Management Of Anemia

Several studies have been performed to assess the efficacy of recombinant erythropoietin (rHuEPO; Epogen, Procrit) administered subcutaneously to patients with MM with a hemoglobin value of less than 10 g/dL.147-150 Although there were methodological flaws making interpretation of the results of individual trials problematic, taken together they suggest that half or more of such patients may benefit in terms of increase in hemoglobin concentration147-150 and reduction in transfusion requirements.147, 150 Based on these results, the American Society of Clinical Oncology and the American Society of Hematology guidelines recommend consideration of rHuEPO use for myeloma patients with anemia that does not improve after initiation of therapy with chemotherapy or glucocorti-coids.151 Concurrent use of rHuEPO with either thalidomide or lenalidomide may be associated with an increased risk of DVTs, and therefore caution is recommended when considering its use in this setting.152 The starting dose of rHuEPO should be 150 units/kg thrice weekly for a minimum of 4 weeks, with consideration of an increase to 300 units/kg/dose for an additional 4-8 weeks if there has been less than a 1-2 g/dL increase in hemoglobin. Forty-thousand units subcuta-neously once weekly, with an increase to 60,000 units as needed, is an accepted and widely used alternative. A randomized study comparing an alternative erythro-poietic agent, weekly darbepoetin alfa (Aranesp; dose: 2.25 ^g/kg/wk), to placebo was published after the release of these guidelines, and the results demonstrate comparable efficacy.153 Studies evaluating administration of higher doses of darbepoetin every 2 to 3 weeks in patients with other cancers receiving chemotherapy suggest that less-frequent dosing is feasible,154, 155 but at present, there is insufficient data in patients with myeloma or other hematologic malignancies.

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