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Meyers M, Salmon M, Libert I, Klášterský J. A meta-analysis on the risk of infection associated with intravenous iron therapy in cancer-associated anaemia: a double-edged sword? Curr Opin Oncol 2024; 36:223-232. [PMID: 38842015 DOI: 10.1097/cco.0000000000001024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
PURPOSE OF REVIEW The increased use of i.v. iron in the treatment of cancer-associated anemia raises concerns about its risk of infectious complications. High levels of circulating iron could increase the risk of infection by compromising natural defence mechanisms and promoting pathogen growth. Since the risk of infection is particularly high in the oncological population, we have examined whether the use of i.v. iron increases the risk of infectious complications among cancer patients. FINDINGS Among 18 randomized trials in our systematic review, only 8 reported infectious complications, with no significant difference linked to the type of i.v. iron preparation. Two trials showed a statistically significant increase in infectious complications, one trial found a lower risk, while the remaining 5 reported no significant difference. Our meta-analysis revealed a numerical increase in infectious complications in the i.v. iron group, but the lack of statistical significance and significant heterogeneity among the trials limit definitive conclusions on the actual infection risk. SUMMARY Our findings suggest some increased risk in infectious complications after the administration of i.v. iron for cancer associated anaemia. However, i.v. iron therapy appears generally safe and effective in cancer-associated anaemia.
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Affiliation(s)
| | - Maurine Salmon
- Data Centre, Institut Jules Bordet and Université Libre de Bruxelles (ULB)
| | - Isabelle Libert
- Medical Oncology, Supportive Care Unit, Institut Jules Bordet, Brussels, Belgium
| | - Jean Klášterský
- Medical Oncology, Supportive Care Unit, Institut Jules Bordet, Brussels, Belgium
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Butler-Laporte G, Farjoun Y, Chen Y, Hultström M, Liang KYH, Nakanishi T, Su CY, Yoshiji S, Forgetta V, Richards JB. Increasing serum iron levels and their role in the risk of infectious diseases: a Mendelian randomization approach. Int J Epidemiol 2023; 52:1163-1174. [PMID: 36773317 PMCID: PMC10396421 DOI: 10.1093/ije/dyad010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 02/02/2023] [Indexed: 02/13/2023] Open
Abstract
OBJECTIVES Increased iron stores have been associated with elevated risks of different infectious diseases, suggesting that iron supplementation may increase the risk of infections. However, these associations may be biased by confounding or reverse causation. This is important, since up to 19% of the population takes iron supplementation. We used Mendelian randomization (MR) to bypass these biases and estimate the causal effect of iron on infections. METHODS As instrumental variables, we used genetic variants associated with iron biomarkers in two genome-wide association studies (GWASs) of European ancestry participants. For outcomes, we used GWAS results from the UK Biobank, FinnGen, the COVID-19 Host Genetics Initiative or 23andMe, for seven infection phenotypes: 'any infections', combined, COVID-19 hospitalization, candidiasis, pneumonia, sepsis, skin and soft tissue infection (SSTI) and urinary tract infection (UTI). RESULTS Most of our analyses showed increasing iron (measured by its biomarkers) was associated with only modest changes in the odds of infectious outcomes, with all 95% odds ratios confidence intervals within the 0.88 to 1.26 range. However, for the three predominantly bacterial infections (sepsis, SSTI, UTI), at least one analysis showed a nominally elevated risk with increased iron stores (P <0.05). CONCLUSION Using MR, we did not observe an increase in risk of most infectious diseases with increases in iron stores. However for bacterial infections, higher iron stores may increase odds of infections. Hence, using genetic variation in iron pathways as a proxy for iron supplementation, iron supplements are likely safe on a population level, but we should continue the current practice of conservative iron supplementation during bacterial infections or in those at high risk of developing them.
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Affiliation(s)
- Guillaume Butler-Laporte
- Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montréal, QC, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, QC, Canada
| | - Yossi Farjoun
- Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montréal, QC, Canada
| | - Yiheng Chen
- Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montréal, QC, Canada
| | - Michael Hultström
- Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montréal, QC, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, QC, Canada
- Anaesthesiology and Intensive Care Medicine, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
- Integrative Physiology, Department of Medical Cell Biology, Uppsala University, Uppsala, Sweden
| | - Kevin Y H Liang
- Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montréal, QC, Canada
| | - Tomoko Nakanishi
- Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montréal, QC, Canada
- Department of Human Genetics, McGill University, Montréal, QC, Canada
- Kyoto-McGill International Collaborative School in Genomic Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
- Japan Society for the Promotion of Science, Tokyo, Japan
| | - Chen-Yang Su
- Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montréal, QC, Canada
| | - Satoshi Yoshiji
- Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montréal, QC, Canada
- Kyoto-McGill International Collaborative School in Genomic Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Vincenzo Forgetta
- Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montréal, QC, Canada
| | - J Brent Richards
- Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montréal, QC, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, QC, Canada
- Department of Human Genetics, McGill University, Montréal, QC, Canada
- Infectious Diseases and Immunity in Global Health Program, Research Institute of the McGill University Health Centre, Montréal, QC, Canada
- Department of Twin Research, King’s College London, London, UK
- 5 Prime Sciences Inc., Montreal, QC, Canada
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Shah AA, Donovan K, Seeley C, Dickson EA, Palmer AJR, Doree C, Brunskill S, Reid J, Acheson AG, Sugavanam A, Litton E, Stanworth SJ. Risk of Infection Associated With Administration of Intravenous Iron: A Systematic Review and Meta-analysis. JAMA Netw Open 2021; 4:e2133935. [PMID: 34767026 PMCID: PMC8590171 DOI: 10.1001/jamanetworkopen.2021.33935] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
IMPORTANCE Intravenous iron is recommended by many clinical guidelines based largely on its effectiveness in reducing anemia. However, the association with important safety outcomes, such as infection, remains uncertain. OBJECTIVE To examine the risk of infection associated with intravenous iron compared with oral iron or no iron. DATA SOURCES Medline, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for randomized clinical trials (RCTs) from 1966 to January 31, 2021. Ongoing trials were sought from ClinicalTrials.gov, CENTRAL, and the World Health Organization International Clinical Trials Search Registry Platform. STUDY SELECTION Pairs of reviewers identified RCTs that compared intravenous iron with oral iron or no iron across all patient populations, excluding healthy volunteers. Nonrandomized studies published since January 1, 2007, were also included. A total of 312 full-text articles were assessed for eligibility. DATA EXTRACTION AND SYNTHESIS Data extraction and risk of bias assessments were performed according to the Preferred Reporting Items of Systematic Reviews and Meta-analyses (PRISMA) and Cochrane recommendations, and the quality of evidence was assessed using the GRADE (Grades of Recommendation, Assessment, Development, and Evaluation) approach. Two reviewers extracted data independently. A random-effects model was used to synthesize data from RCTs. A narrative synthesis was performed to characterize the reporting of infection. MAIN OUTCOMES AND MEASURES The primary outcome was risk of infection. Secondary outcomes included mortality, hospital length of stay, and changes in hemoglobin and red blood cell transfusion requirements. Measures of association were reported as risk ratios (RRs) or mean differences. RESULTS A total of 154 RCTs (32 920 participants) were included in the main analysis. Intravenous iron was associated with an increased risk of infection when compared with oral iron or no iron (RR, 1.17; 95% CI, 1.04-1.31; I2 = 37%; moderate certainty of evidence). Intravenous iron also was associated with an increase in hemoglobin (mean difference, 0.57 g/dL; 95% CI, 0.50-0.64 g/dL; I2 = 94%) and a reduction in the risk of requiring a red blood cell transfusion (RR, 0.93; 95% CI, 0.76-0.89; I2 = 15%) when compared with oral iron or no iron. There was no evidence of an effect on mortality or hospital length of stay. CONCLUSIONS AND RELEVANCE In this large systematic review and meta-analysis, intravenous iron was associated with an increased risk of infection. Well-designed studies, using standardized definitions of infection, are required to understand the balance between this risk and the potential benefits.
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Affiliation(s)
- Akshay A. Shah
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
- National Institute for Health Research Biomedical Research Centre Haematology Theme, Oxford, United Kingdom
- Adult Intensive Care Unit, Oxford University Hospitals National Health Service (NHS) Foundation Trust, Oxford, United Kingdom
| | - Killian Donovan
- Adult Intensive Care Unit, Oxford University Hospitals National Health Service (NHS) Foundation Trust, Oxford, United Kingdom
| | - Claire Seeley
- Department of Anaesthesia, Royal Berkshire Hospitals NHS Foundation Trust, Reading, United Kingdom
| | - Edward A. Dickson
- National Institute for Health Research Biomedical Research Centre in Gastrointestinal and Liver Diseases, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
- Department of Colorectal Surgery, Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, United Kingdom
| | - Antony J. R. Palmer
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Carolyn Doree
- Systematic Review Initiative, NHS Blood & Transplant, Oxford, United Kingdom
| | - Susan Brunskill
- Systematic Review Initiative, NHS Blood & Transplant, Oxford, United Kingdom
| | - Jack Reid
- Department of Anaesthesia, Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom
| | - Austin G. Acheson
- National Institute for Health Research Biomedical Research Centre in Gastrointestinal and Liver Diseases, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
- Department of Colorectal Surgery, Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, United Kingdom
| | - Anita Sugavanam
- Department of Anaesthesia, Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom
| | - Edward Litton
- Intensive Care Unit, Fiona Stanley Hospital, Perth, Australia
| | - Simon J. Stanworth
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
- National Institute for Health Research Biomedical Research Centre Haematology Theme, Oxford, United Kingdom
- Systematic Review Initiative, NHS Blood & Transplant, Oxford, United Kingdom
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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4
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Pirotte M, Fillet M, Seidel L, Jaspers A, Baron F, Beguin Y. Erythroferrone and hepcidin as mediators between erythropoiesis and iron metabolism during allogeneic hematopoietic stem cell transplant. Am J Hematol 2021; 96:1275-1286. [PMID: 34310730 PMCID: PMC9291814 DOI: 10.1002/ajh.26300] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 06/13/2021] [Accepted: 07/15/2021] [Indexed: 12/16/2022]
Abstract
Hematopoietic cell transplantation (HCT) brings important alterations in erythropoiesis and iron metabolism. Hepcidin, which regulates iron metabolism, increases in iron overload or inflammation and decreases with iron deficiency or activated erythropoiesis. Erythroferrone (ERFE) is the erythroid regulator of hepcidin. We investigated erythropoiesis and iron metabolism after allogeneic HCT in 70 patients randomized between erythropoietin (EPO) treatment or no EPO, by serially measuring hepcidin, ERFE, CRP (inflammation), soluble transferrin receptor (sTfR, erythropoiesis), serum iron and transferrin saturation (Tsat; iron for erythropoiesis) and ferritin (iron stores). We identified biological and clinical factors associated with serum hepcidin and ERFE levels. Serum ERFE correlated overall with sTfR and reticulocytes and inversely with hepcidin. Erythroferrone paralleled sTfR levels, dropping during conditioning and recovering with engraftment. Inversely, hepcidin peaked after conditioning and decreased during engraftment. Erythroferrone and hepcidin were not significantly different with or without EPO. Multivariate analyses showed that the major determinant of ERFE was erythropoiesis (sTfR, reticulocytes or serum Epo). Pretransplant hepcidin was associated with previous RBC transfusions and ferritin. After transplantation, the major determinants of hepcidin were iron status (ferritin at all time points and Tsat at day 56) and erythropoiesis (sTfR or reticulocytes or ERFE), while the impact of inflammation was less clear and clinical parameters had no detectable influence. Hepcidin remained significantly higher in patients with high compared to low pretransplant ferritin. After allogeneic HCT with or without EPO therapy, significant alterations of hepcidin occur between pretransplant and day 180, in correlation with iron status and inversely with erythroid ERFE.
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Affiliation(s)
- Michelle Pirotte
- Department of Hematology University Hospital of Liège and ULiege Liège Belgium
| | - Marianne Fillet
- Laboratory for the Analysis of Medicines CIRM, ULiege Liège Belgium
| | - Laurence Seidel
- Department of Biostatistics and Medico‐Economics University Hospital of Liège and ULiege Liège Belgium
| | - Aurélie Jaspers
- Department of Hematology University Hospital of Liège and ULiege Liège Belgium
| | - Fréderic Baron
- Department of Hematology University Hospital of Liège and ULiege Liège Belgium
| | - Yves Beguin
- Department of Hematology University Hospital of Liège and ULiege Liège Belgium
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5
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Macdougall IC, Comin-Colet J, Breymann C, Spahn DR, Koutroubakis IE. Iron Sucrose: A Wealth of Experience in Treating Iron Deficiency. Adv Ther 2020; 37:1960-2002. [PMID: 32297281 PMCID: PMC7467495 DOI: 10.1007/s12325-020-01323-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Indexed: 12/19/2022]
Abstract
Iron deficiency and iron-deficiency anemia are associated with increased morbidity and mortality in a wide range of conditions. In many patient populations, this can be treated effectively with oral iron supplementation; but in patients who are unable to take or who do not respond to oral iron therapy, intravenous iron administration is recommended. Furthermore, in certain conditions, such as end-stage kidney disease, chronic heart failure, and inflammatory bowel disease, intravenous iron administration has become first-line treatment. One of the first available intravenous iron preparations is iron sucrose (Venofer®), a nanomedicine that has been used clinically since 1949. Treatment with iron sucrose is particularly beneficial owing to its ability to rapidly increase hemoglobin, ferritin, and transferrin saturation levels, with an acceptable safety profile. Recently, important new data relating to the use of iron sucrose, including the findings from the landmark PIVOTAL trial in patients with end-stage kidney disease, have been reported. Several years ago, a number of iron sucrose similars became available, although there have been concerns about the clinical appropriateness of substituting the original iron sucrose with an iron sucrose similar because of differences in efficacy and safety. This is a result of the complex and unique physicochemical properties of nanomedicines such as iron sucrose, which make copying the molecule difficult and problematic. In this review, we summarize the evidence accumulated during 70 years of clinical experience with iron sucrose in terms of efficacy, safety, and cost-effectiveness.
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Affiliation(s)
| | - Josep Comin-Colet
- Department of Cardiology, Bellvitge University Hospital and IDIBELL, University of Barcelona, Barcelona, Spain
| | | | - Donat R Spahn
- Institute of Anaesthesiology, University of Zurich and University Hospital Zürich, Zurich, Switzerland
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6
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Zhao JC, Arnall JR, Martin AL, Atrash S, Bhutani M, Voorhees P, Avalos B, Copelan E, Ghosh N, Hamadani M, Usmani S, Ford P. A Review of Growth Factor Support in Bloodless Autologous Hematopoietic Stem Cell Transplant. Biol Blood Marrow Transplant 2019; 25:e305-e309. [PMID: 31295572 DOI: 10.1016/j.bbmt.2019.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 07/02/2019] [Accepted: 07/03/2019] [Indexed: 11/16/2022]
Abstract
Bloodless autologous hematopoietic cell transplantation is associated with risks of severe bleeding and profound anemia. RBC or platelet transfusions are often used to prevent these hematologic complications. However, in patients such as Jehovah's Witnesses who refuse major blood components, the lack of transfusion support is not an absolute contraindication to an autologous hematopoietic cell transplant. Pennsylvania Hospital performed the world's first bloodless hematopoietic cell transplant more than 15 years ago and has gradually improved its technique with a sizable patient population. Erythropoiesis-stimulating agents were successfully employed as part of their pretransplant regimen to prevent severe anemia. Thrombopoietin agonists' potential role in bloodless transplant is also currently being explored. Although there is limited literature, available reports in combination with physiologic reasoning may support the use of these growth factors to promote transplant success. These agents offer potential benefit and may be of utility in minimizing complications of a bloodless transplant. In this review, we summarize the available literature and offer insight into how we may incorporate growth factors to allow bloodless autologous hematopoietic cell transplantation to be an available option to patients who may otherwise be denied.
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Affiliation(s)
- Jennifer C Zhao
- Department of Hematology/Oncology, Smilow Cancer Hospital, Yale New Haven Health, New Haven, Connecticut.
| | - Justin R Arnall
- Department of Hematology/Oncology and Bone Marrow Transplantation, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Allison L Martin
- Department of Hematology/Oncology and Bone Marrow Transplantation, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Shebli Atrash
- Department of Hematology/Oncology and Bone Marrow Transplantation, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Manisha Bhutani
- Department of Hematology/Oncology and Bone Marrow Transplantation, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Peter Voorhees
- Department of Hematology/Oncology and Bone Marrow Transplantation, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Belinda Avalos
- Department of Hematology/Oncology and Bone Marrow Transplantation, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Edward Copelan
- Department of Hematology/Oncology and Bone Marrow Transplantation, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Nilanjan Ghosh
- Department of Hematology/Oncology and Bone Marrow Transplantation, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Mehdi Hamadani
- Department of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Saad Usmani
- Department of Hematology/Oncology and Bone Marrow Transplantation, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Patricia Ford
- Pennsylvania Hospital, Center for Bloodless Medicine and Surgery, Philadelphia, , Pennsylvania
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7
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Stein J, Aksan A, Farrag K, Dignass A, Radeke HH. Management of inflammatory bowel disease-related anemia and iron deficiency with specific reference to the role of intravenous iron in current practice. Expert Opin Pharmacother 2017; 18:1721-1737. [PMID: 29019427 DOI: 10.1080/14656566.2017.1391790] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Anemia is a common extraintestinal manifestation in patients with inflammatory bowel disease, impacting disease prognosis, morbidity, hospitalization rates and time lost from work. While iron deficiency anemia and anemia of chronic inflammation predominate, combinations of hematimetric and biochemical markers facilitate the diagnosis and targeted therapy of other etiologies according to their underlying pathophysiological causes. Intravenous iron replacement is currently recommended in IBD patients with moderate to severe anemia or intolerance to oral iron. Areas covered: This review examines the impact, pathophysiology and diagnostics of iron deficiency and anemia, compares the characteristics and safety profiles of available oral and intravenous iron preparations, and highlights issues which require consideration in decision making for therapy administration and monitoring. Expert opinion: Modern intravenous iron formulations have been shown to be safe and effective in IBD patients, allowing rapid anemia correction and repletion of iron stores. While traditional oral iron preparations are associated with increased inflammation, negative effects on the microbiome, and poor tolerance and compliance, first clinical trial data indicate that newer oral compounds such as ferric maltol and sucrosomial iron offer improved tolerability and may thus offer a viable alternative for the future.
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Affiliation(s)
- Jürgen Stein
- a Crohn Colitis Clinical Research Center Rhein-Main , Frankfurt/Main , Germany.,b Department of Pharmaceutical Chemistry , University of Frankfurt , Frankfurt/Main , Germany.,c Department of Gastroenterology and Clinical Nutrition , DGD Clinics Sachsenhausen , Frankfurt/Main , Germany
| | - Ayşegül Aksan
- a Crohn Colitis Clinical Research Center Rhein-Main , Frankfurt/Main , Germany.,d Faculty of Health Sciences , Hacettepe University , Ankara , Turkey
| | - Karima Farrag
- a Crohn Colitis Clinical Research Center Rhein-Main , Frankfurt/Main , Germany.,c Department of Gastroenterology and Clinical Nutrition , DGD Clinics Sachsenhausen , Frankfurt/Main , Germany
| | - Axel Dignass
- a Crohn Colitis Clinical Research Center Rhein-Main , Frankfurt/Main , Germany.,e Department of Medicine I , Agaplesion Markus Hospital , Frankfurt/Main , Germany
| | - Heinfried H Radeke
- a Crohn Colitis Clinical Research Center Rhein-Main , Frankfurt/Main , Germany.,b Department of Pharmaceutical Chemistry , University of Frankfurt , Frankfurt/Main , Germany
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8
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Muñoz M, Auerbach M. Postoperative intravenous iron: a simple strategy to improve outcomes. LANCET HAEMATOLOGY 2016; 3:e401-2. [DOI: 10.1016/s2352-3026(16)30083-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Accepted: 07/11/2016] [Indexed: 11/30/2022]
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9
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Webb J, Abraham A. Complex Transfusion Issues in Pediatric Hematopoietic Stem Cell Transplantation. Transfus Med Rev 2016; 30:202-8. [PMID: 27439965 DOI: 10.1016/j.tmrv.2016.06.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 06/15/2016] [Indexed: 12/13/2022]
Abstract
Advances in the fields of pediatric transfusion medicine and hematopoietic stem cell transplant have resulted in improved outcomes but also present new questions for research. The diagnostic capabilities involved in transfusion medicine have improved in recent times, now including methods for determination of red blood cell minor antigens, detection of anti-human leukocyte antigen antibodies, and noninvasive iron quantification. At the same time, transplants are being performed for more indications including nonmalignant disease and with less intense conditioning regimens that allow some recipient blood cells to persist after transplant. We are therefore faced with new opportunities to understand the implications of transfusion medicine testing and to develop data-driven guidelines relevant to the current-day approach to transfusion and transplantation.
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Affiliation(s)
- Jennifer Webb
- Division of Transfusion Medicine, Children's National Medical Center, Washington, DC.
| | - Allistair Abraham
- Division of Blood and Marrow Transplantation, Children's National Medical Center, Washington, DC
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10
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Clevenger B, Gurusamy K, Klein AA, Murphy GJ, Anker SD, Richards T. Systematic review and meta-analysis of iron therapy in anaemic adults without chronic kidney disease: updated and abridged Cochrane review. Eur J Heart Fail 2016; 18:774-85. [PMID: 27121474 DOI: 10.1002/ejhf.514] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 11/29/2015] [Accepted: 01/03/2016] [Indexed: 12/16/2022] Open
Abstract
AIMS Anaemia is increasingly recognized as having an independent impact upon patient outcomes in cardiac disease. The role of novel iron therapies to treat anaemia is increasing. This systematic review and meta-analysis assesses the efficacy and safety of iron therapies for the treatment of adults with anaemia. METHODS AND RESULTS Electronic databases and search engines were searched as per Cochrane methodology. Randomized controlled trials (RCTs) of iron vs. inactive control or placebo, as well as alternative formulations, doses, and routes in anaemic adults without chronic kidney disease or in the peri-partum period were eligible. The primary outcome of interest was mortality at 1 year. Secondary outcomes were blood transfusion, haemoglobin levels, quality of life, serious adverse events, and length of hospital stay. A total of 64 RCTs (including five studies of heart failure patients) comprising 9004 participants were included. None of the studies was at a low risk of bias. There were no statistically significant differences in mortality between iron and inactive control. Both oral and parenteral iron significantly reduced the proportion of patients requiring blood transfusion compared with inactive control [risk ratio (RR) 0.66, 95% confidence interval (CI) 0.48-0.90; and RR 0.84, 95% CI 0.73-0.97, respectively]. Haemoglobin was increased more by both oral and parenteral iron compared with inactive control [mean difference (MD) 0.91 g/dL, 95% CI 0.48 to 1.35; and MD 1.04, 95% CI 0.52 to 1.57, respectively], and parenteral iron demonstrated a greater increase when compared with oral iron (MD 0.53 g/dL, 95% CI 0.31-0.75). In all comparisons, there were no differences in the results comparing patients with and without heart failure. CONCLUSION Both oral and parenteral iron are shown to decrease the proportion of people who require blood transfusion and increase haemoglobin levels, without any benefit on mortality. Further trials at a low risk of bias, powered to measure clinically significant endpoints, are still required.
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Affiliation(s)
- Ben Clevenger
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Kurinchi Gurusamy
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Andrew A Klein
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, UK
| | - Gavin J Murphy
- Department of Cardiovascular Sciences and NIHR Cardiovascular Biomedical Research Unit, University of Leicester, and Glenfield General Hospital, Leicester, UK
| | - Stefan D Anker
- Department of Innovative Clinical Trials, University Medical Centre Göttingen (UMG), Göttingen, Germany
| | - Toby Richards
- Division of Surgery and Interventional Science, University College London, London, UK
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11
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Terpos E, Kleber M, Engelhardt M, Zweegman S, Gay F, Kastritis E, van de Donk NWCJ, Bruno B, Sezer O, Broijl A, Bringhen S, Beksac M, Larocca A, Hajek R, Musto P, Johnsen HE, Morabito F, Ludwig H, Cavo M, Einsele H, Sonneveld P, Dimopoulos MA, Palumbo A. European Myeloma Network guidelines for the management of multiple myeloma-related complications. Haematologica 2016; 100:1254-66. [PMID: 26432383 DOI: 10.3324/haematol.2014.117176] [Citation(s) in RCA: 224] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
The European Myeloma Network provides recommendations for the management of the most common complications of multiple myeloma. Whole body low-dose computed tomography is more sensitive than conventional radiography in depicting osteolytic disease and thus we recommend it as the novel standard for the detection of lytic lesions in myeloma (grade 1A). Myeloma patients with adequate renal function and bone disease at diagnosis should be treated with zoledronic acid or pamidronate (grade 1A). Symptomatic patients without lytic lesions on conventional radiography can be treated with zoledronic acid (grade 1B), but its advantage is not clear for patients with no bone involvement on computed tomography or magnetic resonance imaging. In asymptomatic myeloma, bisphosphonates are not recommended (grade 1A). Zoledronic acid should be given continuously, but it is not clear if patients who achieve at least a very good partial response benefit from its continuous use (grade 1B). Treatment with erythropoietic-stimulating agents may be initiated in patients with persistent symptomatic anemia (hemoglobin <10g/dL) in whom other causes of anemia have been excluded (grade 1B). Erythropoietic agents should be stopped after 6-8 weeks if no adequate hemoglobin response is achieved. For renal impairment, bortezomib-based regimens are the current standard of care (grade 1A). For the management of treatment-induced peripheral neuropathy, drug modification is needed (grade 1C). Vaccination against influenza is recommended; vaccination against streptococcus pneumonia and hemophilus influenza is appropriate, but efficacy is not guaranteed due to suboptimal immune response (grade 1C). Prophylactic aciclovir (or valacyclovir) is recommended for patients receiving proteasome inhibitors, autologous or allogeneic transplantation (grade 1A).
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Affiliation(s)
- Evangelos Terpos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Greece
| | - Martina Kleber
- Department of Hematology and Oncology, University of Freiburg Medical Center, Germany Clinic for Internal Medicine, University Hospital Basel, Switzerland
| | - Monika Engelhardt
- Department of Hematology and Oncology, University of Freiburg Medical Center, Germany
| | - Sonja Zweegman
- Department of Hematology, VU University Medical Center, Amsterdam, the Netherlands
| | - Francesca Gay
- Division of Hematology, S. Giovanni Battista Hospital, University of Turin, Italy
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Greece
| | | | - Benedetto Bruno
- Division of Hematology, S. Giovanni Battista Hospital, University of Turin, Italy
| | - Orhan Sezer
- Department of Hematology, Memorial Sisli Hospital, Istanbul, Turkey
| | - Annemiek Broijl
- Department of Hematology, Erasmus University Medical Center Rotterdam, the Netherlands
| | - Sara Bringhen
- Division of Hematology, S. Giovanni Battista Hospital, University of Turin, Italy
| | - Meral Beksac
- Department of Hematology, Ankara University, Turkey
| | - Alessandra Larocca
- Division of Hematology, S. Giovanni Battista Hospital, University of Turin, Italy
| | - Roman Hajek
- Department of Hemato-Oncology, University Hospital Ostrava and Faculty of Medicine OU, Ostrava, Czech Republic
| | - Pellegrino Musto
- Centro di Riferimento Oncologico della Basilicata, Istituto di Ricovero e Cura a Carattere Scientifico, Rionero in Vulture, Italy
| | | | - Fortunato Morabito
- Department of Hematology, Azienda Ospedaliera dell'Annunziata, Cosenza, Italy
| | - Heinz Ludwig
- Department of Medicine I, Center of Oncology, Hematology and Palliative Care, Wilhelminenspital, Vienna, Austria
| | - Michele Cavo
- "Seràgnoli" Institute of Hematology and Medical Oncology, University of Bologna, Italy
| | - Hermann Einsele
- Department of Internal Medicine II, University Hospital Würburg, Würzburg, Germany
| | - Pieter Sonneveld
- Department of Hematology, Erasmus University Medical Center Rotterdam, the Netherlands
| | - Meletios A Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Greece
| | - Antonio Palumbo
- Division of Hematology, S. Giovanni Battista Hospital, University of Turin, Italy
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12
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Abstract
Abstract
Randomized clinical trials (RCTs) have determined, in surgical and critically ill patients, relatively safe hemoglobin (Hb) thresholds of 7-8 g/dL to guide restrictive transfusion of red blood cells (RBCs). However, in patients with various hematologic disorders, strong evidence in support of such an approach is sparse and the optimal transfusion practice is yet to be defined. This review focuses on RBC transfusion practice in three hematologic diseases and a treatment strategy, including autoimmune hemolytic anemia, thalassemia, myelodysplastic syndrome, and hematopoietic stem cell transplantation. These entities manifest in a broad spectrum of anemia, acute or chronic, in patients with different comorbidities and degrees of transfusion requirement. Thus the nuances in the indications of RBC transfusion and the goals to achieve in these specific situations may have been underappreciated. The limited data available highlight the importance of titrating RBC transfusion based on the clinical context and patient characteristics. Future RCTs are necessary to firmly establish the Hb thresholds associated with improved outcomes relevant to these specific patient populations, which will facilitate the personalized decision-making in RBC transfusion.
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13
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Ludwig H, Evstatiev R, Kornek G, Aapro M, Bauernhofer T, Buxhofer-Ausch V, Fridrik M, Geissler D, Geissler K, Gisslinger H, Koller E, Kopetzky G, Lang A, Rumpold H, Steurer M, Kamali H, Link H. Iron metabolism and iron supplementation in cancer patients. Wien Klin Wochenschr 2015; 127:907-19. [PMID: 26373748 PMCID: PMC4679104 DOI: 10.1007/s00508-015-0842-3] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Accepted: 07/29/2015] [Indexed: 12/21/2022]
Abstract
Iron deficiency and iron deficiency-associated anemia are common complications in cancer patients. Most iron deficient cancer patients present with functional iron deficiency (FID), a status with adequate storage iron, but insufficient iron supply for erythroblasts and other iron dependent tissues. FID is the consequence of the cancer-associated cytokine release, while in absolute iron deficiency iron stores are depleted resulting in similar but often more severe symptoms of insufficient iron supply. Here we present a short review on the epidemiology, pathophysiology, diagnosis, clinical symptoms, and treatment of iron deficiency in cancer patients. Special emphasis is given to intravenous iron supplementation and on the benefits and limitations of different formulations. Based on these considerations and recommendations from current international guidelines we developed recommendations for clinical practice and classified the level of evidence and grade of recommendation according to the principles of evidence-based medicine.
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Affiliation(s)
- Heinz Ludwig
- c/o 1. Medizinische Abteilung, Zentrum für Onkologie, Wilhelminen-Krebsforschungsinstitut, Wilhelminenspital, Montleartstraße 37, 1160, Wien, Austria.
| | - Rayko Evstatiev
- Universitätsklinik für Innere Medizin III, MedUni, Wien, Austria
| | - Gabriela Kornek
- Universitätsklinik für Innere Medizin I, MedUni, Wien, Austria
| | - Matti Aapro
- Institut Multidisciplinaire d'Oncologie IMO, Clinique de Genolier, Genolier, Switzerland
| | | | | | | | - Dietmar Geissler
- 1. Medizinische Abteilung, Klinikum Klagenfurt, Klagenfurt, Austria
| | - Klaus Geissler
- 5. Medizinische Abteilung, Krankenhaus Hietzing, Wien, Austria
| | | | | | - Gerhard Kopetzky
- 1. Medizinische Abteilung, Landesklinikum St. Pölten, Pölten, Austria
| | - Alois Lang
- Abteilung für Innere Medizin, Landeskrankenhaus Feldkirch, Feldkirch, Austria
| | - Holger Rumpold
- Abteilung für Interne 1, Krankenhaus der Barmherzigen Schwestern, Linz, Austria
| | - Michael Steurer
- Universitätsklinik für Innere Medizin V, MedUni Innsbruck, Innsbruck, Austria
| | | | - Hartmut Link
- Medizinische Klinik I, Westpfalz-Klinikum, Kaiserslautern, Germany
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14
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Jaspers A, Baron F, Maertens J, De Prijck B, Schots R, Bonnet C, Hafraoui K, Willems É, Servais S, Fillet G, Beguin Y. Long-term safety follow-up of a randomized trial of darbepoetin alpha and intravenous iron following autologous hematopoietic cell transplantation. Am J Hematol 2015; 90:E133-4. [PMID: 25802012 DOI: 10.1002/ajh.24013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Revised: 03/13/2015] [Accepted: 03/13/2015] [Indexed: 01/19/2023]
Affiliation(s)
- Aurélie Jaspers
- Division of Hematology; Department of Medicine; CHU of Liège and University of Liège; Liège Belgium
| | - Frédéric Baron
- Division of Hematology; Department of Medicine; CHU of Liège and University of Liège; Liège Belgium
- Giga-Research, University of Liège; Liège Belgium
| | - Johan Maertens
- Clinical Hematology, Acute Leukemia & Stem Cell Transplantation Unit; , University Hospital Gasthuisberg; Leuven Belgium
| | - Bernard De Prijck
- Division of Hematology; Department of Medicine; CHU of Liège and University of Liège; Liège Belgium
- Division of Hematology; Department of Medicine; CHR La Citadelle; Liège Belgium
| | - Rik Schots
- Department of Clinical Hematology and Stem Cell Laboratory; Universitair Ziekenhuis Brussel; Belgium
| | - Christophe Bonnet
- Division of Hematology; Department of Medicine; CHU of Liège and University of Liège; Liège Belgium
| | - Kaoutar Hafraoui
- Division of Hematology; Department of Medicine; CHU of Liège and University of Liège; Liège Belgium
| | - Évelyne Willems
- Division of Hematology; Department of Medicine; CHU of Liège and University of Liège; Liège Belgium
| | - Sophie Servais
- Division of Hematology; Department of Medicine; CHU of Liège and University of Liège; Liège Belgium
- Giga-Research, University of Liège; Liège Belgium
| | - Georges Fillet
- Division of Hematology; Department of Medicine; CHU of Liège and University of Liège; Liège Belgium
| | - Yves Beguin
- Division of Hematology; Department of Medicine; CHU of Liège and University of Liège; Liège Belgium
- Giga-Research, University of Liège; Liège Belgium
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15
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Bircher AJ, Auerbach M. Hypersensitivity from intravenous iron products. Immunol Allergy Clin North Am 2015; 34:707-23, x-xi. [PMID: 25017687 DOI: 10.1016/j.iac.2014.04.013] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
In the last several years, intravenous therapy with iron products has been more widely used. Although it has been a standard procedure in dialysis-associated anemia since the early 1990s, its use is expanding to a host of conditions associated with iron deficiency, especially young women with heavy uterine bleeding and pregnancy. Free iron is associated with unacceptable high toxicity inducing severe, hemodynamically significant symptoms. Subsequently, formulations that contain the iron as an iron carbohydrate nanoparticle have been designed. With newer formulations, including low-molecular-weight iron dextran, iron sucrose, ferric gluconate, ferumoxytol, iron isomaltoside, and ferric carboxymaltose, serious adverse events are rare.
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Affiliation(s)
- Andreas J Bircher
- Allergy Unit, Dermatology Clinic, University Hospital Basel, Petersgraben 4, Basel 4031, Switzerland.
| | - Michael Auerbach
- Georgetown University School of Medicine, 3900 Reservoir road northwest, Washington, DC 20007, USA; Hematology and Oncology, Private Practice, King Avenue #308, Baltimore, MD 21237, USA
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16
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Avni T, Bieber A, Grossman A, Green H, Leibovici L, Gafter-Gvili A. The safety of intravenous iron preparations: systematic review and meta-analysis. Mayo Clin Proc 2015; 90:12-23. [PMID: 25572192 DOI: 10.1016/j.mayocp.2014.10.007] [Citation(s) in RCA: 272] [Impact Index Per Article: 30.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Revised: 08/23/2014] [Accepted: 10/06/2014] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To amass all available evidence regarding the safety of intravenous (IV) iron preparations to provide a true balance of efficacy and safety. METHODS Systematic review and meta-analysis of all randomized clinical trials comparing IV iron to another comparator. All electronic databases until January 1, 2014, were reviewed. Primary outcome was occurrence of severe adverse events (SAEs). Secondary outcomes included all-cause mortality and other adverse events (AEs). Subgroup analysis was performed on the basis of type of IV iron, comparator, treated condition, and system involved. RESULTS A total of 103 trials published between 1965 through 2013 were included. A total of 10,390 patients were treated with IV iron compared with 4044 patients treated with oral iron, 1329 with no iron, 3335 with placebo, and 155 with intramuscular iron. There was no increased risk of SAEs with IV iron (relative risk [RR], 1.04; 95% CI, 0.93-1.17; I(2)=9%). Subgroup analysis revealed a decreased rate of SAEs when IV iron was used to treat heart failure (RR, 0.45; 95% CI, 0.29-0.70; I(2)=0%). Severe infusion reactions were more common with IV iron (RR, 2.47; 95% CI, 1.43-4.28; I(2)=0%). There was no increased risk of infections with IV iron. Gastrointestinal AEs were reduced with IV iron. CONCLUSION Intravenous iron therapy is not associated with an increased risk of SAEs or infections. Infusion reactions are more pronounced with IV iron.
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Affiliation(s)
- Tomer Avni
- Department of Medicine, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, and the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
| | - Amir Bieber
- Department of Medicine, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, and the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Alon Grossman
- Department of Medicine, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, and the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Hefziba Green
- Department of Medicine, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, and the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Leonard Leibovici
- Department of Medicine, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, and the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Anat Gafter-Gvili
- Department of Medicine, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, and the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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17
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Auerbach M. Intravenous iron in chemotherapy-induced anemia. Am J Hematol 2014; 89:1153. [PMID: 25359517 DOI: 10.1002/ajh.23883] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 10/28/2014] [Indexed: 11/11/2022]
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18
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Martino M, Lanza F, Demirer T, Moscato T, Secondino S, Pedrazzoli P. Erythropoiesis-stimulating agents in allogeneic and autologous hematopoietic stem cell transplantation. Expert Opin Biol Ther 2014; 15:195-211. [PMID: 25315815 DOI: 10.1517/14712598.2015.971749] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Erythropoiesis-stimulating agents (ESAs) are used in treating cancer- and chemotherapy-induced anemia with the aim of accelerating the recovery of red blood cells (RBCs), reduce the risks associated with RBC transfusions and improve quality of life. AREAS COVERED A systematic review has been conducted to examine the current evidence for the efficacy and safety of using ESAs in hematopoietic stem cell transplants (HSCTs). EXPERT OPINION Despite the international recommendations for the use of ESAs in treating different malignancies, there is a lack of guidelines for their use in patients undergoing HSCT. An evaluation of published clinical trials shows that there are no available powerful studies concerning the use of ESAs in this setting, with only heterogeneous and small numbers of patients reported so far. Nevertheless, the more robust and intriguing of these data suggest that the ESA's administration at an appropriate time after the infusion of stem cells may be effective both in autologous and allogeneic HSCTs. New guidelines are required, overseen by an expert in the in the field of stem cell transplantation.
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Affiliation(s)
- Massimo Martino
- Azienda Ospedaliera BMM, Hematology and Stem Cell Transplant Unit , Via Melacrino n.1, 89100 Reggio Calabria , Italy +39 0965393804 ;
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19
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Beguin Y, Jaspers A. Iron sucrose - characteristics, efficacy and regulatory aspects of an established treatment of iron deficiency and iron-deficiency anemia in a broad range of therapeutic areas. Expert Opin Pharmacother 2014; 15:2087-103. [PMID: 25186219 DOI: 10.1517/14656566.2014.953928] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Iron is a key element in the transport and utilization of oxygen and a variety of metabolic pathways. Iron deficiency is a major cause of anemia and can be associated with fatigue, impaired physical function and reduced quality of life. Administration of oral or intravenous (i.v.) iron is the recommended treatment for iron-deficiency anemia (IDA) in different therapeutic areas. AREAS COVERED This article provides an overview of studies that evaluated i.v. iron sucrose for anemia and iron status management, either alone or in combination with erythropoiesis-stimulating agents, across various diseases and conditions. EXPERT OPINION Iron sucrose is an established, effective and well-tolerated treatment of IDA in patients with acute or chronic conditions such as chronic kidney disease, inflammatory bowel disease, pregnancy (second and third trimester), postpartum period, heavy menstrual bleeding and cancer who need rapid iron supply and in whom oral iron preparations are ineffective or not tolerated. Available data on patient blood management warrant further studies on preoperative iron treatment. First experience with iron sucrose follow-on products raises questions about their therapeutic equivalence without comparative clinical data in newly diagnosed patients or patients on existing chronic treatment.
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Affiliation(s)
- Yves Beguin
- University Hospital of Liège , Avenue de l'Hopital1, B-4000 Liège , Belgium +32 43 66 72 01 ; +32 43 66 88 55 ;
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20
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Ludwig H, Aapro M, Bokemeyer C, Glaspy J, Hedenus M, Littlewood T, Österborg A, Rzychon B, Mitchell D, Beguin Y. A European patient record study on diagnosis and treatment of chemotherapy-induced anaemia. Support Care Cancer 2014; 22:2197-206. [PMID: 24659244 PMCID: PMC4082648 DOI: 10.1007/s00520-014-2189-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Accepted: 03/02/2014] [Indexed: 01/28/2023]
Abstract
Purpose Patients with cancer frequently experience chemotherapy-induced anaemia (CIA) and iron deficiency. Erythropoiesis-stimulating agents (ESAs), iron supplementation and blood transfusions are available therapies. This study evaluated routine practice in CIA management. Methods Medical oncologists and/or haematologists from nine European countries (n = 375) were surveyed on their last five cancer patients treated for CIA (n = 1,730). Information was collected on tests performed at diagnosis of anaemia, levels of haemoglobin (Hb), serum ferritin and transferrin saturation (TSAT), as well as applied anaemia therapies. Results Diagnostic tests and therapies for CIA varied across Europe. Anaemia and iron status were mainly assessed by Hb (94 %) and ferritin (48 %) measurements. TSAT was only tested in 14 %. At anaemia diagnosis, 74 % of patients had Hb ≤10 g/dL, including 15 % with severe anaemia (Hb <8 g/dL). Low-iron levels (ferritin ≤100 ng/mL) were detected in 42 % of evaluated patients. ESA was used in 63 % of patients, blood transfusions in 52 % and iron supplementation in 31 % (74 % oral, 26 % intravenous iron). Only 30 % of ESA-treated patients received a combination of ESA and iron supplementation. Blood transfusions formed part of a regular anaemia treatment regimen in 76 % of transfused patients. Management practices were similar in 2009 and 2011. Conclusion Management of anaemia and iron status in patients treated for CIA varies substantially across Europe. Iron status is only assessed in half of the patients. In contrast to clinical evidence, iron treatment is underutilised and mainly based on oral iron supplementation. Implementation of guidelines needs to be increased to minimize the use of blood transfusions.
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Affiliation(s)
- Heinz Ludwig
- Wilhelminen Cancer Research Institute, Wilhelminenspital, Vienna, Austria
| | - M. Aapro
- IMO Clinique de Genolier, Genolier, Switzerland
| | | | - J. Glaspy
- UCLA School of Medicine, Los Angeles, USA
| | | | | | - A. Österborg
- Karolinska Institutet and Karolinska Hospital, Stockholm, Sweden
| | | | | | - Y. Beguin
- CHU of Liège and University of Liège, Liège, Belgium
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21
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Erythropoietin therapy after allogeneic hematopoietic cell transplantation: a prospective, randomized trial. Blood 2014; 124:33-41. [DOI: 10.1182/blood-2014-01-546333] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Key Points
Erythropoietin therapy can be effective to hasten erythroid recovery and reduce transfusion requirements after allogeneic HCT.
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22
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Shander A, Goodnough LT, Javidroozi M, Auerbach M, Carson J, Ershler WB, Ghiglione M, Glaspy J, Lew I. Iron Deficiency Anemia—Bridging the Knowledge and Practice Gap. Transfus Med Rev 2014; 28:156-66. [DOI: 10.1016/j.tmrv.2014.05.001] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Revised: 04/24/2014] [Accepted: 05/09/2014] [Indexed: 12/18/2022]
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23
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Gilreath JA, Stenehjem DD, Rodgers GM. Diagnosis and treatment of cancer-related anemia. Am J Hematol 2014; 89:203-12. [PMID: 24532336 DOI: 10.1002/ajh.23628] [Citation(s) in RCA: 121] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Revised: 10/25/2013] [Accepted: 10/31/2013] [Indexed: 01/04/2023]
Abstract
Cancer-related anemia (CRA) is due to multiple etiologies, including chemotherapy-induced myelosuppression, blood loss, functional iron deficiency, erythropoietin deficiency due to renal disease, marrow involvement with tumor as well as other factors. The most common treatment options for CRA include iron therapy, erythropoietic-stimulating agents (ESAs), and red cell transfusion. Safety concerns as well as restrictions and reimbursement issues surrounding ESA therapy for CRA have resulted in suboptimal treatment. Similarly, many clinicians are not familiar or comfortable using intravenous iron products to treat functional iron deficiency associated with CRA. This article summarizes our approach to treating CRA and discusses commonly encountered clinical scenarios for which current clinical guidelines do not apply.
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Affiliation(s)
- Jeffrey A. Gilreath
- Department of Pharmacy; Huntsman Cancer Institute; University of Utah Hospitals and Clinics; Salt Lake City Utah
| | - David D. Stenehjem
- Department of Pharmacy; Huntsman Cancer Institute; University of Utah Hospitals and Clinics; Salt Lake City Utah
- Department of Pharmacotherapy; Pharmacotherapy Outcomes Research Center, College of Pharmacy, University of Utah; Salt Lake City Utah
| | - George M. Rodgers
- Department of Medicine; University of Utah Hospitals and Clinics; Salt Lake City Utah
- Department of Pathology; University of Utah Hospitals and Clinics; Salt Lake City Utah
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24
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Jaspers A, Baron F, Willems E, Seidel L, Wiegerinck ET, Swinkels DW, Beguin Y. Serum hepcidin following autologous hematopoietic cell transplantation: an illustration of the interplay of iron status, erythropoiesis and inflammation. Haematologica 2014; 99:e35-7. [PMID: 24441148 DOI: 10.3324/haematol.2013.100032] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
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