Annual transfusion rate is 4 times higher in patients with Hb < 10 g/dL vs ≥ 10 g/dL1
Adapted from Gilbertson et al. Am J Kidney Dis. 2013. Retrospective cohort study of prevalent Medicare patients on hemodialysis as of January 1, 1999, to January 1, 2010. Patients were categorized based on mean 3-month Hb levels between April and June of each year. The primary outcome was inpatient or outpatient transfusion during the 6-month follow-up period of each cohort year. Transfusions in patients with Hb < 10 g/dL were compared with transfusions in patients with Hb ≥ 10 g/dL.
*N ranged from 118,338 in 1999 to 188,450 in 2010.
†Data were adjusted for age, sex, race, end-stage renal disease attribution, dialysis duration, ESA dose, antibiotic use, iron use, hospitalization days, comorbid conditions, previous transfusion, and facility ownership.
Risk for transfusion increased when Hb was < 10 g/dL and remained even after adjusting for clinical factors such as age, race, and comorbidities.1
Monitor Hb frequently and intervene with Aranesp® QW and Q2W dosing to reduce the need for RBC transfusions.2
- Physicians and patients should weigh the possible benefits of decreasing transfusions against the increased risks of death and other serious cardiovascular adverse events.
- Initiate Aranesp® treatment when the Hb level > 1 g/dL.
- Individualize dosing and use the lowest dose of Aranesp® sufficient to reduce the need for RBC transfusions.
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Important Safety Information.
Important Safety Information including Boxed WARNINGS
WARNING: ESAs INCREASE THE RISK OF DEATH, MYOCARDIAL INFARCTION, STROKE, VENOUS THROMBOEMBOLISM, THROMBOSIS OF VASCULAR ACCESS AND TUMOR PROGRESSION OR RECURRENCE
Chronic Kidney Disease:
- In controlled trials, patients experienced greater risks for death, serious adverse cardiovascular reactions, and stroke when administered erythropoiesis-stimulating agents (ESAs) to target a hemoglobin level of greater than 11 g/dL.
- No trial has identified a hemoglobin target level, Aranesp® dose, or dosing strategy that does not increase these risks.
- Use the lowest Aranesp® dose sufficient to reduce the need for red blood cell (RBC) transfusions.
- ESAs shortened overall survival and/or increased the risk of tumor progression or recurrence in clinical studies of patients with breast, non-small cell lung, head and neck, lymphoid, and cervical cancers.
- To decrease these risks, as well as the risk of serious cardiovascular and thromboembolic reactions, use the lowest dose needed to avoid RBC transfusions.
- Use ESAs only for anemia from myelosuppressive chemotherapy.
- ESAs are not indicated for patients receiving myelosuppressive chemotherapy when the anticipated outcome is cure.
- Discontinue following the completion of a chemotherapy course.
- Aranesp® is contraindicated in patients with:
- Uncontrolled hypertension
- Pure red cell aplasia (PRCA) that begins after treatment with Aranesp® or other erythropoietin protein drugs
- Serious allergic reactions to Aranesp®
- Use caution in patients with coexistent cardiovascular disease and stroke.
- Patients with CKD and an insufficient hemoglobin response to ESA therapy may be at even greater risk for cardiovascular reactions and mortality than other patients. A rate of hemoglobin rise of > 1 g/dL over 2 weeks may contribute to these risks.
- In controlled clinical trials, ESAs increased the risk of death in patients undergoing coronary artery bypass graft surgery (CABG) and the risk of deep venous thrombosis (DVT) in patients undergoing orthopedic procedures.
- Control hypertension prior to initiating and during treatment with Aranesp®.
- Aranesp® increases the risk of seizures in patients with CKD. Monitor patients closely for new-onset seizures, premonitory symptoms, or change in seizure frequency.
- For lack or loss of hemoglobin response to Aranesp®, initiate a search for causative factors. If typical causes of lack or loss of hemoglobin response are excluded, evaluate for PRCA.
- Cases of PRCA and of severe anemia, with or without other cytopenias that arise following the development of neutralizing antibodies to erythropoietin have been reported in patients treated with Aranesp®.
- This has been reported predominantly in patients with CKD receiving ESAs by subcutaneous administration.
- PRCA has also been reported in patients receiving ESAs for anemia related to hepatitis C treatment (an indication for which Aranesp® is not approved).
- If severe anemia and low reticulocyte count develop during treatment with Aranesp®, withhold Aranesp® and evaluate patients for neutralizing antibodies to erythropoietin.
- Permanently discontinue Aranesp® in patients who develop PRCA following treatment with Aranesp® or other erythropoietin protein drugs. Do not switch patients to other ESAs.
- Serious allergic reactions, including anaphylactic reactions, angioedema, bronchospasm, skin rash, and urticaria may occur with Aranesp®. Immediately and permanently discontinue Aranesp® if a serious allergic reaction occurs.
- Blistering and skin exfoliation reactions including Erythema multiforme and Stevens-Johnson Syndrome (SJS)/Toxic Epidermal Necrolysis (TEN), have been reported in patients treated with ESAs (including Aranesp®) in the postmarketing setting. Discontinue Aranesp® therapy immediately if a severe cutaneous reaction, such as SJS/TEN, is suspected.
- Adverse reactions (≥ 10%) in Aranesp® clinical studies in patients with CKD were hypertension, dyspnea, peripheral edema, cough, and procedural hypotension.
Please click to see accompanying Aranesp® full prescribing information, including Boxed WARNINGS and Medication Guide.
Limitations of Use
- Aranesp® has not been shown to improve quality of life, fatigue, or patient well-being.
- Aranesp® is not indicated for use as a substitute for red blood cell transfusions in patients who require immediate correction of anemia.
Abbreviations and References:
ESA = erythropoiesis-stimulating agent; Hb = hemoglobin; QW = once weekly; Q2W = once every two weeks.
References: 1. Gilbertson DT, Monda KL, Bradbury BD, Collins AJ. RBC transfusions among hemodialysis patients (1999-2010): influence of hemoglobin concentrations below 10 g/dL. Am J Kidney Dis. 2013;62:919-928. 2. Aranesp® (darbepoetin alfa) prescribing information, Amgen.