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Assessment of Risk of Bias in Osteosarcoma and Ewing's Sarcoma Randomized Controlled Trials: A Systematic Review. Curr Oncol 2021; 28:3771-3794. [PMID: 34677240 PMCID: PMC8534836 DOI: 10.3390/curroncol28050322] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 09/14/2021] [Accepted: 09/23/2021] [Indexed: 12/03/2022] Open
Abstract
Aim: The aim of this study was to systematically assess the risk of bias in osteosarcoma and Ewing’s sarcoma (ES) randomized controlled trials (RCT) and to examine the relationships between bias and conflict of interest/industry sponsorship. Methods: An OVID-MEDLINE search was performed (1976–2019). Using the Cochrane Collaboration guidelines, two reviewers independently assessed the prevalence of risk of bias in different RCT design domains. The relationship between conflicts of interest and industry funding with the frequency of bias was examined. Results: 73 RCTs met inclusion criteria. Prevalence of low-risk bias domains was 47.3%, unclear-risk domains 47.8%, and 4.9% of the domains had a high-risk of bias. Domains with the highest risk of bias were blinding of participants/personnel and outcome assessors, followed by randomization and allocation concealment. Overtime, frequency of unclear-risk of bias domains decreased (χ2 = 5.32, p = 0.02), whilst low and high-risk domains increased (χ2 = 8.13, p = 0.004). Studies with conflicts of interest and industry sponsorships were 4.2 and 3.1 times more likely to have design domains with a high-risk of bias (p < 0.05). Conclusion: This study demonstrates that sources of potential bias are prevalent in both osteosarcoma and ES RCTs. Studies with financial conflicts of interest and industry sponsors were significantly more likely to have domains with a high-risk of bias. Improvements in reporting and adherence to proper methodology will reduce the risk of bias and improve the validity of the results of RCTs in osteosarcoma and ES.
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D'Cunha R, Schmidt R, Widness JA, Mock DM, Yan X, Cress GA, Kuruvilla D, Veng-Pedersen P, An G. Target-mediated disposition population pharmacokinetics model of erythropoietin in premature neonates following multiple intravenous and subcutaneous dosing regimens. Eur J Pharm Sci 2019; 138:105013. [PMID: 31340188 DOI: 10.1016/j.ejps.2019.105013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 06/16/2019] [Accepted: 07/18/2019] [Indexed: 01/09/2023]
Abstract
Routine erythropoietin (Epo) therapy for neonatal anemia is presently controversial due to its modest response. We speculate that an important contributor to this modest response is that previous clinical study designs were not driven by rigorous mechanistic and kinetic insights into the complex pharmacokinetics (PK) and pharmacodynamics (PD) of Epo in this population. To address this therapeutic opportunity, we conducted a prospective clinical study to investigate the PK of Epo in very-low-birth-weight (VLBW) premature neonates using a unique Epo dosing algorithm that accounts for complex neonatal erythropoietic physiology. Twenty-seven subjects received up to 10 intravenous or subcutaneous exogenous doses of Epo (600 or 1200 U/kg) during the first 4 weeks of life. Subjects were administered two doses of Epo 1200 U/kg on days 2 and 16, and eight doses of Epo 600 U/kg on days 4, 5, 6, 7, 9, 14, 15, and 28 following birth. We have developed for the first time a mechanistic, target-mediated disposition model that provides novel insights into the mechanisms driving Epo PK in VLBW neonates. Epo association rate, kon, was estimated to be 0.00610 pM-1h-1, and the dissociation rate koff was 0.112 h-1. Internalization of the Epo-target complex (kint) and the total receptor concentration (Rmax) were estimated to be 0.118 h-1 and 133 pM, respectively. Following s.c. administration, the absorption rate (ka) of Epo was 0.0738h-1 and bioavailability was 78.0%. Our mechanism-based population pharmacokinetic analysis provided quantitative insight into Epo kinetics in VLBW neonates; the information gained will assist in deriving dosing strategies for neonatal anemia and for neuroprotection efficacy studies.
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Affiliation(s)
- Ronilda D'Cunha
- Division of Pharmaceutics and Translational Therapeutics, College of Pharmacy, University of Iowa, Iowa City, IA 52242, USA
| | - Robert Schmidt
- Department of Pediatrics Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA
| | - John A Widness
- Department of Pediatrics Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA
| | - Donald M Mock
- Department of Biochemistry and Molecular Biology, University of Arkansas for Medical Sciences, USA
| | - Xiaoyu Yan
- School of Pharmacy, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong
| | - Gretchen A Cress
- Department of Pediatrics Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA
| | - Denison Kuruvilla
- Division of Pharmaceutics and Translational Therapeutics, College of Pharmacy, University of Iowa, Iowa City, IA 52242, USA; MedImmune, LLC., San Francisco, CA, USA
| | - Peter Veng-Pedersen
- Division of Pharmaceutics and Translational Therapeutics, College of Pharmacy, University of Iowa, Iowa City, IA 52242, USA
| | - Guohua An
- Division of Pharmaceutics and Translational Therapeutics, College of Pharmacy, University of Iowa, Iowa City, IA 52242, USA.
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D'Cunha R, Widness JA, Yan X, Schmidt RL, Veng-Pedersen P, An G. A Mechanism-Based Population Pharmacokinetics Model of Erythropoietin in Premature Infants and Healthy Adults Following Multiple Intravenous Doses. J Clin Pharmacol 2019; 59:835-846. [PMID: 30618050 DOI: 10.1002/jcph.1368] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Accepted: 12/05/2018] [Indexed: 01/23/2023]
Abstract
The objective of the current study was to develop a population pharmacokinetics (PK) model for erythropoietin (Epo) in premature infants and healthy adults to characterize the variation in PK, and to study the differences in Epo PK in these 2 populations. Thirteen very low-birth-weight premature infants (<1500 g at birth), and 10 healthy adults received up to 4 intravenous doses of Epo that ranged from 10 to 500 U/kg. The final model had a target-mediated saturable, nonlinear, elimination pathway that incorporated the mechanism of Epo binding to its receptors along with a parallel linear, central elimination pathway. Epo clearance was found to be significantly higher in preterm infants compared to adults. Epo clearance via the nonlinear pathway was found to be much higher in infants; they had an Epo receptor capacity of 133 pM vs 86.6 pM in adults, which is most likely due to the higher erythroid progenitor cell mass per kilogram of body weight in infants. The parallel linear elimination was found to be more dominant in adults, reaching 91% of the total clearance with a 500-U/kg dose compared to just 6.1% of the total clearance following the same dose in preterm infants. Thus, this mechanism-based population PK model revealed that receptor-based nonlinear elimination is the dominant Epo elimination pathway in premature infants, and parallel linear elimination is dominant in adults.
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Affiliation(s)
- Ronilda D'Cunha
- Division of Pharmaceutics and Translational Therapeutics, College of Pharmacy, University of Iowa, Iowa City, IA, USA
| | - John A Widness
- Department of Pediatrics, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Xiaoyu Yan
- School of Pharmacy, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong
| | - Robert L Schmidt
- Department of Pediatrics, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Peter Veng-Pedersen
- Division of Pharmaceutics and Translational Therapeutics, College of Pharmacy, University of Iowa, Iowa City, IA, USA
| | - Guohua An
- Division of Pharmaceutics and Translational Therapeutics, College of Pharmacy, University of Iowa, Iowa City, IA, USA
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Tonia T, Mettler A, Robert N, Schwarzer G, Seidenfeld J, Weingart O, Hyde C, Engert A, Bohlius J. Erythropoietin or darbepoetin for patients with cancer. Cochrane Database Syst Rev 2012; 12:CD003407. [PMID: 23235597 PMCID: PMC8145276 DOI: 10.1002/14651858.cd003407.pub5] [Citation(s) in RCA: 101] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Anaemia associated with cancer and cancer therapy is an important clinical factor in the treatment of malignant diseases. Therapeutic alternatives are recombinant human erythropoiesis stimulating agents (ESAs) and red blood cell transfusions. OBJECTIVES To assess the effects of ESAs to either prevent or treat anaemia in cancer patients. SEARCH METHODS This is an update of a Cochrane review first published in 2004. We searched the Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE and other databases. Searches were done for the periods 01/1985 to 12/2001 for the first review, 1/2002 to 04/2005 for the first update and to November 2011 for the current update. We also contacted experts in the field and pharmaceutical companies. SELECTION CRITERIA Randomised controlled trials on managing anaemia in cancer patients receiving or not receiving anti-cancer therapy that compared the use of ESAs (plus transfusion if needed). DATA COLLECTION AND ANALYSIS Several review authors assessed trial quality and extracted data. One review author assessed quality assessment and extracted data, a second review author checked for correctness. MAIN RESULTS This update of the systematic review includes a total of 91 trials with 20,102 participants. Use of ESAs significantly reduced the relative risk of red blood cell transfusions (risk ratio (RR) 0.65; 95% confidence interval (CI) 0.62 to 0.68, 70 trials, N = 16,093). On average, participants in the ESAs group received one unit of blood less than the control group (mean difference (MD) -0.98; 95% CI -1.17 to -0.78, 19 trials, N = 4,715). Haematological response was observed more often in participants receiving ESAs (RR 3.93; 95% CI 3.10 to 3.71, 31 trials, N = 6,413). There was suggestive evidence that ESAs may improve Quality of Life (QoL). There was strong evidence that ESAs increase mortality during active study period (hazard ratio (HR) 1.17; 95% CI 1.06 to 1.29, 70 trials, N = 15,935) and some evidence that ESAs decrease overall survival (HR 1.05; 95% CI 1.00 to 1.11, 78 trials, N = 19,003). The risk ratio for thromboembolic complications was increased in patients receiving ESAs compared to controls (RR 1.52, 95% CI 1.34 to 1.74; 57 trials, N = 15,498). ESAs may also increase the risk for hypertension (fixed-effect model: RR 1.30; 95% CI 1.08 to 1.56; random-effects model: RR 1.12; 95% CI 0.94 to 1.33, 31 trials, N = 7,228) and thrombocytopenia/haemorrhage (RR 1.21; 95% CI 1.04 to 1.42; 21 trials, N = 4,507). There was insufficient evidence to support an effect of ESA on tumour response (fixed-effect RR 1.02; 95% CI 0.98 to 1.06, 15 trials, N = 5,012). AUTHORS' CONCLUSIONS ESAs reduce the need for red blood cell transfusions but increase the risk for thromboembolic events and deaths. There is suggestive evidence that ESAs may improve QoL. Whether and how ESAs affects tumour control remains uncertain. The increased risk of death and thromboembolic events should be balanced against the potential benefits of ESA treatment taking into account each patient's clinical circumstances and preferences. More data are needed for the effect of these drugs on quality of life and tumour progression. Further research is needed to clarify cellular and molecular mechanisms and pathways of the effects of ESAs on thrombogenesis and their potential effects on tumour growth.
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Affiliation(s)
- Thomy Tonia
- University of BernInstitute of Social and Preventive MedicineBernSwitzerland3012
| | - Annette Mettler
- University of BernInstitute of Social and Preventive MedicineBernSwitzerland3012
| | - Nadège Robert
- Kantonsspitalapotheke WinterthurPharmacyBrauerstrasse 15WinterthurSwitzerlandCH‐8400
| | - Guido Schwarzer
- Institute of Medical Biometry and Medical Informatics, University Medical Center FreiburgGerman Cochrane CentreStefan‐Meier‐Str. 26FreiburgGermanyD‐79104
| | - Jerome Seidenfeld
- American Society of Clinical OncologyDepartment of Quality and Guidelines1900 Duke Street, Suite 200AlexandriaVAUSA22314
| | | | - Chris Hyde
- University of Exeter Medical School, University of ExeterPeninsula Technology Assessment Group (PenTAG)Veysey BuildingSalmon Pool LaneExeterUKEX2 4SG
| | - Andreas Engert
- University Hospital of CologneCochrane Haematological Malignancies Group, Department I of Internal MedicineKerpener Str. 62CologneGermany50924
| | - Julia Bohlius
- University of BernInstitute of Social and Preventive MedicineBernSwitzerland3012
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Shi R, Derendorf H. Pediatric Dosing and Body Size in Biotherapeutics. Pharmaceutics 2010; 2:389-418. [PMID: 27721364 PMCID: PMC3967145 DOI: 10.3390/pharmaceutics2040389] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2010] [Revised: 12/09/2010] [Accepted: 12/15/2010] [Indexed: 01/19/2023] Open
Abstract
Although pediatric doses for biotherapeutics are often based on patients' body weight (mg/kg) or body surface area (mg/m2), linear body size dose adjustment is highly empirical. Growth and maturity are also important factors that affect the absorption, distribution, metabolism and excretion (ADME) of biologics in pediatrics. The complexity of the factors involved in pediatric pharmacokinetics lends to the reconsideration of body size based dose adjustment. A proper dosing adjustment for pediatrics should also provide less intersubject variability in the pharmacokinetics and/or pharmacodynamics of the product compared with no dose adjustment. Biological proteins and peptides generally share the same pharmacokinetic principle with small molecules, but the underlying mechanism can be very different. Here, pediatric and adult pharmacokinetic parameters are compared and summarized for selected biotherapeutics. The effect of body size on the pediatric pharmacokinetics for these biological products is discussed in the current review.
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Affiliation(s)
- Rong Shi
- Department of Pharmaceutics, University of Florida, Gainesville, FL, 32610, USA.
| | - Hartmut Derendorf
- Department of Pharmaceutics, University of Florida, Gainesville, FL, 32610, USA.
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Bohlius J, Schmidlin K, Brillant C, Schwarzer G, Trelle S, Seidenfeld J, Zwahlen M, Clarke MJ, Weingart O, Kluge S, Piper M, Napoli M, Rades D, Steensma D, Djulbegovic B, Fey MF, Ray‐Coquard I, Moebus V, Thomas G, Untch M, Schumacher M, Egger M, Engert A. Erythropoietin or Darbepoetin for patients with cancer--meta-analysis based on individual patient data. Cochrane Database Syst Rev 2009; 2009:CD007303. [PMID: 19588423 PMCID: PMC7208183 DOI: 10.1002/14651858.cd007303.pub2] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Erythropoiesis-stimulating agents (ESAs) reduce anemia in cancer patients and may improve quality of life, but there are concerns that ESAs might increase mortality. OBJECTIVES Our objectives were to examine the effect of ESAs and identify factors that modify the effects of ESAs on overall survival, progression free survival, thromboembolic and cardiovascular events as well as need for transfusions and other important safety and efficacy outcomes in cancer patients. SEARCH STRATEGY We searched the Cochrane Library, Medline, Embase and conference proceedings for eligible trials. Manufacturers of ESAs were contacted to identify additional trials. SELECTION CRITERIA We included randomized controlled trials comparing epoetin or darbepoetin plus red blood cell transfusions (as necessary) versus red blood cell transfusions (as necessary) alone, to prevent or treat anemia in adult or pediatric cancer patients with or without concurrent antineoplastic therapy. DATA COLLECTION AND ANALYSIS We performed a meta-analysis of randomized controlled trials comparing epoetin alpha, epoetin beta or darbepoetin alpha plus red blood cell transfusions versus transfusion alone, for prophylaxis or therapy of anemia while or after receiving anti-cancer treatment. Patient-level data were obtained and analyzed by independent statisticians at two academic departments, using fixed-effects and random-effects meta-analysis. Analyses were according to the intention-to-treat principle. Primary endpoints were on study mortality and overall survival during the longest available follow-up, regardless of anticancer treatment, and in patients receiving chemotherapy. Tests for interactions were used to identify differences in effects of ESAs on mortality across pre-specified subgroups. The present review reports only the results for the primary endpoint. MAIN RESULTS A total of 13933 cancer patients from 53 trials were analyzed, 1530 patients died on-study and 4993 overall. ESAs increased on study mortality (combined hazard ratio [cHR] 1.17; 95% CI 1.06-1.30) and worsened overall survival (cHR 1.06; 95% CI 1.00-1.12), with little heterogeneity between trials (I(2) 0%, p=0.87 and I(2) 7.1%, p=0.33, respectively). Thirty-eight trials enrolled 10441 patients receiving chemotherapy. The cHR for on study mortality was 1.10 (95% CI 0.98-1.24) and 1.04; 95% CI 0.97-1.11) for overall survival. There was little evidence for a difference between trials of patients receiving different cancer treatments (P for interaction=0.42). AUTHORS' CONCLUSIONS ESA treatment in cancer patients increased on study mortality and worsened overall survival. For patients undergoing chemotherapy the increase was less pronounced, but an adverse effect could not be excluded.
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Affiliation(s)
- Julia Bohlius
- University of BernInstitute of Social and Preventive MedicineBernSwitzerland3012
| | - Kurt Schmidlin
- University of BernInstitute of Social and Preventive MedicineBernSwitzerland3012
| | - Corinne Brillant
- University Hospital of CologneCochrane Haematological Malignancies Group, Department I of Internal MedicineKerpener Str. 62CologneGermany50924
| | - Guido Schwarzer
- Insitute of Medical Biometry and Medical InformaticsGerman Cochrane CentreUniversity Medical Center FreiburgStefan‐Meier‐Str. 26FreiburgGermanyD‐79104
| | - Sven Trelle
- University of BernInstitute of Social and Preventive MedicineBernSwitzerland3012
| | - Jerome Seidenfeld
- American Society of Clinical OncologyDepartment of Cancer Policy and Clinical Affairs1900 Duke Street, Suite 200AlexandriaVAUSA22314
| | - Marcel Zwahlen
- University of BernInstitute of Social and Preventive MedicineBernSwitzerland3012
| | - Mike J Clarke
- UK Cochrane CentreNational Institute for Health ResearchSummertown Pavilion, Middle WayOxfordUKOX2 7LG
| | - Olaf Weingart
- University Hospital of CologneCochrane Haematological Malignancies Group, Department I of Internal MedicineKerpener Str. 62CologneGermany50924
| | - Sabine Kluge
- University Hospital of CologneCochrane Haematological Malignancies Group, Department I of Internal MedicineKerpener Str. 62CologneGermany50924
| | - Margaret Piper
- Blue Cross and Blue Shield AssociationTechnology Evaluation Center225 N Michigan AvenueChicagoILUSA60501
| | - Maryann Napoli
- Center for Medical Consumers130 Macdougal StreetNew YorkUSA10012
| | - Dirk Rades
- University HospitalDepartment of Radiation OncologyLübeckGermany
| | | | - Benjamin Djulbegovic
- Center for Evidence Based Medicine and Health Outcomes Research, University of South FloridaProfessor of Medicine and Oncology, H. Lee Moffitt Cancer CenterUSF Health Clinical Research,12901 Bruce B. Downs Boulevard, MDC02TampaFloridaUSA33612
| | - Martin F Fey
- University and Inselspital BernDepartment of Medical OncologyEffingerstraße 102BernSwitzerland3010
| | | | - Volker Moebus
- Academic Hospital Frankfurt am Main HöchstDepartment of GynecologyGotenstraße 6‐8Frankfurt a.M.Germany65929
| | - Gillian Thomas
- University of TorontoOdette Sunnybrook Cancer CentreRoxborough Street WTorontoOntarioCanadaM5R 1V1
| | - Michael Untch
- Helios Hospital Berlin‐BuchClinic for GynaecologySchwanebecker Chaussee 50BerlinGermany13125
| | - Martin Schumacher
- Institute of Medical Biometry and Medical Informatics, University Medical Center FreiburgGerman Cochrane CenterFreiburgGermany
| | - Matthias Egger
- Institute of Social and Preventive MedicineInstitute of Social MedicineFinkenhubelweg 11BernSwitzerland3012
| | - Andreas Engert
- University Hospital of CologneCochrane Haematological Malignancies Group, Department I of Internal MedicineKerpener Str. 62CologneGermany50924
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Blumer J, Berg S, Adamson PC, Loew T, Rossi G, Hastings C. Pharmacokinetic evaluation of darbepoetin alfa for the treatment of pediatric patients with chemotherapy-induced anemia. Pediatr Blood Cancer 2007; 49:687-93. [PMID: 17120240 DOI: 10.1002/pbc.21079] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Cancer patients undergoing chemotherapy often develop anemia, which can increase the risk for transfusions and fatigue. The recombinant erythropoiesis-stimulating agent darbepoetin alfa can effectively treat chemotherapy-induced anemia (CIA) in adults, but limited data are available regarding its use in pediatric cancer patients. The goals of this phase 1, open-label, uncontrolled study were to assess the pharmacokinetic profile and safety of darbepoetin alfa in pediatric patients with CIA. PROCEDURE Pediatric patients with nonmyeloid malignancies and CIA received up to six doses of darbepoetin alfa 2.25 mcg/kg subcutaneously. After the first dose, the pharmacokinetic properties of darbepoetin alfa were assessed during a 14-day sampling period. All subsequent doses were given weekly with predose blood samples collected before study drug administration. RESULTS After a single dose of darbepoetin alfa, the mean (SD) peak serum concentration was 10.5 (3) ng/ml, and the median time to peak concentration was 71.4 hr. Darbepoetin alfa exhibited a mean (SD) terminal half-life of 49.4 (32) hr. Upon repeated weekly administration, no evidence of darbepoetin alfa accumulation was observed though there was high intra- and inter-individual variability. In addition, darbepoetin alfa was well tolerated; some study patients experienced increases in hemoglobin. CONCLUSIONS The pharmacokinetic profile of darbepoetin alfa indicated that it was slowly absorbed and exhibited a long terminal half-life in these pediatric study patients with CIA.
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