Recombinant Human Erythropoietin in Severe Anaemia: Issues of Dosing and Duration

Bloodless Management of the Anemic Patient in the Emergency Department

Anemia is a commonly encountered condition in emergency medicine; transfusion of packed red blood cells is commonly performed for anemic patients in the emergency department (ED), but some patients are unable to accept transfusion of blood products due to medical or religious concerns. The unique, acute, and time-sensitive nature of emergency medicine practice requires that physicians maintain an enhanced awareness of bloodless medicine treatment modalities. Identification of bloodless medicine patient preferences in the ED can help guide physicians in the recommendation of acceptable methods of treating anemia in this patient population. A focus on early hemostasis and resuscitation, instead of attempts to convince the patient to accept blood transfusion, can be lifesaving in patients with acute bleeding. Treatment strategies including the use of methods to reduce unnecessary blood loss, enhance red blood cell production, and increase the oxygen-carrying capacity of blood should also be considered early in patient presentation. Timely involvement of the Hospital Liaison Committee can help facilitate successful interpersonal communication and shared decisionmaking between emergency physicians and bloodless medicine patients. By embracing an understanding of bloodless medicine patient needs as well as available treatment strategies, ED physicians can contribute to optimal overall outcomes for anemic bloodless medicine patients.

Blood transfusion and alternatives in Jehovah's Witness patients

PURPOSE OF REVIEW

More than 8.5 million people in the world observe the Jehovah's Witness faith, and require unique consideration for perioperative blood management as they generally refuse transfusion of blood and blood products. This review addresses a collaborative approach to each patient throughout the perioperative arena. The principles of this approach include optimization of hemoglobin levels preoperatively, attention to blood-salvaging methods intraoperatively, and minimization of blood draws postoperatively. In addition, we review the technologies currently in development as transfusion alternatives, including hemoglobin-based oxygen carriers.

RECENT FINDINGS

Progress has been made recently in the field of synthetic blood alternatives and hemoglobin-based oxygen carriers, which may lead to improved outcomes in this patient population.

SUMMARY

Utilization of multiple prevention and mitigation strategies to optimize oxygen supply and decrease oxygen demand will lead to decreased incidence of critical anemia and subsequent improved mortality in Jehovah's Witness patients.

Early Experiences With PEGylated Carboxyhemoglobin Bovine in Anemic Jehovah’s Witnesses: A Case Series and Review of the Literature

Jehovah’s Witnesses (JW) represent a complex patient population due to their refusal to accept blood transfusions on religious grounds. Pharmacologic management of anemic JW patients is limited to stimulation of hematopoiesis by iron and erythropoietin supplementation and reduction of blood loss by prothrombin complex concentrates (PCCs). Hemoglobin-based oxygen carriers (HBOCs) represent the only pharmacologic modality for JW patients capable of acutely increasing a patient’s oxygen carrying capacity in the setting of organ failure, yet clinical safety and efficacy data are lacking in this population. We report 3 cases in which the HBOC, PEGylated carboxyhemoglobin bovine (Sanguinate®), was requested under emergent circumstances for severely anemic (hemoglobin <5 g/dL) JW patients who refused blood transfusions. Two patients received PEGylated carboxyhemoglobin infusions for severe anemia, while the third patient died prior to receiving the medication. One patient who received Sanguinate died after 5 units of medication. The other patient’s hemoglobin recovered and she was discharged in stable condition. This series demonstrates the complex nature of the critically anemic JW population and highlights the clinical considerations of using HBOCs in clinical practice and the critical need for further research before they can be broadly recommended.

Pharmacotherapy in Acutely Anemic Jehovah’s Witnesses: An Evidence-Based Review

Objective: To determine the pharmacological treatment methods available to anemic Jehovah’s Witnesses (JW). Data Sources: MEDLINE and PubMed were searched from inception through February 2018 using the search terms Jehovah’s Witnesses, treatment, erythropoietin, hemoglobin-based oxygen carrier, Sanguinate, Hemopure, bleeding, and anemia. Study Selection and Data Extraction: All clinical trials, cohort studies, case-control studies, and observational trials involving pharmacotherapy in anemic JW patients were evaluated. Case reports and bibliographies were also analyzed for inclusion. Data Synthesis: Two studies involving the use of erythropoietin (EPO) and one study involving recombinant factor VIIa were included. Information was also included from other pharmacotherapeutic modalities that had case report data only. Current published evidence is limited with regard to evidence-based management of JW patients. High-dose EPO, intravenous iron supplementation, and hemostatic agents have demonstrated good clinical outcomes in case reports. EPO doses as high as 40 000 units daily have been advocated by some experts; however, pharmacokinetic studies do not support dose-dependent effects. Hemoglobin-based oxygen carriers (HBOCs) are currently not Food and Drug Administration approved. They are available through expanded access programs and may represent a lifesaving modality in the setting of severe anemia. Conclusions: There are currently not enough data to make definitive recommendations on the use of pharmacological agents to treat severe anemia in the JW population. Further evidence utilizing EPO and HBOCs will be beneficial to guide therapy.

Use of hyperbaric oxygen therapy and PEGylated carboxyhemoglobin bovine in a Jehovah's Witness with life-threatening anemia following postpartum hemorrhage

We present a case of a Jehovah's Witness patient who refused blood products, with the exception of albumin and clotting factors, and underwent cesarean section under spinal anesthesia complicated by postpartum hemorrhage. She was fluid resuscitated and treated with multiple uterotonics and internal iliac artery embolization. Because of agitation she required emergency tracheal intubation. Her hemoglobin concentration dropped from a preoperative value of 12mg/dL to 3mg/dL on postoperative day one. She was acidotic, requiring vasopressors for hemodynamic stability and remained ventilated and sedated. She was treated with daily erythropoietin, iron therapy and cyanocobalamin. Because of ongoing hemorrhage, continued acidemia and vasopressor requirements she was co-treated with PEGylated carboxyhemoglobin bovine and hyperbaric oxygen therapy to reverse her oxygen debt. On postoperative day eight her hemoglobin concentration was 7mg/dL, she was hemodynamically stable and vasopressors were discontinued. She was extubated and discharged from the intensive care unit on postoperative day eight. This report highlights the multiple modalities used in treating a severely anemic patient who refused blood, the use of an investigational new drug, the process of obtaining this drug via the United States Food and Drug Administration emergency expanded access regulation for single patient clinical treatment, and ethical dilemmas faced during treatment.

Profound Anaemia in a Jehovah's Witness following Upper Gastrointestinal Haemorrhage: Intensive Care Management

Management of the profoundly anaemic patient who competently refuses blood transfusion will always prove challenging. This article provides a review of treatment strategies based around a recent case of a patient presenting after major gastrointestinal haemorrhage. The main part of management involves providing supportive intensive care, paying particular attention to oxygen delivery and consumption, and minimising further blood loss. Specific treatments, such as pharmacotherapy to promote erythropoiesis, are based largely on indirect evidence or expert opinion. Virtually all aspects of care involve carefully balancing a shifting profile of risks and benefits; a team approach and close communication with the family are essential. This patient's successful outcome has extended our understanding of this area, which is discussed.

Epoetin in the 'untransfusable' anaemic patient: a retrospective case series and systematic analysis of literature case reports

BACKGROUND

Erythropoiesis stimulating agents [erythropoietin (EPO)] have been recommended to treat anaemic patients who cannot receive or refuse blood tranfusion ('untransfusable' patients).

OBJECTIVE

The objective of the study was to quantify the association of EPO use with haemoglobin (Hgb) recovery in anaemic untransfusable hospitalised patients.

METHODS/MATERIALS

EPO treated anaemic untransfusable patients were identified through the combination of a retrospective case review and a systematic review of the medical literature. Literature reports of untransfusable patients not treated with any EPO were used as a comparator group. Hgb concentrations before and following EPO use were abstracted and used to determine the rate of Hgb recovery for each case. Multilevel mixed effects modelling was used to determine the association of Hgb recovery with EPO use.

RESULTS

A total of 76 EPO treated cases (19 cases from the retrospective hospital case review and 57 from the literature), and 33 non-EPO treated comparator patients from the literature were included in the study. Hgb increased similarly over time in all groups at an overall mean standard error (SE) rate of 0·13 (0·01) g dL(-1)  day(-1) . The Hgb recovery rate was higher in patients with lower baseline Hgb, regardless of EPO use. No association was found between the rate of Hgb recovery and EPO use, dose or therapy duration.

CONCLUSIONS

In anaemic, 'untransfusable' hospitalised patients, EPO use was not associated with increased Hgb recovery at anytime within 28 days.

Iron Supplementation and Epoetin Alfa in a Jehovah's Witness with Severe Iron Deficiency Anemia

Objective:

To report a case of severe iron deficiency anemia (IDA) in a Jehovah's Witness, successfully treated with iron supplementation and epoetin alfa.

Case Summary:

A 69-year-old African man, a Jehovah's Witness, presented with severe IDA of unknown cause and was admitted to the general medicine service. He was treated with oral and intravenous iron and subcutaneous epoetin alfa. His serum hemoglobin concentration steadily improved. He was discharged to home on epoetin alfa and iron supplementation. His hemoglobin concentration was stable 1 month later.

Discussion:

Iron is a critical factor in hemoglobin synthesis and erythropoiesis, and iron deficiency is a common cause of anemia. Jehovah's Witnesses with severe anemia pose a challenge to providers because of their refusal to accept blood products. Alternative treatment regimens are few, and little evidence exists to guide treatment decisions. Recombinant human erythropoietin (rHuEpo) may play a role, but little is known about its use in IDA. Most studies on rHuEpo focus on its use in the setting of surgery, burns, trauma, pregnancy, and severe gastrointestinal bleeding.

Conclusions:

This case demonstrates that rHuEpo plus iron supplementation may be an acceptable alternative to blood transfusion in a Jehovah's Witness patient with severe IDA.

Management of Jehovah's Witnesses in otolaryngology, head and neck surgery

It is imperative that surgeons should have some knowledge and understanding of the beliefs of Jehovah's Witnesses to respect the patient's wishes and effectively minimize and manage blood loss. The objective of this review was to provide a management strategy for Jehovah's Witness patients undergoing otolaryngology, head and neck surgery, because there is paucity of information regarding this within our literature. A systematic review of medical literature was conducted. Articles were identified using MEDLINE (1966-2007). The search strategy used Medical Subject Heading terms Jehovah's Witnesses, Beliefs, Ethical and Legal issues, Blood transfusion alternatives, ENT, Head and Neck surgery in Jehovah' witnesses. There is a broad range of nonblood surgical management strategies available in other specialities, making major surgery possible within this population. This review suggests recommendations in elective surgery, trauma, and emergencies.

Klinische Aspekte der Therapie mit Erythrozyten

With the decreased risk of homologous blood transfusions, the costs of blood products have become increasingly important for hospitals with major surgical procedures and oncologic treatment. It is well established from clinical physiology that a hemoglobin concentration (cHb) lower than 6.21 mmol/l (10 g/dl) is enough to serve the oxygen demand of the tissues, but transfusion of erythrocytes is still liberally carried out. Data obtained from Jehovah's Witnesses, who categorically refuse blood transfusions, demonstrate that they have an outcome similar to patients who are transfused. The lessons we have learned from Jehovah's Witnesses should result in an emotionless discussion, and a reduction in transfusion requirements.