Guideline 3.10 and 3.11 – Treatment of Anaemia with ESA Therapy – ESA Dose Adjustments/Specific Situations

Guideline 3.10 – Treatment of Anaemia with ESA Therapy – ESA Dose Adjustments:

We recommend that adjustments to ESA doses should be considered when Hb is <105 or >115 g/L in adults, young people and children aged 2 years and older. (1A)

Guideline 3.10.1

We suggest these thresholds for intervention should achieve a population distribution centered on a mean of 110 g/L with a range of 100-120 g/L. (2B)

Guideline 3.10.2

We suggest in children younger than 2 years to keep the Hb level within the aspirational range, do not wait until Hb levels are outside the aspirational range before adjusting treatment (for example, take action when Hb levels are within 5 g/L of the range’s limits). (not graded)

Guideline 3.10.3

We suggest that ESA doses should ideally be decreased rather than withheld when a downward adjustment of Hb level is desirable. (2B)

Guideline 3.11 – Treatment of Anaemia with ESA Therapy – Specific Situations:

We suggest that ESA administration in ESA-dependent people should continue during acute illness, surgical procedures or any other cause of hospitalisation, unless there is a clear contra-indication (for example, acute stroke or vascular access thrombosis). (2B)

Rationale

The NICE Guidelines for anaemia management in chronic kidney disease recommend an “aspirational” Hb of 100-120 g/L. It is anticipated that if a population Hb distribution is centred on this outcome with a mean of 110 g/L, then 85% of the population will have Hb > 100 g/L (1).

In people receiving HD, withholding ESA doses for Hb levels greater than the target range is associated with subsequent downward Hb excursions often to levels less than target Range (2). The time between withholding ESA doses and return of Hb to target range is variable and unpredictable. In HD patients with Hb values greater than 140 g/L, the median time for Hb to return to 120 g/L or less after withholding of a SC-administered ESA is 7-9 weeks. The difference between withholding long and short acting ESAs on the rate of Hb reduction is not significant (3).

ESA dose adjustment may be higher during initiation (or titration after switching between different ESAs) than maintenance phases of ESA therapy. In a randomized double-blind trial comparing a short-acting ESA with a long-acting ESA in people on haemodialysis previously receiving epoetin α, dose adjustments were made in 25% increments or decrements of the baseline dose, aiming to maintain individual Hb concentrations within a range of 90 to 130 g/L (4). Approximately 70% of patients required dose adjustment in the 20-week titration period, and 50% required dose adjustment during the 8-week maintenance period.

References

1. National Collaborating Centre for Chronic Conditions, Royal College of Physicians. Chronic kidney disease: assessment and management. 2021. National Institute for Clinical Excellence.
2. Fishbane S, Berns JS: Haemoglobin cycling in haemodialysis patients treated with recombinant human erythropoietin. Kidney Int 2005; 68:1337-1343.
3. Locatelli F, Olivares J, Walker R, et al; European/ Australian NESP 980202 Study Group. Novel erythropoiesis stimulating protein for treatment of anaemia in chronic renal insufficiency. Kidney Int. 2001 Aug;60(2):741-7.
4. Nissenson AR, Swan SK, Lindberg JS, et al. Randomized, controlled trial of darbepoetin alfa for the treatment of anaemia in haemodialysis patients. Am J Kidney Dis. 2002 Jul; 40(1):110-8.5.