Adults: Dosage evaluation of iron stores and nutritional factors
Check the iron status of every patient before and during treatment, and keep iron repletion maintained. Correct or rule out other causes of anemia before starting Erythropoietin alfa (for example vitamin deficiency, metabolic or chronic inflammatory conditions, bleeding, etc.).
For all patients with CKD, monitor hemoglobin at least weekly when starting or adjusting therapy, until it is stable, and then at least monthly. When adjusting the dose, consider the hemoglobin rate of rise, the rate of decline, ESA responsiveness and hemoglobin variability. A single hemoglobin excursion may not need a dose change. Don't increase the dose more often than once every 4 weeks. Decreases can be made more often, but avoid frequent dose adjustments. When hemoglobin rises rapidly (e.g., more than 1 g/dL in any 2-week period), reduce the dose of Erythropoietin alfa by 25% or more as needed to slow the response. For patients who do not respond adequately, meaning the hemoglobin has not increased by more than 1 g/dL after 4 weeks of therapy, increase the dose by 25%. Over a 12-week escalation period without adequate response, raising the Erythropoietin alfa dose further is unlikely to improve the response and may increase risks. Use the lowest dose that will maintain a hemoglobin level sufficient to reduce the need for RBC transfusions. Evaluate other causes of anemia, and discontinue Erythropoietin alfa if responsiveness does not improve.
For patients with CKD on dialysis, start Erythropoietin alfa when the hemoglobin level is less than 10 g/dL. If the level approaches or exceeds 11 g/dL, reduce or interrupt the dose. The recommended starting dose for adults is 50 to 100 units/kg, 3 times weekly, intravenously or subcutaneously. For pediatric patients the recommended starting dose is 50 units/kg, 3 times weekly, intravenously or subcutaneously. The intravenous route is recommended for patients on hemodialysis.
For patients with CKD not on dialysis, consider starting Erythropoietin alfa only when the hemoglobin level is less than 10 g/dL and the following apply: the rate of hemoglobin decline indicates the likelihood of needing an RBC transfusion, and reducing the risk of alloimmunization and/or other RBC transfusion-related risks is a goal. Once the hemoglobin level exceeds 10 g/dL, reduce or interrupt the dose, and use the lowest dose sufficient to reduce the need for RBC transfusions. The recommended starting dose for adults is 50 to 100 units/kg, 3 times weekly, intravenously or subcutaneously.
Zidovudine-treated HIV-infected patients
The recommended starting dose in adults is 100 units/kg as an intravenous or subcutaneous injection 3 times per week. If hemoglobin does not increase after 8 weeks of therapy, increase the dose by approximately 50 to 100 units/kg at 4- to 8-week intervals, until hemoglobin reaches the level needed to avoid RBC transfusions or the dose reaches 300 units/kg. Withhold Erythropoietin alfa if hemoglobin exceeds 12 g/dL. Resume therapy at a dose 25% below the previous dose when hemoglobin declines to less than 11 g/dL. Discontinue Erythropoietin alfa if hemoglobin has not increased at a dose of 300 units/kg for 8 weeks.
Patients on cancer chemotherapy
Start Erythropoietin alfa only when the hemoglobin is less than 10 g/dL and a minimum of two additional months of chemotherapy is planned. Use the lowest dose necessary to avoid RBC transfusions. Adults receive 150 units/kg subcutaneously 3 times per week, or 40,000 units subcutaneously weekly, until the chemotherapy course is completed. Pediatric patients (5 to 18 years) receive 600 units/kg intravenously weekly until the chemotherapy course is completed.
Prevention of anemia of prematurity
Erythropoietin alfa is given subcutaneously at a dose of 3x250 IU/kg b.w. per week. Treatment should start as early as possible, preferably by day 3 of life. Premature infants who have received a transfusion before starting Erythropoietin alfa are not likely to benefit as much as infants who have not had a transfusion. The treatment should last for 6 weeks.
