Switching from subcutaneous to intravenous erythropoietin α in haemodialysis patients requires a major dose increase

Erythropoietin Administration for Anemia Due to Chronic Kidney Disease - Subcutaneous OR Intravenous, What Do We Know So Far?

The prevalence of anemia in chronic kidney disease (CKD) patients is almost twice that of the normal population and its severity increases exponentially as the disease worsens, dramatically affecting the quality of an individual’s life. The advent of erythropoiesis stimulating agents (ESA) in the 1980s saw a revolutionary change in the treatment of anemia in CKD patients, drastically improving quality of life (QoL), overall health and reducing the need for blood transfusions. Numerous ESAs have been developed ever since and are in current use, with the primary routes of administration being intravenous (IV) and subcutaneous (SC) injections. Their use, however, has stirred significant controversy over the last two decades. Additionally, despite numerous studies and trials, the latest international recommendations for their use do not provide clear cut guidance with well-grounded evidence on the recommended route of administration for different sets of patients. Instead, this decision has mainly been left up to the physician’s discretion, whilst keeping certain key factors in mind. This review shall summarize, discuss and compare the findings of previous studies on various factors governing the two aforementioned routes of administration and identify areas that need further exploration.

The optimal choice of medication administration route regarding intravenous, intramuscular, and subcutaneous injection

BACKGROUND

Intravenous (IV), intramuscular (IM), and subcutaneous (SC) are the three most frequently used injection routes in medication administration. Comparative studies of SC versus IV, IM versus IV, or IM versus SC have been sporadically conducted, and some new findings are completely different from the dosage recommendation as described in prescribing information. However, clinicians may still be ignorant of such new evidence-based findings when choosing treatment methods.

METHODS

A literature search was performed using PubMed, MEDLINE, and Web of Sciences™ Core Collection to analyze the advantages and disadvantages of SC, IV, and IM administration in head-to-head comparative studies.

RESULTS

"SC better than IV" involves trastuzumab, rituximab, antitumor necrosis factor medications, bortezomib, amifostine, recombinant human granulocyte-macrophage colony-stimulating factor, granulocyte colony-stimulating factor, recombinant interleukin-2, immunoglobulin, epoetin alfa, heparin, and opioids. "IV better than SC" involves ketamine, vitamin K1, and abatacept. With respect to insulin and ketamine, whether IV has advantages over SC is determined by specific clinical circumstances. "IM better than IV" involves epinephrine, hepatitis B immu-noglobulin, pegaspargase, and some antibiotics. "IV better than IM" involves ketamine, morphine, and antivenom. "IM better than SC" involves epinephrine. "SC better than IM" involves interferon-beta-1a, methotrexate, human chorionic gonadotropin, hepatitis B immunoglobulin, hydrocortisone, and morphine. Safety, efficacy, patient preference, and pharmacoeconomics are four principles governing the choice of injection route. Safety and efficacy must be the preferred principles to be considered (eg, epinephrine should be given intramuscularly during an episode of systemic anaphylaxis). If the safety and efficacy of two injection routes are equivalent, clinicians should consider more about patient preference and pharmacoeconomics because patient preference will ensure optimal treatment adherence and ultimately improve patient experience or satisfaction, while pharmacoeconomic concern will help alleviate nurse shortages and reduce overall health care costs. Besides the principles, the following detailed factors might affect the decision: patient characteristics-related factors (body mass index, age, sex, medical status [eg, renal impairment, comorbidities], personal attitudes toward safety and convenience, past experience, perception of current disease status, health literacy, and socioeconomic status), medication administration-related factors (anatomical site of injection, dose, frequency, formulation characteristics, administration time, indication, flexibility in the route of administration), and health care staff/institution-related factors (knowledge, human resources).

CONCLUSION

This updated review of findings of comparative studies of different injection routes will enrich the knowledge of safe, efficacious, economic, and patient preference-oriented medication administration as well as catching research opportunities in clinical nursing practice.

Diagnosis and treatment of cancer-related anemia

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.

Administration of the same dose of epoetin-beta intravenously and subcutaneously to patients with renal anaemia

OBJECTIVE

Subcutaneous (s.c.) administration of erythropoietin (EPO) is recommended over the intravenous (i.v.) route to reduce doses and costs. Optimal iron treatment is important for the optimal EPO effect. This study investigated whether the haemoglobin (Hb) level of a single patient could be preserved with the same dose of EPO given i.v. as given s.c.

MATERIAL AND METHODS

One-hundred and forty-five haemodialysis patients with the same weekly EPO dose s.c. for 3 months and a stable Hb (maximum fluctuation of 1 mmol/l) were randomized in a crossover study to group A (4 months i.v. then 4 months s.c. EPO) or group B (4 months s.c. then 4 months i.v. EPO, with unchanged EPO dose). Ferritin had to be 300-800 μg/l or transferrin saturation ≥ 20%. Patients with a fall in Hb >1 mmol/l were withdrawn.

RESULTS

Ferritin and transferrin saturation remained within the target range, and mean Hb in the range of 1 mmol/l. Mean EPO doses were unchanged in both groups, and no difference was found between the dropouts due to Hb fall >1 mmol/l in the i.v. and s.c. groups during the first period of the trial.

CONCLUSION

In iron-replete haemodialysis patients the same EPO dose given intravenously is just as effective as given subcutaneously.

Translational pharmacokinetics: challenges of an emerging approach to drug development in stroke

INTRODUCTION

There is increasing recognition of the importance of translational pharmacokinetics in stroke research, lack of which has been cited as one of the main contributing factors to failure of Phase III trials.

AREAS COVERED

The article reviews the translational issues in administration, distribution and sampling in the pharmacokinetics of putative therapeutic drugs in stroke. In addition, the role of translational pharmacometrics in drug development is discussed. The review uses the anti-inflammatory agent, IL-1 receptor antagonist, as an example. The reader will gain an insight into the pitfalls that are commonplace in translating pharmacokinetics from the preclinical to the clinical scenario. The reader will also gain an understanding of the complexities of blood-central nervous system (CNS) barriers in relation to brain pharmacokinetics and the increasing use of translational pharmacometrics in stroke research.

EXPERT OPINION

The translation of preclinical to clinical pharmacokinetics is a discipline that is traditionally overlooked and is likely to be a key factor responsible for failure of clinical trials. With a clear comprehensive insight into the benefits and limitations of translational pharmacokinetics in stroke, translational pharmacokinetics can be safely used to enhance the efficacy of clinical trials in stroke and their likelihood of success.

Long-term outcomes in online hemodiafiltration and high-flux hemodialysis: a comparative analysis

BACKGROUND AND OBJECTIVES

Theoretical advantages exist of online hemodiafiltration (HDF) over high-flux hemodialysis (HD), but outcome data are scarce. Our objective was to compare outcomes between these modalities.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We studied 858 incident patients in our incremental high-flux HD and online HDF program during an 18-yr period. We compared outcomes, including survival, in those who were treated predominantly with HDF (>50% sessions) and those with high-flux HD. Survival comparisons used a Cox model taking into account the time-varying proportion of time spent on HDF. All data were prospectively collected.

RESULTS

A total of 152,043 sessions were delivered as HDF and 291,222 as high-flux HD. A total of 232 (27%) patients were treated predominantly with HDF and 626 (73%) with high-flux HD. Total Kt/V, serum albumin, erythropoietin resistance index, and BP were similar in both groups up to 5 yr after HD initiation. Intradialytic hypotension was less frequent in the predominant HDF group. Predominant HDF treatment was associated with a reduced risk for death after correction for confounding variables. In a second Cox model, proportion of time spent on HDF predicted survival, such that patients who were treated solely by HDF would have a hazard for death of 0.66 compared with those who solely used high-flux HD.

CONCLUSIONS

We found no benefits of HDF over high-flux HD with respect to anemia management, nutrition, mineral metabolism, and BP control. The mortality benefit associated with HDF requires confirmation in large randomized, controlled trials. These data may contribute to their design.

Randomized Equivalence Study Evaluating the Possibility of Switching Hemodialysis Patients Receiving Subcutaneous Human Erythropoietin Directly to Intravenous Darbepoetin Alfa

Background:

Darbepoetin alfa is an erythropoiesis-stimulating agent (ESA) used either intravenously or subcutaneously with no dose penalty; however, the direct switch from subcutaneous recombinant human erythropoietin (rHuEPO) to intravenous darbepoetin has barely been studied.

Objective:

To establish the equivalence of a direct switch from subcutaneous rHuEPO to intravenous darbepoetin versus an indirect switch from subcutaneous rHuEPO to intravenous darbepoetin after 2 months of subcutaneous darbepoetin in patients undergoing hemodialysis.

Methods:

In this open, randomized, 6-month, prospective study, patients with end-stage kidney disease who were on hemodialysis were randomized into 2 groups: direct switch from subcutaneous rHuEPO to intravenous darbepoetin (group 1) and indirect switch from subcutaneous rHuEPO to intravenous darbepoetin after 2 months of subcutaneous darbepoetin (group 2). A third, nonrandomized group (control), consisting of patients treated with intravenous rHuEPO who were switched to intravenous darbepoetin, was also studied to reflect possible variations of hemoglobin (Hb) levels due to change from one type of ESA to the other. The primary outcome was the proportion of patients with stable Hb levels at month 6. Secondary endpoints included Hb stability at month 3, dosage requirements for darbepoetin, and safety of the administration route.

Results:

Among 154 randomized patients, the percentages with stable Hb levels were equivalent in groups 1 and 2, respectively, at month 3 (86.0% vs 91.3%) and month 6 (82.1% vs 81.6%; difference –0.5 [90% CI –12.8 to 11.8]). Mean Hb levels between baseline and month 6 remained stable in both groups, with no variation in mean darbepoetin dose. Mean ferritin levels remained above 100 μg/L in the 3 groups during the whole study, and darbepoetin was well tolerated.

Conclusions:

This study has shown equivalent efficacy on Hb stability without the need for dosage increase in patients switched directly from subcutaneous rHuEPO to intravenous darbepoetin.

A comparison of haemoglobin levels and doses in haemodialysis patients treated with subcutaneous or intravenous darbepoetin alfa: a German prospective, randomized, multicentre study

BACKGROUND

The different efficacy of subcutaneous and intravenous rHuEPO results in higher doses and costs in intravenously treated patients. Darbepoetin alfa has a different pharmacokinetic profile compared to rHuEPO, and previous clinical experience suggests that subcutaneous and intravenous darbepoetin alfa may have similar efficacy. Objective. The aim of this study was to compare the efficacy of intravenous and subcutaneous darbepoetin alfa regarding haemoglobin levels and doses.

METHODS

Patients treated with subcutaneous darbepoetin alfa for at least 6 months were randomized 1:1 to continue with subcutaneous treatment of darbepoetin alfa or to switch to the intravenous administration route. The application frequency was not altered. Darbepoetin alfa dose as well as haemoglobin concentrations were evaluated as per patient average at baseline (Week -3 +/- 1), Week 24 +/- 3 and Week 48 +/- 3.

RESULTS

One hundred fourteen patients in 9 German dialysis centres were included. Fifty-three patients were treated intravenously and 61 patients continued the subcutaneous therapy. Mean haemoglobin levels and mean weekly darbepoetin alfa dose did not change significantly in either treatment group.

CONCLUSIONS

Our data suggest that the darbepoetin alfa dose can be kept constant if patients are switched from subcutaneous to intravenous treatment.

Dose of epoetin alfa used in haemodialysis patients when switching from subcutaneous to intravenous administration

AIM

To determine whether there is a change in the dose of epoetin alfa when switching from subcutaneous (SC) to intravenous (IV) administration in Australian haemodialysis patients.

METHODS

Validated data from 2214 haemodialysis patients at 16 Australian hospitals who switched from SC to IV administration of epoetin alfa from January 2002 to September 2003 were extracted from the Renal Anaemia Management database provided by Janssen-Cilag. Of these patients, 806 had dosing data for at least 1 month before switch through to 6 months post switch (6 month cohort).

RESULTS

In the 6 month cohort, the mean dose was 10 776 IU/week (95% CI: 10 235, 11 317) at switch compared with 12 008 IU/week (95% CI: 11 447, 12 569) 6 months post switch, an increase in a dose of 1232 IU/week (95% CI: 868, 1596). The mean haemoglobin levels at switch were 11.55 g/dL (95% CI: 11.45, 11.66) compared with 11.59 g/dL (95% CI: 11.49, 11.68) 6 months after switch. Centre and dosing frequency of epoetin alfa before switch were determinants of increased dose.

CONCLUSION

Changing from SC to IV administration of epoetin alfa resulted in an 11% increase in mean dose to maintain haemoglobin levels in Australian haemodialysis patients.