory chronic disease, anemia of CKD, and anemia of cancer. process causes erythrocytes to have a decreased life Initial suspicion of anemia is based on a low Hgb or span, as well as a poor bone marrow erythropoiesis Hct. Anemia is generally classified by cell size. RBC response. More recently, the designation anemia of indices will give the MCV, which is the size, thickness, inflammation has been recommended because it is and volume of the RBC. Microcytic anemias are those thought to be more reflective of the pathophysiology of with low MCV. These cells are also hypochromic, indi- this anemia, which also includes anemia of critical ill- cating that they have a low Hgb concentration. These ness, a condition that presents similarly to anemia of anemias are generally associated with iron deficiency chronic disease but develops acutely within days of the and chronic inflammation.3 Macrocytic anemias are onset of illness.5 those with elevated MCV and are generally associated For the purpose of this article, anemia of chronic with vitamin B12 and folic acid deficiency. Last is nor- disease will be used. This anemia is thought to be mocytic anemia, which presents with normal-sized caused by inhibitory effects of inflammatory cytokines RBCs. This anemia can be found in renal insufficiency released in response to the effects of an underlying and bone marrow infiltration.3 chronic disease on erythropoiesis.6 Erythropoietin pro- Serum ferritin, Tsat, and TIBC can be used individu- duction is less than expected, and the inflammatory ally or in conjunction to aid in diagnosing anemia. process also induces a relative resistance to the effects of Serum ferritin measures iron provisions in the body. erythropoietin. Iron availability is also compromised 342 Copyright © 2015 Infusion Nurses Society Journal of Infusion Nursing Copyright © 2015 Infusion Nurses Society. Unauthorized reproduction of this article is prohibited. JIN-D-14-00056.indd 342 28/08/15 9:22 PM Figure 1 Classification of anemia by laboratory findings. Data from Young and Koda-Kimble (1995).4 Abbreviations:
Load more

Recommended publications
  • New Brunswick Drug Plans Formulary
    New Brunswick Drug Plans Formulary August 2019 Administered by Medavie Blue Cross on Behalf of the Government of New Brunswick TABLE OF CONTENTS Page Introduction.............................................................................................................................................I New Brunswick Drug Plans....................................................................................................................II Exclusions............................................................................................................................................IV Legend..................................................................................................................................................V Anatomical Therapeutic Chemical (ATC) Classification of Drugs A Alimentary Tract and Metabolism 1 B Blood and Blood Forming Organs 23 C Cardiovascular System 31 D Dermatologicals 81 G Genito Urinary System and Sex Hormones 89 H Systemic Hormonal Preparations excluding Sex Hormones 100 J Antiinfectives for Systemic Use 107 L Antineoplastic and Immunomodulating Agents 129 M Musculo-Skeletal System 147 N Nervous System 156 P Antiparasitic Products, Insecticides and Repellants 223 R Respiratory System 225 S Sensory Organs 234 V Various 240 Appendices I-A Abbreviations of Dosage forms.....................................................................A - 1 I-B Abbreviations of Routes................................................................................A - 4 I-C Abbreviations of Units...................................................................................A
    [Show full text]
  • How Do We Treat Life-Threatening Anemia in a Jehovah's Witness
    HOW DO I...? How do we treat life-threatening anemia in a Jehovah’s Witness patient? Joseph A. Posluszny Jr and Lena M. Napolitano he management of Jehovah’s Witness (JW) The refusal of allogeneic human blood and blood prod- patients with anemia and bleeding presents a ucts by Jehovah’s Witness (JW) patients complicates clinical dilemma as they do not accept alloge- the treatment of life-threatening anemia. For JW neic human blood or blood product transfu- patients, when hemoglobin (Hb) levels decrease Tsions.1,2 With increased understanding of the JW patient beyond traditional transfusion thresholds (<7 g/dL), beliefs and blood product limitations, the medical com- alternative methods to allogeneic blood transfusion can munity can better prepare for optimal treatment of severe be utilized to augment erythropoiesis and restore life-threatening anemia in JW patients. endogenous Hb levels. The use of erythropoietin- Lower hemoglobin (Hb) is associated with increased stimulating agents and intravenous iron has been mortality risk in JW patients. In a study of 300 patients shown to restore red blood cell and Hb levels in JW who refused blood transfusion, for every 1 g/dL decrease patients, although these effects may be significantly in Hb below 8 g/dL, the odds of death increased 2.5-fold delayed. When JW patients have evidence of life- (Fig. 1).3 A more recent single-center update of JW threatening anemia (Hb <5 g/dL), oxygen-carrying patients (n = 293) who declined blood transfusion capacity can be supplemented with the administration reported an overall mortality rate of 8.2%, with a twofold of Hb-based oxygen carriers (HBOCs).
    [Show full text]
  • Intravenous Iron Replacement Therapy (Feraheme®, Injectafer®, & Monoferric®)
    UnitedHealthcare® Commercial Medical Benefit Drug Policy Intravenous Iron Replacement Therapy (Feraheme®, Injectafer®, & Monoferric®) Policy Number: 2021D0088F Effective Date: July 1, 2021 Instructions for Use Table of Contents Page Community Plan Policy Coverage Rationale ....................................................................... 1 • Intravenous Iron Replacement Therapy (Feraheme®, Definitions ...................................................................................... 3 Injectafer®, & Monoferric®) Applicable Codes .......................................................................... 3 Background.................................................................................... 4 Benefit Considerations .................................................................. 4 Clinical Evidence ........................................................................... 5 U.S. Food and Drug Administration ............................................. 7 Centers for Medicare and Medicaid Services ............................. 8 References ..................................................................................... 8 Policy History/Revision Information ............................................. 9 Instructions for Use ....................................................................... 9 Coverage Rationale See Benefit Considerations This policy refers to the following intravenous iron replacements: Feraheme® (ferumoxytol) Injectafer® (ferric carboxymaltose) Monoferric® (ferric derisomaltose)* The following
    [Show full text]
  • Venofer ® (Iron Sucrose Injection, USP)
    NDA 21-135/S-017 Page 3 Venofer ® (iron sucrose injection, USP) Rx Only DESCRIPTION Venofer® (iron sucrose injection, USP) is a brown, sterile, aqueous, complex of polynuclear iron (III)- hydroxide in sucrose for intravenous use. Iron sucrose injection has a molecular weight of approximately 34,000 – 60,000 daltons and a proposed structural formula: [Na2Fe5O8(OH) ⋅3(H2O)]n ⋅m(C12H22O11) where: n is the degree of iron polymerization and m is the number of sucrose molecules associated with the iron (III)-hydroxide. Each mL contains 20 mg elemental iron as iron sucrose in water for injection. Venofer® is available in 5 mL single dose vials (100 mg elemental iron per 5 mL) and 10 mL single dose vials (200 mg elemental iron per 10 mL). The drug product contains approximately 30% sucrose w/v (300 mg/mL) and has a pH of 10.5- 11.1. The product contains no preservatives. The osmolarity of the injection is 1,250 mOsmol/L. Therapeutic class: Hematinic CLINICAL PHARMACOLOGY Pharmacodynamics: Following intravenous administration of Venofer®, iron sucrose is dissociated by the reticuloendothelial system into iron and sucrose. In 22 hemodialysis patients on erythropoietin (recombinant human erythropoietin) therapy treated with iron sucrose containing 100 mg of iron, three times weekly for three weeks, significant increases in serum iron and serum ferritin and significant decreases in total iron binding capacity occurred four weeks from the initiation of iron sucrose treatment. Pharmacokinetics: In healthy adults treated with intravenous doses of Venofer®, its iron component exhibits first order kinetics with an elimination half-life of 6 h, total clearance of 1.2 L/h, non-steady state apparent volume of distribution of 10.0 L and steady state apparent volume of distribution of 7.9 L.
    [Show full text]
  • Ferric Maltol 30Mg Hard Capsules (Feraccru®) SMC No
    ferric maltol 30mg hard capsules (Feraccru®) SMC No. (1202/16) Shield TX UK Limited 04 November 2016 The Scottish Medicines Consortium (SMC) has completed its assessment of the above product and advises NHS Boards and Area Drug and Therapeutic Committees (ADTCs) on its use in Scotland. The advice is summarised as follows: ADVICE: following a full submission ferric maltol (Feraccru®) is not recommended for use within NHS Scotland. Indication under review: in adults for the treatment of iron deficiency anaemia (IDA) in patients with inflammatory bowel disease (IBD). In a pooled analysis of two phase III studies in IBD patients with IDA who had failed previous treatment with oral ferrous products, there was a significantly greater increase in haemoglobin concentrations after 12 weeks of ferric maltol treatment compared with placebo. The submitting company did not present sufficiently robust clinical and economic analyses to gain acceptance by SMC. Overleaf is the detailed advice on this product. Chairman, Scottish Medicines Consortium Published 12 December 2016 1 Indication In adults for the treatment of iron deficiency anaemia (IDA) in patients with inflammatory bowel disease (IBD). Dosing Information One capsule twice daily, morning and evening, on an empty stomach. Treatment duration will depend on severity of iron deficiency but generally at least 12 weeks treatment is required. The treatment should be continued as long as necessary to replenish the body iron stores according to blood tests. Ferric maltol capsules should be taken whole on an empty stomach (with half a glass of water) as the absorption of iron is reduced when it is taken with food.
    [Show full text]
  • A Randomized Controlled Trial of Repeated Doses of Ferumoxytol Or Iron Sucrose in Patients on Hemodialysis: Background and Rationale Iain C
    Macdougall et al. BMC Nephrology (2017) 18:117 DOI 10.1186/s12882-017-0523-8 STUDY PROTOCOL Open Access The Ferumoxytol for Anemia of CKD Trial (FACT)—a randomized controlled trial of repeated doses of ferumoxytol or iron sucrose in patients on hemodialysis: background and rationale Iain C. Macdougall1, Naomi V. Dahl2, Kristine Bernard2, Zhu Li2, Alka Batycky2 and William E. Strauss2* Abstract Background: Iron deficiency anemia (IDA) is a common manifestation of chronic kidney disease (CKD), affecting most patients on hemodialysis and imposing a substantial clinical burden. Treatment with iron supplementation increases hemoglobin levels and can reduce the severity of anemia in patients with CKD. While correcting anemia in these patients is an important therapeutic goal, there is a lack of long-term trials directly comparing intravenous iron therapies in patients with CKD receiving hemodialysis. Methods/Design: The Ferumoxytol for Anemia of CKD Trial (FACT) is a 13-month, open-label, randomized, multicenter, international, prospective study with 2 substudies. Entry criteria for the main study include adults with IDA (defined as hemoglobin <11.5 g/dL [<115.0 g/L] and a transferrin saturation <30%), serum ferritin <800 ng/mL (<1798 pmol/L), and receiving hemodialysis for ≥3 months. Patients are randomized to receive ferumoxytol (1.02 g over 2 doses) or iron sucrose (1.0 g over 10 doses) during the initial 5-week treatment period. Those with persistent/recurrent IDA over the 11-month observation period will receive additional 5-week treatment periods, as appropriate. The primary efficacy endpoint of the main study is the mean change in hemoglobin from Baseline to Week 5 for each treatment period.
    [Show full text]
  • Anemia Landmark Trials Chart
    ANEMIA OF CKD: Hemoglobin Control – Landmark Trials Summary Z Dumont BSP, P Ricci, L Gross, B Lang, A Wiebe © www.RxFiles.ca May 2021 Trials Intervention Population Key Baseline Indices Results Comments Mean follow-up, n CKD stage, age, etc. (e.g. Iron Studies) 1 Charytan et al. Oral vs IV iron for ND-CKD ND-CKD; Age mean ~61; mostly ♀, Hgb (g/L): 97 oral vs 98 IV Hgb (g/L): +7 oral vs +10 IV; NS Iron therapy: 43 days; n=96; FeSO4 325mg po TID x 29 days vs (71% oral, 60% IV); multi-racial Ferritin (ng/mL): 103 oral vs 125 IV Ferritin (ng/mL): -5.1 oral vs 288 IV; p<0.0001 Should be guided by iron status tests, Hgb Iron sucrose 200mg IV weekly x 5 doses; Included: CrCl(C-G)≤40ml/min, RCT, OL TSAT (%): 15.6 oral vs 16.6 IV Change in TSAT (%): day 36=2.1 oral vs 5.1 IV | day 43=0.5 oral vs 4.5 IV; sig levels, ESA dose, & pt status CSN 2008 Guidelines assessments made up to 14 days after last Hgb<105g/L, TSAT<25%, increase for IV, but not oral dose ferritin<300ug/L | Excluded: iron tx # of pts achieved Hgb >110g/L: 31.3% vs 54.2% IV (p=0.028) Iron Therapy in Non-hemodialysis CKD pts or blood transfusion w/in last month, AE: similar between groups, most common is GI in oral group, & taste- (ND-CKD) disturbances more common in IV group apparent GI bleed, Alb<30g/L Route of admin has been shown to have no 2 Van Wyck et al.
    [Show full text]
  • Iron Sucrose, Folic Acid, Cyanocobalamin Capsule MARTIN EKWEALOR PHARMACEUTICALS, INC
    MYFERON 150 FORTE - iron sucrose, folic acid, cyanocobalamin capsule MARTIN EKWEALOR PHARMACEUTICALS, INC. Disclaimer: This drug has not been found by FDA to be safe and effective, and this labeling has not been approved by FDA. For further information about unapproved drugs, click here. ---------- DESCRIPTION: Myferon 150 Forte capsules are highly water soluble low molecular weight polysaccharide iron complex and vitaminns. Each capsule contains: Elemental Iron .......... 150 mg (as Polysaccharide Iron Complex) Folic Acid .................. 1 mg Vitamin B 12 ............... 25 mcg. (Cyanocobalamin) Other ingredients: Microcrystalline Cellulose, Gelatin, Dicalcium, Phosphate, Stearic Acid, Pharmaceutical Glaze, Magnesium Stearate, Iron Oxides, Titanium Dioxide, FD and C Red #40 Lake and FD and C Blue #1 Lake. CLINICAL PHARMACOLOGY: Iron is an essential component in the formation of hemoglobin. Adequate amounts of iron are necessary for effective erythropoiesis. Iron also serves as a cofactor of several enzymes, including cytochromes that are involved in electron transport. Folic acid is required for nucleoprotein synthesis and the maintenance of normal erythropoiesis. Folic acid is converted in the liver and plasma to its metabolically active form, tetrahydrofolic acid by dihydrofolate reductase. Vitamin B 12 is required for the maintenance of normal erythhropoiesis, nucleoprotein and myelin synthesis, cell reproduction and normal growth. Intrinsic factor, a glycoprotein secreted by the gastric mucosa, is required for active absorption of Vitamin B 12 from the gastric tract. INDICATIONS AND USAGE: Myferon 150 Forte is indicated for the prevention and treatment of iron deficiency anemia and/or nutritional megaloblastic anemias. CONTRAINDICATIONS: Myferon 150 Forte is contraindicated in patients with a known hypersensitivity to any of the components of this product.
    [Show full text]
  • Treatment of Anemia of Chronic Disease with True Iron Deficiency in Pregnancy
    1 Treatment of anemia of chronic disease with true iron deficiency in pregnancy Gabriela AMSTAD BENCAIOVA, Alexander KRAFFT, Roland ZIMMERMANN, Tilo BURKHARDT Department of Obstetrics and Gynecology University Hospital of Zurich Frauenklinikstrasse 10 CH-8091 Zurich SWITZERLAND Phone: +41 44 255 51 92 Email: [email protected] Treatment of anemia of chronic disease with true iron deficiency in pregnancy 31.10.2017 2 Study population and criteria Fifty anemic pregnant women with moderate anemia were prospectively observed and treated in the Anemia clinic at the Department of Obstetrics, University Hospital Zurich. All patients had singleton pregnancies. All pregnant women fulfilled criteria of moderate iron deficiency anemia defined as hemoglobin between 8.0 and 9.9 g/dl and serum ferritin <15 µg/l. In all women, the analyses of a blood count, iron status, erythropoietin, cross reactive protein (CRP), folic acid and vitamin B12 were conducted. Primary endpoint was the assessment and comparison of the efficacy of anemia treatment in pregnant women with iron deficiency anemia and anemia of chronic disease with true iron deficiency. Secondary endpoint was the target hemoglobin ≥10.5 g/dl. Exclusion criteria were anemia of other etiology (i.e. vitamin B12 deficiency, folic acid deficiency, hemoglobinopathy etc.), liver or kidney disease, and multiples. Women with mean corpuscular hemoglobin (MCH) ≤25 pg, mean corpuscular volume (MCV) ≤75 fl; and percentage of microcytic erythrocytes (MRC) ≥3% were tested for hemoglobinopathies. Flow cytometry was used to determine the total iron demand of erythropoiesis by measuring HRC, CHr, and RDW. Iron deficiency anemia is defined as anemia with depleted iron stores and with elevated levels of HRC >2.5%, decreased CHr <28 pg and elevated RDW >15%.
    [Show full text]
  • How I Treat Cancer Anemia
    American Society of Hematology 2021 L Street NW, Suite 900, Washington, DC 20036 Phone: 202-776-0544 | Fax 202-776-0545 [email protected] How I treat Cancer Anemia Downloaded from https://ashpublications.org/blood/article-pdf/doi/10.1182/blood.2019004017/1745373/blood.2019004017.pdf by IMPERIAL COLLEGE LONDON user on 19 June 2020 Tracking no: BLD-2019-004017-CR1 Jeffrey Gilreath (Huntsman Cancer Institute, United States) George Rodgers (University of Utah Huntsman Cancer Institute, United States) Abstract: Despite increasing use of targeted therapies to treat cancer, anemia remains a common complication of cancer therapy. Physician concerns about the safety of intravenous (IV) iron products and erythropoiesis-stimulating agents (ESAs) have resulted in many patients with cancer receiving no or suboptimal anemia therapy. In this article, we present four patient cases illustrating both common and complex clinical scenarios. We first present a review of erythropoiesis, then describe our approach to cancer anemia by identifying contributing causes before selecting specific treatments. We summarize clinical trial data affirming the safety and efficacy of currently-available IV iron products used to treat cancer anemia, and illustrate how we use commonly-available laboratory tests to assess iron status during routine patient management. We compare adverse event rates associated with IV iron versus red cell transfusion and discuss using front-line IV iron monotherapy to treat anemic patients with cancer, decreasing the need for ESAs. A possible mechanism behind ESA-induced tumor progression is discussed. Finally, we review the potential of novel therapies such as ascorbic acid, prolyl hydroxylase inhibitors, activin traps, hepcidin and bone morphogenetic protein antagonists, in treating cancer anemia.
    [Show full text]
  • Intravenous Iron in Chemotherapy and Cancer-Related Anemia Michael Auerbach, MD,1 April S
    Review Intravenous iron in chemotherapy and cancer-related anemia Michael Auerbach, MD,1 April S. Liang,2 and John Glaspy, MD3 1 Private practice, Baltimore, Maryland; Georgetown University, Washington, DC; 2 Princeton University, Princeton, New Jersey; 3 University of California, Los Angeles Recent guidance from the Centers for Medicare and Medicaid Services restricting erythropoiesis-stimulating agents (ESAs) in chemotherapy and cancer-related anemias has resulted in an increase in transfusions. Nine studies, without published contradictory evidence, have shown optimization of the response to ESAs by intravenous (IV) iron when the iron was added to the treatment of chemotherapy-induced anemia. The synergy observed, although greater in iron deficiency, was independent of pretreatment iron parameters. Three studies demonstrated decreased transfusions when IV iron is administered without ESAs. Discordant recommendations regarding IV iron currently exist among the American Society of Hematology/American Society of Clinical Oncology guidelines, the National Comprehensive Cancer Network, and the European Society of Medical Oncology. This discordance is at least partly the result of misconceptions about the clinical nature and incidence of adverse effects with IV iron. Other reasons for this discordance are presented in this review. Based on thousands of studied patients, we conclude that IV iron is safe and probably safer than most physicians realize. Education is needed relating to the interpretation of minor, subclinical infusion reactions that resolve without therapy. IV iron without ESAs may be an effective treatment for chemotherapy- induced anemia and warrants further study. We present evidence supporting the conclusion that baseline serum hepcidin levels may predict responses to IV iron, and we examine the published evidence supporting the conclusion that IV iron should be a standard addition to the management of chemotherapy and cancer-related anemia.
    [Show full text]
  • Blue Cross and BCN Utilization Management Medical Drug List
    Blue Cross and BCN utilization management medical drug list For Blue Cross PPO (commercial) and BCN HMOSM (commercial) members Note: All requests for pediatric patients require clinical documentation A B C D E F G H I J K L M N O P Q R S T U V W X Y Z Revised September 2021 The Blue Cross and BCN Requirements for Drugs Covered under the Medical Benefit document outlines the various programs select drugs participate in under your medical coverage. The medical benefit contains drugs that require administration by a healthcare professional. Drugs on this list need to be approved by BCBSM/BCN before you receive them. Various programs include but are not limited to the Prior Authorization Program and the Site of Care program. This list applies to all BCN commercial members with medical coverage, and Blue Cross commercial members that are subject to the PA program. • Prior Authorization Program: This program ensures the medication is medically necessary and appropriate for your situation. For drugs covered under the commercial Blue Cross or BCN pharmacy benefit please see the Blue Cross and BCN Prior Authorization and Step Therapy Guidelines. • Site of Care Program: This program redirects members’ receiving select injectable or infusible drugs in the outpatient hospital setting to a lower cost, alternate site of care, such as the physician’s office or member’s home. • Oncology Management Program: Medical oncology and supportive care drugs require authorization. Requests can be submitted by calling 1-844-377-1278 or logging into AIM Provider Portal . Blue Cross commercial fully insured and BCN commercial Medical Oncology Prior Authorization list Note: This program does not apply to Blue Cross commercial fully insured members covered through the Federal Employee Program® and the Michigan Education Special Services Association .
    [Show full text]