1
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Han J, Ahmadi H, Ladi-Seyedian SS, Clifford TG, Douglawi A, Xu W, Bazargani ST, Mingo S, Thangathurai D, Daneshmand S, Djaladat H. Safety and feasibility of urological procedures in Jehovah's Witness patients. Int J Urol 2021; 29:83-88. [PMID: 34642972 DOI: 10.1111/iju.14721] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 09/17/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To describe the safety and feasibility of urological transfusion-free surgeries in Jehovah's Witness patients. METHODS An institutional review board-approved, retrospective review of Jehovah's Witness patients who underwent urological transfusion-free surgeries between 2003 and 2019 was carried out. Surgeries were stratified into low, intermediate and high risk based on complexity, invasiveness and bleeding potential. Patient demographics, perioperative data and clinical outcomes are reported. RESULTS A total of 161 Jehovah's Witness patients (median age 63.4 years) underwent 171 transfusion-free surgeries, including 57 (33.3%) in low-, 82 (47.9%) in intermediate- and 32 (18.8%) in high-risk categories. The mean estimated blood loss increased with risk category at 48 mL (range 10-50 mL), 150 mL (range 50-200 mL) and 388 mL (range 137-500 mL), respectively (P < 0.001). Implementing blood augmentation and conservation techniques increased with each risk category (3.5% vs 29% vs 69%, respectively; P < 0.001). Average length of stay increased concordantly at 1.6 days (range 0-12 days), 2.9 days (range 1-13 days) and 5.6 days (range 2-12 days), respectively (P ≤ 0.001). However, there was no increase in complication rates and readmission rates attributed to bleeding among the risk categories at 30 days (P = 0.9 and 0.4, respectively) and 90 days (P = 0.7 and 0.7, respectively). CONCLUSIONS Transfusion free urological surgery can be safely carried out on Jehovah's Witness patients using contemporary perioperative optimization. Additionally, these techniques can be expanded for use in the general patient population to avoid short- and long-term consequences of perioperative blood transfusion.
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Affiliation(s)
- Jullet Han
- Department of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, California, USA
| | - Hamed Ahmadi
- Department of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, California, USA
| | - Seyedeh-Sanam Ladi-Seyedian
- Department of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, California, USA
| | - Thomas G Clifford
- Department of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, California, USA
| | - Antoin Douglawi
- Department of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, California, USA
| | - Willem Xu
- Department of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, California, USA
| | - Soroush T Bazargani
- Department of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, California, USA
| | - Samuel Mingo
- Department of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, California, USA
| | - Duraiyah Thangathurai
- Department of Anesthesia, Keck Medical Center, University of Southern California, Los Angeles, California, USA
| | - Siamak Daneshmand
- Department of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, California, USA
| | - Hooman Djaladat
- Department of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, California, USA
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2
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Vega A, Zhang R, Wong HL, Wernecke M, Alexander M, Feng Y, Lo AC, Lufkin B, Ryan Q, Izem R, MaCurdy TE, Kelman JA, Graham DJ. Trends in Erythropoiesis-stimulating agent use and blood transfusions for chemotherapy-induced anemia throughout FDA's risk evaluation and mitigation strategy lifecycle. Pharmacoepidemiol Drug Saf 2021; 30:626-635. [PMID: 33534188 DOI: 10.1002/pds.5202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 01/28/2021] [Indexed: 11/11/2022]
Abstract
PURPOSE Erythropoiesis-stimulating agents (ESAs), indicated for treating some patients with chemotherapy-induced anemia (CIA), may increase the risk of tumor progression and mortality. FDA required a Risk Evaluation and Mitigation Strategy (REMS) to mitigate these risks. We assessed REMS impact on ESA administration and red blood cell (RBC) transfusion as surrogate metrics for REMS effectiveness. METHODS Retrospective cohort study including data from January 1, 2006 to December 31, 2018 for beneficiaries ≥65 years enrolled in Centers for Medicare & Medicaid Services (CMS) Medicare Parts A/B with a cancer diagnosis; patients with other indications for ESA use were excluded. Study time was divided into five periods demarcated by issuance of CMS National Coverage Determination (NCD) (Pre-NCD, Pre-REMS) and REMS milestones (Grace Period, REMS, post-REMS). Study outcomes were monthly proportion of chemotherapy episodes (CTEs) with concomitant ESA administration, with post-CTE ESA administration, and with RBC transfusions. RESULTS Of 1 778 855 beneficiaries treated with CT, 308742 received concomitant ESA for CIA. The proportion of CTEs with concomitant and post-CTE ESA administration decreased Pre-REMS (9.0 percentage points [pp] and 3.5 pp, respectively). There were no significant post-REMS changes in the proportion of CTEs with concomitant (0.0 pp) and post-CTE ESA administration (0.1 pp). Fluctuation in RBC transfusions was <4 pp throughout the study period. CONCLUSIONS Medicare beneficiaries showed a substantive decrease in ESA administration after NCD, with minimal impact by the REMS and its removal. Small changes in RBC transfusion over the study period were likely due to a national secular trend.
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Affiliation(s)
- Amarilys Vega
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Rongmei Zhang
- Office of Biostatistics, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, United States
| | - Hui-Lee Wong
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | | | | | - Yuhui Feng
- Acumen, LLC, Burlingame, California, USA
| | - An-Chi Lo
- Acumen, LLC, Burlingame, California, USA
| | | | - Qin Ryan
- Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Rima Izem
- Office of Biostatistics, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, United States
| | - Thomas E MaCurdy
- Acumen, LLC, Burlingame, California, USA.,Department of Economics, Stanford University, Stanford, California, USA
| | - Jeffrey A Kelman
- Centers for Medicare & Medicaid Services, Washington, District of Columbia, USA
| | - David J Graham
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
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3
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Schoen MW, Hoque S, Witherspoon BJ, Schooley B, Sartor O, Yang YT, Yarnold PR, Knopf KB, Hrushesky WJM, Dickson M, Chen BJ, Nabhan C, Bennett CL. End of an era for erythropoiesis-stimulating agents in oncology. Int J Cancer 2020; 146:2829-2835. [PMID: 32037527 DOI: 10.1002/ijc.32917] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 12/17/2019] [Accepted: 01/07/2020] [Indexed: 12/15/2022]
Abstract
Erythropoiesis-stimulating agents (ESAs) are available to treat chemotherapy-induced anemia (CIA). In 2007-2008, regulatory notifications advised of venous thromboembolism and mortality risks while the Center for Medicare and Medicaid Services' restricted ESA initiation to patients with hemoglobin <10 g/dl. In 2010, a Risk Evaluation and Mitigation Strategies required consent prior to administration. We evaluated ESA utilization from 2003 to 2012 and obtained private health insurer claims data for persons with lung, colorectal, or breast cancer from 2001 to 2012. ESA use for CIA was determined by an ESA claim after chemotherapy, up to 6 months after treatment. We identified 839,948 commercially insured patients, including 24,785 patients with ESA-treated CIA (3.2%). Darbepoetin use increased 3.9-fold from 2003 to 2007 (12.3% to 48.7%) and then decreased 95% to 2.6% by 2012. Epoetin use decreased 90% from 2003 to 2012 (30.3% to 3.1%). Between 2003 and 2012, mean epoetin dosing decreased 0.8-fold (244,979 in 2003 vs. 196,216 units in 2012), but increased 1.8-fold for darbepoetin-treated CIA (262 in 2003 to 467 μg in 2012). Among CIA patients, transfusions were low (4.5%) in 2002-2007, then increased 2.2-fold between 2008 and 2012. Safety initiatives between 2007 and 2010 facilitated reductions in ESA use combined with changes in coverage. These data show the efficacy of regulatory efforts, publication of adverse events and changes in reimbursement in reducing use of ESAs. Future studies are warranted to optimize deimplementation strategies to improve patient safety.
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Affiliation(s)
- Martin W Schoen
- Department of Medicine, Saint Louis University School of Medicine, St. Louis, Missouri.,John Cochran Veterans Affairs Medical Center, St. Louis, Missouri
| | - Shamia Hoque
- Department of Civil and Environmental Engineering, University of South Carolina, Columbia, South Carolina
| | | | - Benjamin Schooley
- Department of Civil and Environmental Engineering, University of South Carolina, Columbia, South Carolina
| | - Oliver Sartor
- Tulane University School of Medicine, New Orleans, Louisiana
| | - Y Tony Yang
- George Washington University, Washington, District of Columbia
| | - Paul R Yarnold
- Medical University of South Carolina, Charleston, South Carolina.,The University of South Carolina College of Pharmacy, Columbia, South Carolina
| | - Kevin B Knopf
- The University of South Carolina College of Pharmacy, Columbia, South Carolina
| | - William J M Hrushesky
- Medical University of South Carolina, Charleston, South Carolina.,The University of South Carolina College of Pharmacy, Columbia, South Carolina
| | - Michael Dickson
- The University of South Carolina College of Pharmacy, Columbia, South Carolina
| | - Brian J Chen
- Arnold School of Public Health of the University of South Carolina, Columbia, South Carolina
| | - Chadi Nabhan
- The University of South Carolina College of Pharmacy, Columbia, South Carolina
| | - Charles L Bennett
- Medical University of South Carolina, Charleston, South Carolina.,The University of South Carolina College of Pharmacy, Columbia, South Carolina
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4
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Woei-A-Jin FJSH, Zheng SZ, Kiliçsoy I, Hudig F, Luelmo SAC, Kroep JR, Lamb HJ, Osanto S. Lifetime Transfusion Burden and Transfusion-Related Iron Overload in Adult Survivors of Solid Malignancies. Oncologist 2019; 25:e341-e350. [PMID: 32043782 DOI: 10.1634/theoncologist.2019-0222] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Accepted: 07/31/2019] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Limited data exist on transfusion burden and transfusion-related iron overload in adult survivors of solid malignancies. METHODS Hospital-specific cancer registry data of patients with solid tumor receiving systemic anticancer treatment between January 2008 and September 2009 at the Oncology Department of the Leiden University Medical Center (The Netherlands) were retrieved and cross-referenced with red blood cell (RBC) transfusion records. Individual lifetime transfusion burden was captured in April 2015. Multitransfused long-term survivors with serum ferritin >500 μg/L were subsequently screened for hepatic and cardiac iron overload using 1.5 Tesla magnetic resonance imaging. RESULTS The study population consisted of 775 adult patients with solid cancer (45.2% male; median age, 58 years; >75% chemotherapy-treated), 423 (54.6%) of whom were transfused with a median of 6.0 RBC units (range 1-67). Transfusion triggers were symptomatic anemia or hemoglobin <8.1-8.9 g/dL prior to each myelosuppressive chemotherapy cycle. We identified 123 (15.9%) patients across all tumor types with a lifetime transfusion burden of ≥10 RBC units. In the absence of a hemovigilance program, none of these multitransfused patients was screened for iron overload despite a median survival of 4.6 years. In 2015 at disclosure of transfusion burden, 26 multitransfused patients were alive. Six (23.1%) had hepatic iron overload: 3.9-11.2 mg Fe/g dry weight. No cardiac iron depositions were found. CONCLUSION Patients with solid malignancies are at risk for multitransfusion and iron overload even when adhering to restrictive RBC transfusion policies. With improved long-term cancer survivorship, increased awareness of iatrogenic side effects of supportive therapy and development of evidence-based guidelines are essential. IMPLICATIONS FOR PRACTICE In the presence of a restrictive transfusion policy, ∼30% of transfused adult patients with solid cancer are multitransfused and ∼50% become long-term survivors, underscoring the need for evidence-based guidelines for the detection and management of transfusion-related iron overload in this group of patients. In each institution, a hemovigilance program should be implemented that captures the lifetime cumulative transfusion burden in all patients with cancer, irrespective of tumor type. This instrument will allow timely assessment and treatment of iron overload in cancer survivors, thus preventing organ dysfunction and decreased quality of life.
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Affiliation(s)
- F J Sherida H Woei-A-Jin
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Laboratory of Clinical Chemistry and Hematology, Haga Hospital, The Hague, The Netherlands
| | - Shu Zhen Zheng
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Inci Kiliçsoy
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Francisca Hudig
- Department of Laboratory of Clinical Chemistry and Hematology, Haga Hospital, The Hague, The Netherlands
| | - Saskia A C Luelmo
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Judith R Kroep
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Hildo J Lamb
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Susanne Osanto
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
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5
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Gawade PL, Berlin JA, Henry DH, Tomita D, Brooks BD, Franklin J, Bradbury BD, Critchlow CW. Changes in the use of erythropoiesis-stimulating agents (ESAs) and red blood cell transfusion in patients with cancer amidst regulatory and reimbursement changes. Pharmacoepidemiol Drug Saf 2017; 26:1357-1366. [DOI: 10.1002/pds.4293] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 06/13/2017] [Accepted: 07/23/2017] [Indexed: 11/07/2022]
Affiliation(s)
- Prasad L. Gawade
- Center for Observational Research; Amgen Inc.; Thousand Oaks CA USA
| | | | - David H. Henry
- Department of Medicine; University of Pennsylvania; Philadelphia PA USA
| | - Dianne Tomita
- Global Biostatistical Science; Amgen Inc.; Thousand Oaks CA USA
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6
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Noxon V, Knopf KB, Norris LB, Chen B, Yang YT, Qureshi ZP, Hrushesky W, Lebby AA, Schooley B, Hikmet N, Dickson M, Thamer M, Cotter D, Yarnold PR, Bennett CL. Tale of Two Erythropoiesis-Stimulating Agents: Utilization, Dosing, Litigation, and Costs of Darbepoetin and Epoetin Among South Carolina Medicaid-Covered Patients With Cancer and Chemotherapy-Induced Anemia. J Oncol Pract 2017; 13:e562-e573. [PMID: 28504901 DOI: 10.1200/jop.2016.019364] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The US Food and Drug Administration (FDA) has approved epoetin and darbepoetin for chemotherapy-induced anemia (CIA). Approved epoetin and darbepoetin dosing schedules were three times per week and weekly, respectively, although off-label, less frequent scheduling was common. In 2004, 2007, and 2008, a US Food and Drug Administration Advisory Committees warned of risks associated with erythropoiesis-stimulating agents. During this period, lawsuits alleging illegal darbepoetin marketing practices have concluded, resulting in $1.1 billion in fines and settlements and one criminal conviction. No prior study, to our knowledge, has reported on the use of darbepoetin versus epoetin for CIA. METHODS We evaluated the dosing, utilization, and costs of erythropoiesis-stimulating agents among 3,761 South Carolina Medicaid patients with CIA. RESULTS Epoetin and darbepoetin utilization rates were 22% and 28% in 2003, 10% and 33% in 2007, and 3% and 7% in 2010, respectively. Mean per-patient per-administration epoetin and darbepoetin doses were 40,983 IU and 191 µg, respectively, in 2003 and 47,753 IU and 369 µg, respectively, in 2010. Mean monthly patient costs for epoetin and darbepoetin were $1,030 and $981, respectively, in 2003 and $932 and $1,352, respectively, in 2010. Epoetin use decreased steadily between 2002 and 2010; darbepoetin use increased steadily between 2003 and 2007 and then decreased steadily thereafter. Per-patient dosing of darbepoetin, but not epoetin, increased steadily between 2003 and 2010, and monthly per-patient epoetin costs decreased 3% while the per-patients costs of darbepoetin increased 30% between 2003 and 2010. CONCLUSION To our knowledge, our findings are the first data reporting on epoetin versus darbepoetin use for CIA and support recently concluded lawsuits involving allegations of illegal marketing practices of the manufacturer of darbepoetin.
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Affiliation(s)
- Virginia Noxon
- University of South Carolina; William Jennings Bryan Dorn Veterans Affairs Medical Center, Columbia; Hollings Cancer Center, Medical University of South Carolina, Charleston, SC; George Mason University, Fairfax, VA; and Medical Technology and Practice Patterns Institute, Washington, DC
| | - Kevin B Knopf
- University of South Carolina; William Jennings Bryan Dorn Veterans Affairs Medical Center, Columbia; Hollings Cancer Center, Medical University of South Carolina, Charleston, SC; George Mason University, Fairfax, VA; and Medical Technology and Practice Patterns Institute, Washington, DC
| | - LeAnn B Norris
- University of South Carolina; William Jennings Bryan Dorn Veterans Affairs Medical Center, Columbia; Hollings Cancer Center, Medical University of South Carolina, Charleston, SC; George Mason University, Fairfax, VA; and Medical Technology and Practice Patterns Institute, Washington, DC
| | - Brian Chen
- University of South Carolina; William Jennings Bryan Dorn Veterans Affairs Medical Center, Columbia; Hollings Cancer Center, Medical University of South Carolina, Charleston, SC; George Mason University, Fairfax, VA; and Medical Technology and Practice Patterns Institute, Washington, DC
| | - Y Tony Yang
- University of South Carolina; William Jennings Bryan Dorn Veterans Affairs Medical Center, Columbia; Hollings Cancer Center, Medical University of South Carolina, Charleston, SC; George Mason University, Fairfax, VA; and Medical Technology and Practice Patterns Institute, Washington, DC
| | - Zaina P Qureshi
- University of South Carolina; William Jennings Bryan Dorn Veterans Affairs Medical Center, Columbia; Hollings Cancer Center, Medical University of South Carolina, Charleston, SC; George Mason University, Fairfax, VA; and Medical Technology and Practice Patterns Institute, Washington, DC
| | - William Hrushesky
- University of South Carolina; William Jennings Bryan Dorn Veterans Affairs Medical Center, Columbia; Hollings Cancer Center, Medical University of South Carolina, Charleston, SC; George Mason University, Fairfax, VA; and Medical Technology and Practice Patterns Institute, Washington, DC
| | - Akida A Lebby
- University of South Carolina; William Jennings Bryan Dorn Veterans Affairs Medical Center, Columbia; Hollings Cancer Center, Medical University of South Carolina, Charleston, SC; George Mason University, Fairfax, VA; and Medical Technology and Practice Patterns Institute, Washington, DC
| | - Benjamin Schooley
- University of South Carolina; William Jennings Bryan Dorn Veterans Affairs Medical Center, Columbia; Hollings Cancer Center, Medical University of South Carolina, Charleston, SC; George Mason University, Fairfax, VA; and Medical Technology and Practice Patterns Institute, Washington, DC
| | - Neset Hikmet
- University of South Carolina; William Jennings Bryan Dorn Veterans Affairs Medical Center, Columbia; Hollings Cancer Center, Medical University of South Carolina, Charleston, SC; George Mason University, Fairfax, VA; and Medical Technology and Practice Patterns Institute, Washington, DC
| | - Michael Dickson
- University of South Carolina; William Jennings Bryan Dorn Veterans Affairs Medical Center, Columbia; Hollings Cancer Center, Medical University of South Carolina, Charleston, SC; George Mason University, Fairfax, VA; and Medical Technology and Practice Patterns Institute, Washington, DC
| | - Mae Thamer
- University of South Carolina; William Jennings Bryan Dorn Veterans Affairs Medical Center, Columbia; Hollings Cancer Center, Medical University of South Carolina, Charleston, SC; George Mason University, Fairfax, VA; and Medical Technology and Practice Patterns Institute, Washington, DC
| | - Dennis Cotter
- University of South Carolina; William Jennings Bryan Dorn Veterans Affairs Medical Center, Columbia; Hollings Cancer Center, Medical University of South Carolina, Charleston, SC; George Mason University, Fairfax, VA; and Medical Technology and Practice Patterns Institute, Washington, DC
| | - Paul R Yarnold
- University of South Carolina; William Jennings Bryan Dorn Veterans Affairs Medical Center, Columbia; Hollings Cancer Center, Medical University of South Carolina, Charleston, SC; George Mason University, Fairfax, VA; and Medical Technology and Practice Patterns Institute, Washington, DC
| | - Charles L Bennett
- University of South Carolina; William Jennings Bryan Dorn Veterans Affairs Medical Center, Columbia; Hollings Cancer Center, Medical University of South Carolina, Charleston, SC; George Mason University, Fairfax, VA; and Medical Technology and Practice Patterns Institute, Washington, DC
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7
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On-label and off-label prescribing patterns of erythropoiesis-stimulating agents in inpatient hospital settings in the US during the period of major regulatory changes. Res Social Adm Pharm 2016; 13:778-788. [PMID: 27595426 DOI: 10.1016/j.sapharm.2016.07.005] [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: 03/18/2016] [Revised: 07/11/2016] [Accepted: 07/13/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND A number of policy and labeling interventions aimed at reducing inappropriate prescribing of erythropoiesis-stimulating agents (ESAs) were implemented in the U.S. between 2006 and 2010. These interventions included the addition of an FDA Black Box Warning to ESA labeling, the implementation of a Risk Evaluation and Mitigation Strategy program, and the adoption of payment restrictions by the Centers for Medicare and Medicaid Services (CMS). The impact of these safety interventions on different types of ESA prescribing (on-label, off-label; evidence-based, not evidence-based) has not been investigated in a single study. OBJECTIVES The objective of this study was to explore the prescribing patterns of ESAs for on- and off-label indications in the U.S. hospital inpatients during the period of major policy and labeling changes. METHODS A retrospective analysis of ESAs utilization patterns was conducted using Cerner Health Facts® database from January 1, 2005 to June 30, 2011. The study population consisted of adult patients admitted to hospitals during the study period who received at least one ESAs order. Indications for ESA use were assigned based on ICD-9 CM diagnosis codes, procedure codes, and medication records. ESA use was then classified based on FDA-approval and the strength of scientific evidence supporting its use. Indication categories included (1) on-label use (ONS); (2) off-label use, supported (OFS); and (3) off-label use, unsupported (OFU). Descriptive statistics were used to examine ESA use by patient, hospital, and physician characteristics and over time. RESULTS ESAs were most frequently prescribed for ONS (48.7%), followed by OFU (42.7%) and OFS indications (8.6%). Of all off-label use, 83.2% were for unsupported indications. Between 2005 and 2010, the percent of inpatient visits with ESA use decreased for supported indications, both on-label (-63.2%) and off-label (-78.2%), but increased for unsupported indications (80%). OFU use surpassed ONS use as the most common type of ESA use in 2009. CONCLUSIONS Total and ONS ESA use decreased markedly, while OFU ESA use continued to increase during the period of major policy and labeling changes.
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8
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Xu L, Xu H, Cannavale K, Sattayapiwat O, Rodriguez R, Page JH, Chao C. Trends in anemia treatment among patients with five non-myeloid malignancies treated with chemotherapy in a large integrated health care delivery system in California, 2000–2013. Support Care Cancer 2016; 24:2989-98. [DOI: 10.1007/s00520-016-3078-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 01/03/2016] [Indexed: 11/30/2022]
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9
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Hollingsworth K, Romney MC, Crawford A, McAna J. The Impact of the Risk Evaluation Mitigation Strategy for Erythropoiesis-Stimulating Agents on Their Use and the Incidence of Stroke in Medicare Subjects with Chemotherapy-Induced Anemia with Lung and/or Breast Cancers. Popul Health Manag 2016; 19:63-9. [DOI: 10.1089/pop.2015.0017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | | | | | - John McAna
- Thomas Jefferson University, Philadelphia, Pennsylvania
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10
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Butler AM, Kshirsagar AV, Olshan AF, Nielsen ME, Wheeler SB, Brookhart MA. Trends in Anemia Management in Hemodialysis Patients with Cancer. Am J Nephrol 2015; 42:206-15. [PMID: 26439712 DOI: 10.1159/000440771] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 08/13/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND Erythropoiesis-stimulating agents (ESAs), intravenous iron, and blood transfusion are used to treat anemia in both end-stage renal disease (ESRD) and cancer. However, anemia treatment patterns have not been described among ESRD patients undergoing hemodialysis with concurrent cancer, especially in the recent era of ESA-related safety concerns. METHODS We analyzed Medicare data from a cohort of hemodialysis patients diagnosed with incident cancer. We used multivariable generalized linear models to estimate trends and patterns in ESA use, iron use, transfusion use, epoetin alfa (EPO) dose, iron dose, and resulting hemoglobin levels (2000-2011). RESULTS Of 43,760 eligible patients, quarterly ESA use declined slightly from a peak of 94.1 to 90.0%. Quarterly EPO dose increased from 2000 to 2004, then declined; quarterly hemoglobin levels followed a similar pattern. Iron use increased rapidly from 46.9 to 79.3%. Iron dose increased until 2010 and then declined. There was an increase in the quarterly transfusion use (6.3-11.7%) and in the mean number of transfusion days per year (1.4-1.8). Anemia treatment patterns varied by demographic/clinical subgroups, especially among patients receiving chemotherapy, who required higher ESA use, EPO dose, and frequency of transfusions. CONCLUSIONS Despite safety concerns about ESAs in both the ESRD and cancer populations, the proportion of hemodialysis patients with cancer who used ESAs between 2000 and 2011 remained extremely high. EPO dose and hemoglobin levels increased and then decreased. Iron use, iron dose, and transfusions increased substantially. Future research examining the risk-benefit profile of different anemia management strategies in the dialysis population with cancer is needed.
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Affiliation(s)
- Anne M Butler
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, N.C., USA
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11
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Xu H, Kaye JA, Saltus CW, Crawford J, Gasal E, Goodnough LT. Blood utilization and hemoglobin levels in cancer patients after label and coverage changes for erythropoiesis-stimulating agents. Expert Rev Hematol 2014; 7:617-33. [DOI: 10.1586/17474086.2014.943730] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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12
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Li X, Yan Z, Kong D, Zou W, Wang J, Sun D, Jiang Y, Zheng C. Erythropoiesis-stimulating agents in the management of cancer patients with anemia: a meta-analysis. Chin J Cancer Res 2014; 26:268-76. [PMID: 25035653 DOI: 10.3978/j.issn.1000-9604.2014.05.03] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 05/26/2014] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Erythropoiesis-stimulating agents (ESAs) are widely used in the management of anemia in cancer patients. Despite their apparent effectiveness, recent studies have suggested that ESAs could result in serious adverse events and even higher mortality. The aim of the current study was to evaluate the benefits and risks of ESAs in the management of cancer patients with anemia using a meta-analysis. METHODS The initial literature search covered Medline, PubMed, Embase, and the Cochrane Center Register of Controlled Trials, and identified 1,569 articles. The final meta-analysis included eight randomized controlled trials (n=2,387) in cancer patients with <11 g/dL hemoglobin (Hb) at the baseline and target Hb (for stopping ESA treatment) at no more than 13 g/dL. The assessment measures included Hb response, blood transfusion rate and adverse events that included venous thromboemblism (VTE), hypertension, and on-study mortality. The results are expressed as pooled odds ratio (OR). Publication bias was assessed using funnel plot analysis. RESULTS ESAs significantly increased the Hb concentration [OR 7.85, 95% confidence interval (CI): 5.85 to 10.53, P<0.001] and reduced the red blood cell (RBC) transfusion rate (OR 0.52, 95% CI: 0.42 to 0.65, P<0.001). ESAs did not increase the accumulated adverse events (OR 0.95, P=0.82), or the on-study mortality (OR 1.09, P=0.47). CONCLUSIONS ESAs are not associated with increased frequency of severe adverse events in anemic cancer patients when the target Hb value is no more than 13 g/dL.
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Affiliation(s)
- Xiaomei Li
- 1 Cancer Center of the Second Hospital, 2 Institute of Biotherapy for Hematological Malignancies, 3 Cardiovascular Department of the Second Hospital, 4 Hematology Department of the Second Hospital, 5 Pharmacology Department of the Second Hospital, Shandong University, Jinan 250100, China
| | - Zhi Yan
- 1 Cancer Center of the Second Hospital, 2 Institute of Biotherapy for Hematological Malignancies, 3 Cardiovascular Department of the Second Hospital, 4 Hematology Department of the Second Hospital, 5 Pharmacology Department of the Second Hospital, Shandong University, Jinan 250100, China
| | - Dexiao Kong
- 1 Cancer Center of the Second Hospital, 2 Institute of Biotherapy for Hematological Malignancies, 3 Cardiovascular Department of the Second Hospital, 4 Hematology Department of the Second Hospital, 5 Pharmacology Department of the Second Hospital, Shandong University, Jinan 250100, China
| | - Wen Zou
- 1 Cancer Center of the Second Hospital, 2 Institute of Biotherapy for Hematological Malignancies, 3 Cardiovascular Department of the Second Hospital, 4 Hematology Department of the Second Hospital, 5 Pharmacology Department of the Second Hospital, Shandong University, Jinan 250100, China
| | - Jihua Wang
- 1 Cancer Center of the Second Hospital, 2 Institute of Biotherapy for Hematological Malignancies, 3 Cardiovascular Department of the Second Hospital, 4 Hematology Department of the Second Hospital, 5 Pharmacology Department of the Second Hospital, Shandong University, Jinan 250100, China
| | - Dianshui Sun
- 1 Cancer Center of the Second Hospital, 2 Institute of Biotherapy for Hematological Malignancies, 3 Cardiovascular Department of the Second Hospital, 4 Hematology Department of the Second Hospital, 5 Pharmacology Department of the Second Hospital, Shandong University, Jinan 250100, China
| | - Yuhua Jiang
- 1 Cancer Center of the Second Hospital, 2 Institute of Biotherapy for Hematological Malignancies, 3 Cardiovascular Department of the Second Hospital, 4 Hematology Department of the Second Hospital, 5 Pharmacology Department of the Second Hospital, Shandong University, Jinan 250100, China
| | - Chengyun Zheng
- 1 Cancer Center of the Second Hospital, 2 Institute of Biotherapy for Hematological Malignancies, 3 Cardiovascular Department of the Second Hospital, 4 Hematology Department of the Second Hospital, 5 Pharmacology Department of the Second Hospital, Shandong University, Jinan 250100, China
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Goodnough LT, Shander A. Update on erythropoiesis-stimulating agents. Best Pract Res Clin Anaesthesiol 2013; 27:121-9. [DOI: 10.1016/j.bpa.2012.11.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2012] [Accepted: 11/07/2012] [Indexed: 12/21/2022]
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Stroupe KT, Tarlov E, Lee TA, Weichle TW, Zhang QL, Michaelis LC, Ozer H, Durazo-Arvizu R, Browning MM, Hynes DM. Hemoglobin Levels Triggering Erythropoiesis-Stimulating Agent Therapy in Patients with Cancer: the Shift After United States Food and Drug Administration Policy Changes. Pharmacotherapy 2012; 32:988-97. [DOI: 10.1002/phar.1134] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Kevin T. Stroupe
- Center for Management of Complex Chronic Care; Hines VA Hospital; Hines Illinois
- Veterans Affairs Information Resource Center (K.T. Stroupe, E. Tarlov, M.M. Browning, and D.M. Hynes); Hines Veterans Affairs Hospital; Hines Illinois
- Stritch School of Medicine; Loyola University Chicago; Maywood Illinois
| | - Elizabeth Tarlov
- Center for Management of Complex Chronic Care; Hines VA Hospital; Hines Illinois
- Veterans Affairs Information Resource Center (K.T. Stroupe, E. Tarlov, M.M. Browning, and D.M. Hynes); Hines Veterans Affairs Hospital; Hines Illinois
| | - Todd A. Lee
- Center for Management of Complex Chronic Care; Hines VA Hospital; Hines Illinois
- College of Pharmacy; University of Illinois at Chicago; Chicago Illinois
| | - Thomas W. Weichle
- Center for Management of Complex Chronic Care; Hines VA Hospital; Hines Illinois
| | - Qiuying L. Zhang
- Center for Management of Complex Chronic Care; Hines VA Hospital; Hines Illinois
| | | | - Howard Ozer
- College of Medicine; University of Illinois at Chicago; Chicago Illinois
| | | | - Margaret M. Browning
- Center for Management of Complex Chronic Care; Hines VA Hospital; Hines Illinois
- Veterans Affairs Information Resource Center (K.T. Stroupe, E. Tarlov, M.M. Browning, and D.M. Hynes); Hines Veterans Affairs Hospital; Hines Illinois
| | - Denise M. Hynes
- Center for Management of Complex Chronic Care; Hines VA Hospital; Hines Illinois
- Veterans Affairs Information Resource Center (K.T. Stroupe, E. Tarlov, M.M. Browning, and D.M. Hynes); Hines Veterans Affairs Hospital; Hines Illinois
- College of Medicine; University of Illinois at Chicago; Chicago Illinois
- Institute for Health Research and Policy (D.M. Hynes); University of Illinois at Chicago; Chicago Illinois
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Shander A, Van Aken H, Colomina MJ, Gombotz H, Hofmann A, Krauspe R, Lasocki S, Richards T, Slappendel R, Spahn DR. Patient blood management in Europe. Br J Anaesth 2012; 109:55-68. [PMID: 22628393 PMCID: PMC3374574 DOI: 10.1093/bja/aes139] [Citation(s) in RCA: 196] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Preoperative anaemia is common in patients undergoing orthopaedic and other major surgery. Anaemia is associated with increased risks of postoperative mortality and morbidity, infectious complications, prolonged hospitalization, and a greater likelihood of allogeneic red blood cell (RBC) transfusion. Evidence of the clinical and economic disadvantages of RBC transfusion in treating perioperative anaemia has prompted recommendations for its restriction and a growing interest in approaches that rely on patients' own (rather than donor) blood. These approaches are collectively termed ‘patient blood management’ (PBM). PBM involves the use of multidisciplinary, multimodal, individualized strategies to minimize RBC transfusion with the ultimate goal of improving patient outcomes. PBM relies on approaches (pillars) that detect and treat perioperative anaemia and reduce surgical blood loss and perioperative coagulopathy to harness and optimize physiological tolerance of anaemia. After the recent resolution 63.12 of the World Health Assembly, the implementation of PBM is encouraged in all WHO member states. This new standard of care is now established in some centres in the USA and Austria, in Western Australia, and nationally in the Netherlands. However, there is a pressing need for European healthcare providers to integrate PBM strategies into routine care for patients undergoing orthopaedic and other types of surgery in order to reduce the use of unnecessary transfusions and improve the quality of care. After reviewing current PBM practices in Europe, this article offers recommendations supporting its wider implementation, focusing on anaemia management, the first of the three pillars of PBM.
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Affiliation(s)
- A Shander
- Department of Anaesthesiology, Critical Care Medicine, Pain Management and Hyperbaric Medicine, Englewood Hospital and Medical Center, 350 Engle Street, Englewood, NJ, USA.
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Abstract
PURPOSE OF REVIEW To describe the recent developments in the strategies to reduce allogeneic blood transfusions with emphasis on the impact on clinical outcomes. RECENT FINDINGS Concerns over the safety, efficacy, and supply of allogeneic blood continue to necessitate its judicious use as the standard of care. Patient blood management is emerging as a multidisciplinary, multimodality strategy to address anemia and decrease bleeding with the goal of reduced transfusions and improved patient outcomes. Common risk factors for transfusion include anemia, blood loss, and inappropriate transfusion decisions. Several approaches are available to mitigate these. Recent data continue to support the effectiveness of various hematinics, hemostatic agents and devices, as well as intermittent discontinuation of anticoagulant therapy. Use of autotransfusion techniques, particularly cell salvage, is the other strategy with accumulating data supporting its safety and efficacy. Finally, implementation of evidence-based transfusion guidelines will help to target allogeneic blood to those patients who are likely to benefit from it and thus reduce or eliminate unnecessary exposure to blood. SUMMARY Patient blood management is the timely use of safe and effective medical and surgical techniques designed to prevent anemia and decrease bleeding in an effort to improve patient outcome.
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Trends in anemia management in lung and colon cancer patients in the US Department of Veterans Affairs, 2002–2008. Support Care Cancer 2011; 20:1649-57. [DOI: 10.1007/s00520-011-1255-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2011] [Accepted: 08/09/2011] [Indexed: 10/17/2022]
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