Medications for Anemia Treatment

Question 1

When should iron supplementation be employed?

Answer 1

TSAT < 30%
Serum ferritin <500 ng/mL

Question 2

When can oral iron be used?

Answer 2

Oral iron will not be sufficient in patients undergoing hemodialysis

-Can be used for CKD patients or peritoneal dialysis patients

Question 3

What are examples of oral iron medications?

Answer 3

Ferrous salts (sulfate, gluconate, fumerate)

Question 4

What dosing is used for oral iron?

Answer 4

200mg of elemental iron per day at least

Question 5

What are some considerations when using oral iron as a treatment?

Answer 5

-Best absorbed in an acidic environment!

-Can be taken with orange juice (unless patient is taking a megavitamin with Vitamin C)

-Is not enteric coated a this would prevent absorption in the acidic stomach

-Should not be used in patients who take medications that affect the acidity of the stomach (H2 blockers, PPI)

-Separate from calcium by 2 hours!

-Can cause upset stomach

Question 6

Why do we switch to oral iron in ESKD?

Answer 6

Hepcidin blocks FPN in the liver which prevents patients from being able to absorb the iron into their bloodstream

**Dialysis is not the reason why we switch, even though the switch often occurs when a patient goes on dialysis

Question 7

What are the 5 IV iron agents?

Answer 7

1) Iron dextran (InFed, Dexferrum)
2) Sodium ferric gluconate (Ferrlicit)
3) Iron sucrose (Venofer)
4) Ferric carboxymaltose (Injectafer)
5) Ferumoxytol (Feraheme)

Question 8

What are some considerations when using IV Iron dextran (InFed, Dexferrum)?

Answer 8

-CHEAP
-Needs test dose (25 mg)

Question 9

What are some considerations when using Iron sucrose (Venofer)?

Answer 9

Has a second indication for non-dialysis chronic kidney disease patients

Question 10

What are some considerations when using Ferumoxytol (Feraheme)?

Answer 10

Supaparamagnetic compound
*Not a good choice if patient is going to have MRI’s!

Question 11

What is Triferic (ferric pyrophosphate citrate)?

Answer 11

An iron compound added to dialysate

Question 12

When should Erythropoiesis Stimulating Agents (ESAs) be used to treat anemia?

Answer 12

After all other correctable causes of anemia have been addressed

*To raise Hb

*Used to prevent a blood transfusion

Question 13

At what lab values should ESAs be started?

Answer 13

CKD 3-5: Hb< 10g/dL, Hb falling at rapid rate
CKD 5: Hb between 9 and 10 g/dL

Question 14

What warning is associated with ESA use and how long you should use it?

Answer 14

Do not use ESA to push Hb above 11.5 g/dL

*increased risk of cardiovascular events

Question 15

What are the 3 kinds of Erythropoiesis Stimulating Agents (ESAs)?

Answer 15

1) Recombinant human erythropoietin (rHuEPO, epoetin alfa, Epogen, Procrit EPO)
2) Darbepoetin alfa (Aranesp)
3) Methoxy polyethylene glycol-epoetin beta (Mircera)

Question 16

Which ESA has the longest half-life?

Answer 16

Methoxy polyethylene glycol-epoetin beta (Mircera)

Question 17

What is the main adverse effect that can occur when taking ESAs?

Answer 17

23% of patients will develop high blood pressure

*But if we do not give them this medication they will likely die, so we just have to monitor patients closely

Question 18

What is a major cause of ESA therapy failure?

Answer 18

Lack of vitamins or IRON

Question 19

Can ESAs be used in combination with iron supplements?

Answer 19

Yes, PSA is often used with iron because when more red blood cells are being generated, the need for iron increases

Question 20

When should Hypoxia Inducible Factor (HIF) Prolyl Hydroxylase Inhibitors (PHI) (HIF-PHIs) be used?

Answer 20

For the treatment of anemia due to chronic kidney disease in patients who have been on dialysis for at least 4 months

Question 21

What is the name of the singular HIF-PHI drug?

Answer 21

Daprodustat (Jesduvroq)

Question 22

What is the role of hypoxia-inducible factor in anemia?

Answer 22

Promotes gene transcription of erythropoietin (EPO)that is necessary for the maturation of red blood cells

Question 23

What are the considerations associated with Daprodustat (Jesduvroq) use?

Answer 23

-Discontinue use if the hemoglobin (Hb) >12 g/dL
-Decrease dose by 1/2 if patient has any hepatic impairment
-Do not give with strong CYP2C8 inhibitors

Question 24

Which of the following IV products requires a test dose the first time it is administered?
A. iron sucrose
B. iron dextran
C. sodium ferric gluconate
D. ferrous sulfate

Answer 24

B. iron dextran