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Uso de hierro y epo. alternativas a la transfusión. tarragona 2010. garcía erce
1. ALTERNATIVAS A LA TRANSFUSIÓN ALOGÉNICAALTERNATIVAS A LA TRANSFUSIÓN ALOGÉNICA
““USO DE HIERRO Y EPO”USO DE HIERRO Y EPO”
ALTERNATIVAS FARMACOLÓGICASALTERNATIVAS FARMACOLÓGICAS
PARA ESTIMULAR LA ERITROPOYESISPARA ESTIMULAR LA ERITROPOYESIS
Tarragona, 13 y 14 de Mayo 2010
José Antonio García-Erce
Servicio Regional de Hematología y Hemoterapia
Hospital “Universitario” Miguel Servet“, Zaragoza.
2. Agradecimientos
Prof. Manolo Muñoz Gómez
GIEMSA. Facultad de Medicina
Universidad de Málaga
Dr. Jorge Cuenca Espiérrez
Department of Orthopaedic Surgery
University Hospital Miguel Servet, Zaragoza
Prof. Antonio Herrera Rodríguez
Cátedra Department of Orthopaedic Surgery
University Hospita Miguel Servet, Zaragoza
Dra. Elvira Bisbe
Department of Anaesthesiology
University Hospital Mar-Esperança, Barcelona
3. Razones para reducir el uso de las
transfusiones sanguíneas
Regan y Taylor, BMJ 2002
Shander, Semin Hematol 2004
Muñoz et al, Med Clin (Barc) 2007
Costes de producción elevados
Sangre humana: un recurso limitado
TSA no está libre de riesgos:
Errores de identificación
TRALI
Sobrecarga de fluidos
Infección postoperatoria
Recidiva de cáncer
Normativa legal: alternativas
4. Hb 130-140 g/l
100
75
62
46
25
0 20 40 60 80 100
%TRANSFUSION
Hb < 110 g/l Hb 110-120 g/l Hb 120-130 g/l
Hb > 140 g/l
García Erce JA, et al. FACTORES PREDICTIVOS DE LA NECESIDAD DE
TRANSFUSION EN LA FRACTURA SUBCAPITAL DE CADERA EN
PACIENTES DE MÁS DE 65 AÑOS. Med Clin (Barc) 2003;120(5):161-6.
NIVEL DE HEMOGLOBINA Y RIESGO TRANSFUSIONAL
Nivel de hemoglobina y
Riesgo transfusional
5. 0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
TRANSFUSIÓN
Hb<120 G/L Hb 120-140 G/L Hb> 140 G/L
García-Erce JA, Solano VM, Cuenca J, Ortega P. “LA HEMOGLOBINA
PREOPERATORIA COMO ÚNICO FACTOR PREDICTOR DE LAS
NECESIDADES TRANSFUSIONALES EN LA ARTROPLASTIA DE
RODILLA”. Rev Esp Anestesiol Reanim 2002; 49: 131-5
NIVEL DE HEMOGLOBINA Y RIESGO TRANSFUSIONAL
Nivel de hemoglobina y
Riesgo transfusional
7. • Entre un 30% y un 50% de los pacientes quirúrgicos puede presentar
una anemia preoperatoria, causada o no por la patología motivo de
la cirugía.
• Hasta un 90% de los pacientes quirúrgicos pueden presentar anemia
postoperatoria debido al sangrado y/o la inhibición de la
eritropoyesis.
• En los pacientes quirúrgicos, la presencia de anemia se correlaciona
con un aumento de la morbi-mortalidad postoperatoria y un
descenso de la calidad de vida.
Nivel de hemoglobina y
Riesgo transfusional
8. “Lo primero que debemos hacer con un paciente
quirúrgico es detectar la presencia de anemia y
determinar su causas con la suficiente antelación
como para poder hacer algo con ella”
Goodnough LT et al . Anesth Analg 2005; 101: 1858-61
El tratamiento de la anemia preoperatoria ha demostrado
ser eficaz para reducir los requerimientos transfusionales
y mejorar la evolución postoperatoria y la calidad de vida
de los pacientes quirúrgicos.
Shander A et al. Am J Med 2004; 116 (suppl 7A): 58S-69S.
Nivel de hemoglobina y
Riesgo transfusional
9. Prevalencia de anemia preoperatoria
1.0 2.0 3.0 4.0 5.0 6.0
0
10
20
30
Male Female
6.0%
8.7%
1.5%
12.2%
4.4%
6.8%
7.8%
8.5%
15.7%
10.3%
26.1%
20.1%
1-16 17- 49 50 - 64 65 - 74 75 - 84 85+
Age group (years)
Percentwhohaveanemia
26,372 individuals
WHO criteria
12. Prevalencia de anemia preoperatoria
La correción de estas deficiencias es de
capital importancia para:
• Optimizar los niveles preoperatorios de Hb,
especialmente en los pacientes en tratamiento
con agentes estimuladores de la eritropoyesis.
• Acelerar la recuperación de la anemia
postoperatoria.
15. Spanish Consensus Statement on
Alternatives to Allogeneic Blood Transfusions
“An update of Seville’s Document”
11th
Annual Symposium
Barcelone, Spain. April 8 - 9 , 2010
H
S E
H H
S E
H H
S E
H
16. AABT
Seville’s document update
Scientific Societies and Panel Members
HEMATOLOGY
Enric Contreras
José A. García Erce
José A. Páramo
Carmen Fernández
Carmen Paniagua
María L. López-Fernández
Nelly Carpio
Víctor Jiménez Yuste
Ramón Salinas Argente
HOSPITAL PHARMACY
Auxiliadora Castillo Muñoz
Bruno Montoro Ronsano
José A. Romero Garrido
Fco. Javier Bautista Paloma
Mónica Izuel Rami
Eduardo López-Briz
José Antonio Martín Conde
OBSERVERS
The Societies’ Presidents
CRITICAL CARE
Ramón Leal
Manuel Muñoz
Manuel Quintana
Abelardo G. de Lorenzo
José L. Bóveda
Juan Carlos Ruiz
Pablo Torrabadella
Enrique Fdez. Mondéjar
Carmen Ferrándiz
ANESTHESIOLOGY
Marisol Asuero
Victoria Moral
Juan V. Llau
Elvira Bisbe
Carmen Gomar
Aurelio Gómez
Calixto Sánchez
María J. Colomina
Misericordia Basora
SEDAR SEFH
H
S E
H H
S E
H H
S E
H
17. AABT
Seville’s document update
Objective of the consensus
Target population:
Surgical or critically ill patients expected to require ABT.
Question:
How to reduce ABT rate and/or the volume of blood transfused?
Proposed interventions:
Use of pharmacologic and non-pharmacologic alternatives to ABT.
Relevant outcome:
Reduction of ABT rate and/or the volume of blood transfused.
GRADE Working Group. BMJ 2004;328:1490-7.
Evidence-Based Recommendations
18. Sangre autóloga
• Donacion preoperatoria
• Hemodilución
• Recuperación perioperatoria
Criterio restrictivo
de transfusión
Hb <70-80 g/L
Reducción del
sangrado
• Aprotinina
• Antifibrinoliticos
• Desmopresina
• rFVIIa
Estimulación de la
eritropoyesis
• Vitamina B12
• Acido Fólico
• rHuEpo
• Hierro
Alternativas
a la TSA
19. AABT
Seville’s document update
Estimulation of erythropoiesis
Iron therapy
For patients awaiting for elective surgery where significant blood
loss is expected, we suggest the administration of oral iron to
reduce ABT rate and/or volume, especially in those with iron
deficiency
- Preoperative oral iron
2B
• Several studies of patients scheduled for colorectal cancer resection
(1 RCT, 1 Obs) or lower limb arthroplasty (1 RCT, 2Obs) have
shown that preoperative supplementation with oral iron for a few
weeks increase Hb levels and reduces ABT rate.
• Preoperative oral iron therapy might also decrease postoperative Hb
fall and length of hospital stay.
PROVISIONAL (presentado en NATA 2010, Barcelona)
20. Transfus Med, 1997; 7:281 – 286
Iron pre-load for major joint replacement
C.M. Andrews, D.W. Lane, and J.G. Bradley
-2.5
-2.0
-1.5
-1.0
-0.5
0.0
Anaemic Control Iron
Hbfall(g/dl)
Postoperative fall in Hb
with 95% confidence limits
P=0·008
Table 4. Homologous blood transfused
Mean units
transfused
Transfusion
rate
Anaemic 2·8 4/16 (25.0%)
Control 1·8 3/40 (7.5%)
Iron 1·7 0/35 (0.0%)
Anaemic ferrous sulphate 200 mg b.d. 4-weeks
Iron: ferrous sulphate 200 mg b.d. 4-weeks
Control: no treatment
Non anaemic
Administración de hierro oral
Hierro oral preoperatorioHierro oral preoperatorio
21. Patients and methods: We assessed the requirements for ABT in 156 consecutive patients
undergoing surgery for primary TKR, who received iron ferrous sulphate (256 mg/day; 80
mg of Fe2+
), vitamin C (1000 mg/day) and folic acid (5 mg/day) during the 30-45 days
preceding surgery, and who were transfused if Hb <80 g/L and/or clinical signs/symptoms
of acute anaemia or hypoxemia (Group 2). A previous series of 156 TKR patients serves as a
control group (Group 1).
Administración de hierro oral
Hierro oral preoperatorioHierro oral preoperatorio
23. Administración de hierro oral
Hierro oral preoperatorioHierro oral preoperatorio
Patients and methods: We report a randomised, controlled trial of oral ferrous
sulphate 200 mg TDS for 2 weeks’ pre-operatively versus no iron therapy.
Patients diagnosed with colorectal cancer were recruited from out-patient clinic
and haematological parameters assessed. Randomisation was co-ordinated via
a telephone randomisation centre.
24. Administración de hierro oral
Hierro oral preoperatorioHierro oral preoperatorio
Administración de hierro oral
Hierro oral preoperatorioHierro oral preoperatorio
Administración de hierro oral
Hierro oral preoperatorioHierro oral preoperatorio
25. Este es un proceso que consume mucho tiempo:
• Una persona de 70 kg de peso con una Hb de 8.5 g/dL presenta un
déficit de hierro corporal de alrededor de 1600-1700 mg.
• Incluso en presencia de este grado de anemia, la maxima absorción
de hierro sería de solo 10 mg/dia
• Por lo que se necesitarían unos 6 meses de terapia con hierro oral
para corregir el déficit de hierro de este paciente.
Unos cálculos matemáticos simples!!!:
si 1 g/dL Hb = 165 mg hierro,
ante una pérdida de 3–5 g/dL de Hb,
la pérdida de hierro será = 495 – 825 mg
y podríamos administrar hasta 600 mg de hierro sacarosa por semana
¡PERIODO INACEPTABLE EN ESTA CIRUGÍA!
Administración de hierro oral
Hierro oral preoperatorioHierro oral preoperatorio
26. Administración de hierro IV
NATA Expert Panel on Intravenous Iron
ANAEMIA MANAGEMENT IN SURGERY –
CONSENSUS STATEMENT ON THE ROLE OF INTRAVENOUS IRON
Photis Beris, Manuel Muñoz, José A. García-Erce,
Dafydd Thomas, Alice Maniatis & Philippe Van der Linden.
Modificado de Van der Linden et al. Vox Sang 2007
“Siempre que sea clínicamente factible, en los pacientes programados
para una cirugía con alto riesgo de desarrollar anemia postoperatoria
grave, se debería determinar la hemoglobina y el status férrico, al
menos 30 días antes de la intervención. En los pacientes >60 años,
se deberían determinar también los niveles de vitamina B12 y folatos”.
27. Manejo de la anemia preoperatoria
Aunque el hierro oral es el tratamiento convencional, dada
su facilidad de administración y bajo coste, el hierro IV ha
emergido como una alternativa segura y efectiva para el
tratamiento de la anemia perioperatoria.
¿Cúal es el papel del hierro IV?
28. Manejo de la anemia preoperatoria
Esta indicación tiene en cuenta varios factores, como:
Intolerancia ó contraindicación al hierro oral (eg, EII).
Poco tiempo antes de la cirugía.
Anemia preoperatoria grave.
Uso de estimuladores de la eritropoyesis
Estado inflamatorio del paciente.
Sangrado perioperatorio estimado.
¿Cúal es el papel del hierro IV?
29. Manejo de la anemia preoperatoria
Enfermedad Inflamatoria Intestinal (E. Chrön, Colitis Ulcerosa)
Cirugía Gastro-intestinal (Obesidad mórbida, gastrectomía, etc)
Ulcus péptico, hemorragia activa
Anemia perioperatoria (ginecológica, cáncer colon, urológica, etc)
Programas de autotransfusión predepósito
Anemia en paciente nefrológico
Anemia asociada a neoplasias o a quimioterapia
Anemia durante el embarazo ó el puerperio
Anemia e insuficiencia cardíaca
Síndrome de anemia cardiorrenal
Síndrome de piernas inquietas
Indicaciones del hierro IV?
30. Manejo de la deficiencia de hierro
20-30
mg/día
Músculo
(250 mg)
Médula ósea
(300 mg)
Eritrocitos
(2.000 mg)
Macrófagos SRE
(500 mg)
Hígado
(1000 mg)
Absorción intestinal de hierro
(1-2 mg/día)
Transferrina
(3 mg)
Pérdidas de hierro
(1-2 mg/día)
Hierro IV
31. Requerimientos de hierro
Déficit de hierro (mg) :
(Hbobjetivo – Hb actual) (g/dL) x Peso (kg) x 2.4* + 500**
*Factor: 2.4 = 0.0034 x 0.07 x 10.000
**Depósitos de hierro
***Añadir 200 mg por cada 500 mL de sangre perdida
33. AABT
Seville’s document update
Estimulation of erythropoiesis
Iron therapy
For anemic patients with absolute or functional iron deficiency
awaiting for major elective surgery, we suggest the administration
of IV iron to improve Hb levels and/or decrease ABT rate.
- Preoperative IV iron
2A
• In 2 RCTs and 1 Obs study of women with anemia due to gynecological
bleeding, preoperative IV iron administration (600 mg to TID) improved
Hb levels and/or reduced ABT rate (1B).
• In 1 RCTs in colorectal cancer, IV did not increase Hb levels, but resulted
in a trend to lower ABT rate in anemic patients (22% vs. 55%)
• In 2 series of patients undergoing elective orthopedic surgery,
preoperative IV iron (900-1000 mg over 3-4 weeks) improved Hb levels.
• No clinically relevant side effect of IV iron was observed.
PROVISIONAL (presentado en NATA 2010, Barcelona)
34. Anemia preoperatoria
Hierro iv ± rHuEPO?
PACIENTES Y MÉTODOS: Incluimos desde inicio de 2003 hasta julio de
2004 a 27 pacientes consecutivos de cirugía ortopédica mayor
tratados con hierro sacarosa endovenoso en el preoperatorio por
intolerancia al hierro oral, mala absorción intestinal, anemia inflamatoria
crónica o déficit funcional de hierro. En 20 casos fue asociado a epoetina
alfa preoperatoria (EPO+FEV) y 7 recibieron solamente hierro endovenoso
(FEV), ya que estaban excluidos del tratamiento con epoetina por patología
cardiovascular o tromboembólica o por presentar déficit de hierro puro.
35. Hierro iv solo
Bisbe et al. Rev Esp Anestesiol Reanim 2005; 52: 532-40
+ 1.7 g/dL
Resultados del tratamiento
37. Administración de hierro IV
Tasa transfusional
Control : 32%
Hierro IV: 0%
FEEV preoperatorioFEEV preoperatorio
38. FEEV preoperatorioFEEV preoperatorio
Administración de hierro IV
Methods: After obtaining written informed consent, 20 patients with iron deficiency anemia
received 900 mg intravenous iron sucrose over 10 days starting 4 weeks before surgery.
44. Manejo de la anemia preoperatoria
Administración ambulatoria FEEV
Autor Tratamiento Período N Indicación Resultado
Maslovsky J (1) Fe sacarosa
Fe gluconato
4 años 57 Anemia grave ferropénica
sintomática incapaz Fe oral
Hb +2,3 g/dL
Ferritina +137 mcg/L
Bisbe E ’(2) Fe sacarosa ±EPO
(media 733 mg)
1,5 años 27 Anemia preoperatoria COT Hb +1,7 g/dL
Delfini
Cançado R (3)
Fe sacarosa
(media 1100 mg)
1 año 25 Hb < 7g/dL con intolerancia o
respuesta inadecuada Fe oral
Hb +4,33 g/dL
Ferritina +83,6 mcg/L
Abello V (4) Fe sacarosa
(1227±169 mg)
1 año 40 Anemia ferropénica Hb +5,04 g/dL
Reddy CM (5) Fe dextran 4 años 214 Anemia ferropénica Hb +2 g/dL
Theusinger (6) Fe sacarosa
(900 mg)
Ensayo 20 Anemia preoperatoria COT Hb +0,9 g/dL
Muñoz (7) Fe sacarosa
(media 1000 mg)
Multi
céntrico
80 Anemia preoperatoria Hb +2,0 g/dL
(1) Maslovsky I. Intravenous in a primare-care clinic. American Journal Hematology 2005;78:261-264. (2) Bisbe E, Rodríguez C, Ruiz A, Sáez M, Castillo J, Santiveri X. Uso
preoperatorio de hierro endovenoso. Una nueva terapéutica en medicina transfusional. Rev Esp Anestesiol Reanim 2005;52:536-40. (3) Delfini Cançado R, Buzian Brasil SA,
Gomes Noronha T, Chiattone CS. O uso intravenoso de sacarato de hidróxido de ferro III em pacientes com anemia ferropriva. Rev Assoc Med Bras 2005;51:323-8. (4) Abello
V, Solano MH, Ramirez CA, Sanabria A. Acta Med Colomb 2004;29:322-327. (5) Reddy CM, Kathula SK, Ali SA, Bekal R, Walsh M. Safety and efficacy of total dose infusion of
iron dextran in iron deficiency anaemia. Int J Clin Pract 2008; 62: 413-5. (6) Theusinger OM, Leyvraz PF, Schanz U, Seifert B, Spahn DR. Treatment of iron deficiency anemia
in orthopedic surgery with intravenous iron: efficacy and limits: a prospective study. Anesthesiology. 2007;107:923-7. (7) Muñoz M, García-Erce JA, Díez-Lobo AI, Campos A,
Sebastianes C, Bisbe E. [usefulness of the administration of intravenous iron sucrose for the correction of preoperative anemia in major surgery patients] Med Clin (Barc). 2009;
132(8): 303-6.
48. Manejo de la anemia con hierro IV dosis alta
• 33 pacientes, 8♂/25♀, 56 ± 24 años.
• COT, ginecología, urología, digestivo, cáncer colon, otros.
• Dosis hierro: 1400 ± 500 mg (≥ 500 mg/sesión).
• Duración: 21 ± 11 días (1-3 sesiones)
Hospital de día, Miguel Servet, Zaragoza
Diagnóstico Hemoglobina (g/dL)
n Pre-tto Post-tto p
COT 5 10.2 ± 2.6 13.1 ± 1.8 0.029
Ginecología 6 9.9 ± 1.8 12.3 ± 1.7 0.045
Urología 2 10.1 11.3
Digestivo 7 9.0 ± 0.2 11.2 ± 1.6 0.012
C. Colon 5 9.5 ± 0.6 12.3 ± 2.0 0.041
Otros 8 9.8 ± 1.3 12.5 ± 1.5 0.001
Total 33 9.6 ± 1.7 12.1 ± 1.6 0.001
49. AABT
Seville’s document update
Estimulation of erythropoiesis
Iron therapy
We do not recommend the use of oral iron in the early
postoperative period for reducing ABT rate or hastening the
recovery from anemia
- Postoperative oral iron
1B
• In 6 out of 7 RCTs of non iron deficiency patients who underwent
elective or non elective orthopedic surgery or cardiac surgery, oral
iron supplementation for 4-10 weeks did not improve Hb levels with
respect to placebo.
• Moreover, only 1 out of 7 RCTs patients recovered baseline Hb
levels after 8 weeks on oral iron.
• Up to 30% of patients experienced adverse side effect to oral iron
(mostly gastrointestinal). Up to 10% of patients discontinued therapy
due to side effects.
PROVISIONAL (presentado en NATA 2010, Barcelona)
53. AABT
Seville’s document update
Estimulation of erythropoiesis
Iron therapy
For patients undergoing orthopedic surgery expected to develop
severe postoperative anemia we currently suggest IV iron
administration during the perioperative period.
- Perioperative IV iron
2B
• NATA Consensus Statement:
Beris P, Muñoz M, García-Erce JA, Thomas D, Maniatis A, Van der
Linden P. Anaemia management in surgery—consensus statement
on the role of intravenous iron. Br J Anaesth 2008; 100: 599-604.
• No clinically relevant side effect of IV iron was observed, neither
postoperative infection or 30d mortality rates were increased.
PROVISIONAL (presentado en NATA 2010, Barcelona)
54. - Grade of recommendation: .
“For patients undergoing orthopaedic surgery expected to develop
severe postoperative anaemia we currently suggest IV iron
administration during the perioperative period”.
For all other surgeries no evidence-based recommendation can be
made. We strongly recommend that large prospective randomised
controlled trials are undertaken in patients undergoing surgery expected
to develop severe post operative anaemia.
Manejo de la anemia perioperatoria
67. AABT
Seville’s document update
Estimulation of erythropoiesis
Iron therapy
For critically ill patients with expected long stay at the ICU, we
suggest that iron supplementation might prevent Hb fall and/or the
need for transfusion.
- Critically ill patients
2C
• In a RCT of 200 critically ill patients, oral iron reduced ABT rate and
volume in those with IDE.
• In another small RCT (36 patients), IV iron increased reticulocyte
counts, decreased CRP levels, and resulted in a trend to lower ABT
volume.
• Among several RCTs on the use of rHuEPO in critical care, a net Hb
increase at the end of treatment was only observed in one
administering adjuvant therapy with IV iron.
• Iron therapy did not increase the risk for infection.
PROVISIONAL (presentado en NATA 2010, Barcelona)
68. PROVISIONAL (presentado en NATA 2010, Barcelona)
AABT
Seville’s document update
Estimulation of erythropoiesis
Iron therapy - IV iron in other clinical scenarios
For patients with inflammatory bowell disease suffering
moderate-severe anemia we recommend the use of IV iron for
correcting anemia, reducing transfusion risk, and preventing the
recurrence of iron deficiency.
1A
For patients with severe postpartum anemia we recommend the
replenishment of TID by in-hospital administration of IV iron for
hastening the correction from anemia and reducing the exposure
to ABT.
1A
In oncology patients receiving ESAs for treating chemotherapy-
induced anemia we recommend adjuvant treatement with IV iron
1A
69. AABT
Seville’s document update
Estimulation of erythropoiesis
Iron therapy
According to data from the FDA, the rates of life-threatening
ADEs and deaths associated with IV iron in CKD patients, are
much lower than those associated with ABT.
Nevertheless, the administration of IV iron should be avoided
in patient with signs of iron overload or ongoing bacteremia.
The availability of strong IV formulations allowing for the
administration of large single doses may greatly facilitate iron
therapy.
No recommendation can be made for the
use of vitamin B12 or folic acid to diminish
ABT rate and/or ABT volume
0
PROVISIONAL (presentado en NATA 2010, Barcelona)
71. AABT
Seville’s document update
Estimulation of erythropoiesis
Erythropoiesis Stimulating Agents (ESAs)
We recommend the preoperative use of ESAs plus iron in anemic
patients scheduled for major elective orthopedic surgery for
decreasing perioperative needs for ABT.
- Elective orthopedic surgery
1A
• The efficacy of perioperative administration of rHuEPO plus oral or
IV iron in anemic patients undergoing hip, knee or spine surgery has
been documented in several large RCTs.
• However, the minimum effective rHuEPO dose to attain a blood
sparing effect in this patient population is largely unknown, especially
when used with IV iron.
• In patients undergoing complex or revision surgery, rHuEPO may be
enhanced the efficacy of PCS or PABD (combination of techniques)
PROVISIONAL (presentado en NATA 2010, Barcelona)
73. AABT
Seville’s document update
Estimulation of erythropoiesis
For anemic patients scheduled for cardiac surgery with
cardiopulmonary bypass we suggest preoperative ESAs use plus
iron for reducing perioperative ABT rate.
- Cardiac surgery
2B
• Several small RCTs have documented the efficacy of perioperative
administration of rHuEPO plus oral or IV iron for reducing ABT in
anemic patients undergoing on-pump cardiac procedures.
• However, there is no evidence supporting the use of rHuEPO in off-
pump surgery, whereas the evidence supporting a role for rHuEPO
in hastening the recovery from postoperative anemia in this patient
population is inconclusive.
• It must be borne in mind that this is an “off-label” use of rHuEPO.
Erythropoiesis Stimulating Agents (ESAs)
PROVISIONAL (presentado en NATA 2010, Barcelona)
74. Administración de EPO
Hierro y EPO perioperatorio en cirugía cardíaca
Estudio, ańo + rHuEPO Placebo Hierro
Tipo, dosis, dias
rHuEPO
(U/kg)n %ABT n %ABT
Sowade, 97 36 11 36 53* Oral, 300 mg,14d 2.500 IV
D’Ambra, 97 63 32 56 48 Oral, 975 mg, >8d 2.400 SC
D’Ambra, 97 63 28 56 48 Oral, 975 mg, >8d 1.200 SC
Shimpo, 97 21a
0 16b
31* a
IV, 4d 1.200 IV
Shimpo, 97 11 a
9 16b
31 b
Oral, 4s 600 IV
Yazicioglu, 01 25 ? 28 ?** No hierro 100 IV
* Reducción de la tasa (%) y el índice de transfusión (U/pt)
** Reducción del índice de transfusión solamente.
75. AABT
Seville’s document update
Estimulation of erythropoiesis
We suggest that preoperative ESAs use in anemic patients
scheduled for neoplasic colorectal surgery could decrease the
perioperative needs for allogeneic blood transfusions.
- Colorectal cancer surgery
2B
• This recommendation derives from several RCTs and Obs of
gastrointestinal cancer patients (mostly colorectal cancer) with different
rHuEPO doses and treatment duration.
• rHuEPO efficacy was increased by adjuvant IV iron therapy.
• Again, it must be remembered that this is an “off-label” use of rHuEPO
and that there are safety concerns in despite of being a short-term
therapy.
Erythropoiesis Stimulating Agents (ESAs)
PROVISIONAL (presentado en NATA 2010, Barcelona)
76. Administración de EPO
Estudio, año + rHuEPO Placebo Hierro
Tipo, dosis, días
rHuEPO
(U/kg)n %ABT n %ABT
Braga, 99 10 29 --- --- IV, 125 mg,15d 200
Braga, 99 10 29 --- --- IV, 125 mg,15d 400
Braga, 97 10 10 10 50* IV, 125 mg, 4d 500
Qvist, 99 38 34 43 54** Oral, 200 mg, 4d 1.350
Christodoulakis, 05 69 49 68 52 Oral, 200 mg, 10d 1.800
Kettelhack, 98 48 33 54 28 No especificado 3.000
Christodoulakis, 05 67 40 68 52** Oral, 200 mg, 10d 3.600
Kosmadakis, 03 31 29 32 59* IV, 100 mg, 14d 4.200
Hierro y EPO perioperatorio en cirugía colo-rectal
* Reducción de la tasa (%) y el índice de transfusión (U/pt)
** Reducción del índice de transfusión solamente.
77. AABT
Seville’s document update
Estimulation of erythropoiesis
We do not recommend the routine use of ESAs for sparing
allogeneic blood transfusions in critically ill patients without an on-
label indication for them.
- Critically ill patients
1A
• Only in one small RCT, rHuEPO + IV iron has documented a
reduction in ABT requirements when a restrictive transfusion protocol
was applied.
• In a very large multicenter RCT, rHuEPO + oral iron did not reduce
ABT rate, but there was a dose-dependent increase of the risk for
thromboembolic events in patients without thrombo-prophylaxis.
• rHuEPO reduced mortality in patients that were younger (<55 years),
less critically ill (APACHE II <20), or with admitting diagnosis of
trauma (especially TBI), but further studies are needed.
Erythropoiesis Stimulating Agents (ESAs)
PROVISIONAL (presentado en NATA 2010, Barcelona)
87. AABT
Seville’s document update
Estimulation of erythropoiesis
The use of ESAs in surgical and critically ill patients might not
be related with increased risk for vascular thromboembolic
events when associated with adequate iron supplementation
and antithrombotic prophylaxis.
Similarly, the use of ESAs in chemotherapy-induced anemia
does not increase tromboembolic risk provided that the right
regime is used (initiate treatment when symptomatic anemia
and Hb 9-11 g/dl, target Hb 12-13 g/dl; adjuvant IV iron)
(EORCT).
- Safety concerns
Erythropoiesis Stimulating Agents (ESAs)
PROVISIONAL (presentado en NATA 2010, Barcelona)
88. ALTERNATIVAS A LA TRANSFUSIÓN ALOGÉNICAALTERNATIVAS A LA TRANSFUSIÓN ALOGÉNICA
““USO DE HIERRO Y EPOUSO DE HIERRO Y EPO
en pacientesen pacientes
oncohematológicos”oncohematológicos”
ALTERNATIVAS FARMACOLÓGICASALTERNATIVAS FARMACOLÓGICAS
PARA ESTIMULAR LA ERITROPOYESISPARA ESTIMULAR LA ERITROPOYESIS
José Antonio García-Erce
Servicio Regional de Hematología y Hemoterapia
Hospital “Universitario” Miguel Servet“, Zaragoza.
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INCIDENCIA ANEMIA EN ONCOHEMATOLOGÍA I
ANEMIA INDUCIDA QUIMIOTERAPIA
Ludwig H, Van Belle S, Barrett-Lee P et al. Eur J Cancer 2004;40:2293-2306
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Ludwig H, Van Belle S, Barrett-Lee P et al. Eur J Cancer 2004;40:2293-2306
INCIDENCIA ANEMIA EN ONCOHEMATOLOGÍA II
ANEMIA PACIENTE ONCOLÓGICO
91. MANAGEMENT PATTERNS IN EUROPE:
Anaemia is under-recognised and undertreated
ECAS data
*With or without iron
**With or without iron or transfusions
HIERRO SÓLO
6,5%
AEEs**
17.4%
Ludwig et al. Eur J Cancer 2004;40:2293–306
SIN TRATAMIENTO
61,1%
TRANFUSIÓN*
14,9%
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MANEJO ANEMIA ONCOHEMATOLOGÍA EUROPA
ANEMIA PACIENTE ONCOLÓGICO
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TRATAMIENTO ANEMIA
INDUCIDA QUIMIOTERAPIA
Principales ventajas y riesgos
TRANSFUSIÓN SANGUÍNEA • Immediate correction of anaemia1
, however associated with risks
HIERRO ORAL • None – IV iron superior to oral iron1
AGENTES ESTIMULANTES
ERITROPOYESIS (AEEs) sin hierro
• 50-70% response rate 2,3,4,5
• Reduction of transfusion requirements5,6,7
• Improvement of quality of life5,6,7,8
AEEs con hierro oral • Same advantages as without oral iron, however more side effects1, 8, 14
AEEs con hierro endovenoso • Up to 90% response rate9-12
• Correction of FID 9-12
• Reduction of transfusion requirements 9
• Improved quality of life 10
ESA=Erythropoiesis-stimulating agents, FID=Functional iron deficiency, QoL=Quality of life
1. NCCN Guidelines 2009; 2. Glaspy J, 1997; 3. Demetric GD, 1998; 4.Gabrilove JL, 2001; 5: Littlewood TJ, 2001; 6. Vansteenkiste J, 2002; 7. Bohilus J, 2006; 8.
Bokemeyer C, 2007; 9. Bastit L, 2008; 10. Auerbach M, 2004; 11. Pedrazzoli P, 2008; 12 Henry DH, 2007; 13. Hedenus M, 2007; 14. Aapro M, 2008
ANEMIA ASOCIADA A CÁNCER
(not treatment related/ or related
to other causes)
Principales ventajas y riesgos
TRANSFUSIÓN SANGUÍNEA • Immediate correction of anaemia1
, however associated with risks
AGENTES ESTIMULANTES
ERITROPOYESIS (AEEs)
• EORTC (Europe): ESAs may be given in selected patients with an Hb level
of 9–11g/dl if justified by anaemia-related symptoms and careful assessment
of need14
. (Note: In certain countries this is not an approved indication).
• NCCN (US): Underlying condition should be treated and transfusion is the
only recommended option1
AEEs con hierro endovenoso • Increases response to ESA13
However, the recommendations do not
support ESA use in cancer related anaemia (see above)
ANEMIA PACIENTE ONCOLÓGICO
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GUÍAS DE PRÁCTICA CLÍNICA
ASCO/ASH
2008
EORTC
2007
NCCN
2008
ESMO
2007
INICIO DEL
TRATAMIENTO ≤10 g/dl* 9-11 g/dl** 10-11 g/dl 9-11 g/dl
NIVELES
DIANA DE Hb
12 g/dl 12-13 g/dl 12 g/dl 12 g/dl
* Se puede considerar el uso de EPO si Hb de 10–12 g/dL, según las circunstancias clínicas
** En pacientes asintomáticos si Hb < 11,9 g/dl (grado D) en función de las circunstancias
individuales y en pacientes sintomáticos desde 9-11 g/dl (grado A).
PRESENCIA DE SÍNTOMAS
ANEMIA PACIENTE ONCOLÓGICO
GUÍAS SOCIEDADES INTERNACIONALES
95. Recombinant Human Erythropoietins and
Cancer Patients: Updated Meta-Analysis of 57
Studies Including 9353 Patients
Bohlius Jet al , Journal of the National Cancer Institute 2006; 98: 708-14
96. Methods: Primary endpoints were on-study mortality and overall survival in
patients receiving chemotherapy, defined as all patients from studies in which =/>
70% of study population received chemotherapy, and in all cancer patients
regardless of anticancer therapy.
Data from 13,933 cancer patients enrolled in 53 studies were included in the
analysis; 38 trials including 10,441 patients used mainly chemotherapy.
Recombinant Human Erythropoiesis Stimulating Agents in Cancer
Patients: Individual Patient Data Meta-Analysis on Behalf of the EPO
IPD Meta-Analysis Collaborative Group. Bohlius et al.
Blood (ASH Annual Meeting Abstracts) 2008 112: Abstract 6
Results: Including all cancer patients ESAs increased on-study
mortality by 17% (Hazard Ratio 1.17; 1.06–1.30), with little evidence for a
difference between chemotherapy and other trials (p for interaction=0.42),
and worsened overall survival by 6% (HR 1.06; 1.00–1.12).
In the chemotherapy population on-study mortality was increased by
10% (HR 1.10, 0.98–1.24) and overall survival was worsened by 4% (HR
1.04; 95% CI 0.97–1.11).
97. LA AEMPS CONSIDERA NECESARIO INFORMAR A LOS PROFESIONALES SANITARIOS DE
LO SIGUIENTE:
• La administración de Epoetinas debe restringirse únicamente a las indicaciones autorizadasindicaciones autorizadas
para cada una de ellas, en las cuales elpara cada una de ellas, en las cuales el beneficio-riesgobeneficio-riesgo se mantiene favorablese mantiene favorable..
• El uso de epoetinas para el tratamiento de la anemia asociada a la IRC ó a la quimioterapia
antineoplásica debe realizarse únicamente si esúnicamente si es sintomáticasintomática y tiene un impacto en el estado dey tiene un impacto en el estado de
salud del paciente.salud del paciente.
• La concentración de Hb a alcanzar comoLa concentración de Hb a alcanzar como objetivoobjetivo debe establecerse en el intervalo dedebe establecerse en el intervalo de 10 a10 a
12 grs/dl sin superar los 12 grs/dl12 grs/dl sin superar los 12 grs/dl. Niveles superiores a los necesarios para controlar la
sintomatología del paciente o evitar la transfusión no aportan beneficios adicionales y van
acompañados de un incremento del riesgo de morbi-mortalidad.
Agencia Española de
M e d i c am e n t o s y
Productos Sanitarios
26 de junio de 2008
98.
99.
100. Recombinant Human Erythropoiesis Stimulating Agents in Cancer
Patients: Individual Patient Data Meta-Analysis on Behalf of the EPO
IPD Meta-Analysis Collaborative Group. Bohlius et al.
Blood (ASH Annual Meeting Abstracts) 2008 112: Abstract 6
Outcome Hazard Ratio
(95% CI)
P value
On-study mortality 1.10
(0.98 - 1.24)
0.12
Overall survival 1.04
(0.97 - 1.11)
0.26
Results for Cancer Patients Receiving Chemotherapy
Who Received ESAs (n = 10,441)
The majority of the cancer patients in these clinical trials were receiving
chemotherapy [75%]. In this patient population, the increase in on-study
mortality and decrease in overall survival was not significant.
For patients undergoing chemotherapy, the increased risk for death "was
less pronounced, but could not be excluded“. (Chemotherapy-induced anemia
is currently the only approved indication for the use of ESAs in cancer patients)
101. Design: Observational study using a state discharge database. Nonfederal
acute care hospitals in Maryland performing colorectal cancer resections
between January 1, 1994, and December 31, 2000.
Patients: We obtained data on 14 014 adult patients having a primary diagnosis
code for colorectal cancer and a primary procedure code for colorectal resection.
Main Outcome Measures: The primary outcome variable was a discharge
diagnosis of VTE.
Results: VTE occurred in 1% of patients and was associated with an adjusted
3.8-fold increase in mortality (OR 3.8; 2.1-6.8), a 61% increase in mean hospital
length of stay, and a 72% increase in mean total hospital charges.
102. Multivariate analysis:
RBC transfusion (OR: 1.60; 1.53-1.67) and
platelet transfusion (OR: 1.20; 1.11-1.29)
were independently associated with an
increased risk of VTE.
Both RBC transfusion (OR, 1.53; 1.46-1.61)
and platelet transfusion (1.55; 1.40-1.71)
were also associated with ATE (p<0.001).
Transfusions were also associated with an
increased risk of inhospital mortality
(RBCs: OR, 1.34; 1.29-1.38; platelets: 2.40;
2.27-2.52; p<0.001).
105. A
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Metaanálisis del uso FEEV en pacientes
oncológicos tratados con EPO
TRANSFUSIÓN SANGUÍNEA
RESPUESTA HEMATOLÓGICA
Favours control Favours
treatment
Notas del editor
Even though blood transfusion has been used for over 100 years there is little evidence of it’s efficacy in many clinical situations. Blood transfusion should only be prescribed to increase the oxygen consumption, and there are many reasons supporting this statement
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
The Seville document is the result of a combined effort of five Spanish medical societies who carried out a consensus on ABT.Briefly, I’ll explain to you the objective, the method and the experts involved in this adventure.
Even though blood transfusion has been used for over 100 years there is little evidence of it’s efficacy in many clinical situations. Blood transfusion should only be prescribed to increase the oxygen consumption, and there are many reasons supporting this statement
This update version of the consensus document has been elaborated by a panel of 40 professionals convened by 6 Spanish Societies involved in Health Care. There were one general coordinator, 9 topic coordinators, 25 collaborators and 6 observers.
Our main objective was to provide evidence-based recommendations on the use of pharmacological and non-pharmacological alternatives for reducing ABT rate and /or ABT volume in surgical and critically ill patients expected to require ABT
The available evidence on the efficacy and safety of these alternatives was analyzed according to GRADE methodology, previously used…..
Even though blood transfusion has been used for over 100 years there is little evidence of it’s efficacy in many clinical situations. Blood transfusion should only be prescribed to increase the oxygen consumption, and there are many reasons supporting this statement
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
The same applies for the use of modified hemoglobin solutions.
Thanks for your attention.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Even though blood transfusion has been used for over 100 years there is little evidence of it’s efficacy in many clinical situations. Blood transfusion should only be prescribed to increase the oxygen consumption, and there are many reasons supporting this statement
For immediate correction of Hb, transfusion is the treatment of choice
Oral iron may be beneficial in the treatment of absolute iron deficiency but substantial evidence exists from studies that IV iron is superior to oral iron in patients receiving ESA treatment
Functional iron deficiency frequently arises after continued ESA treatment and iron supplementation will be required in most patients to obtain optimal erythropoiesis. This is because rapid ESA- stimulated RBC production surpasses the rate at which iron is released from stores. Release of iron can be further delayed by inflammatory cytokines which cause the sequestration iron within iron stores
Combining ESA with IV iron allows correction of FID, a higher haematopoietic response and a faster correction of Hb levels compared with ESA alone
1. NCCN (National Comprehensive Cancer Network) Clinical Practice Guidelines in Oncology, Cancer-and chemotherapy-induced anemia. V3 2009. www.nccn.org/professionals/physician_gls/PDF/anemia.pdf
2. Glaspy J, Bukowski R, Steinberg D et al. J Clin Oncol. 1997; 15:1218-1234
3. Demetri GD, Kris M, Wade J et al. J Clin Oncol 1998; 16:3412-3425
4. Gabrilove JL, Cleeland CS, Livingston RB et al. J Clin Oncol. 2001;19:2875-2882
5. Littlewood TJ. Bajetta E, Nortier JWR et al. J Clin Oncol 2001;19:2865-2874
6. Vansteenkiste J, Pirker R, Massulti B et al. J Natl Cancer Inst. 2002;94:1211-1220
7. Bohlius J , Wilson J Seidenfeld J et al. J Natl Cancer Inst,. 2006;98:708-714
8. Bokemeyer C, Aapro MS, Courdi A et al. Eur J Cancer 2007;43:258-270
9. Bastit L, Vandenbroek A, Altintas S et al. J Clin Oncol 2008;26(10):1611-1618
10. Auerbach M, Ballard H, Trout JR et al. J Clin Oncol 2004;22:1301-1307.
11. Pedrazzoli P, Farris A, Del Prete S et al. J Clin Oncol 2008;26(10):1619-1625.
12. Henry DH, Dahl NV, Auerbach M, Tchekmedyian S et al. The Oncologist 2007;12:231-242
13. Hedenus M, Birgegard G, Nasman P et al. Leukemia 2007;21:627-632.
14. Aapro MS & Link H. The Oncologist 2008;13 (Suppl): 33-36
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.