Epogen extremely high doses. Anyone having this experience?

[Adelaide]

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hello all,

I am intrigued by an oncologist's practice.
He has been prescribing ridiculous doses of Erythropoietin to overcame what he claims as "resistance to Epogen" by cancer patients.
Does anybody have any experience or reference that would help to prove that spending $18,000 per month on Epogen is not the answer for those cases?

My last patient he ordered 120,000 units of epogen, pt has low iron, low TIBC but highly elevated tranferrin (1054)
So I do not think this patient needs iron supplementation. I found papers that recommend iron supplementation in cases of low iron and low ferritin, but this is not the case.

Any references that would help me to explain this oncologist that he needs to reevaluate epogen's dosage?

thanks!
Adelaide

 

[StaviZFingerZ]

CMS will only reimburse 40,000 units per week or Epo. For a good reason. And if patient doesn't respond, then an one time increase of 25% is allowed..up to 50,000 units per week or 150units/kg TIW.

Think about it... every cell in the body has erythropoetin receptors including cancer cells. So why give cell proliferating agent to these patients?

Sounds like to me a quackery.

 

[Pharmavixen]

Are you talking iron supplementation, or the epo?

If you go to www.nccn.org and sign up (it's free), you can look at the National Comprehensive Cancer Network, and download their anemia guidelines.

In a nutshell: NCCN doesn't recommend epo in cancer pts where a cure is possible. And epo should only be used in association with chemo regimens.

That said, sometimes epo doesn't work so well because the pt requires iron supplementation.

I know that sometimes people with metastatic cancer will develop a high serum ferritin that is factitious because ferritin is also an acute phase reactant, so high ferritin in that setting has nothing to do with iron. (A friend whose father died of melanoma the end of last year had a serum ferritin of 15,000; he had metastases all through him and died within a couple of months of diagnosis.)

 

[njac]

we were taught to be cautious with epo in cancer pt's because it basically feeds the cancer cells as well.

But I think Pri would be a good reference here.

 

[npage148]

Do they have antibodies against EPO by chance?

 

[VCU2011]

we were taught to be cautious with epo in cancer pt's because it basically feeds the cancer cells as well.

But I think Pri would be a good reference here.

I looked into this a couple of months ago and basically found literature supporting both theories- that it protects the cancer cells and that it has no effect on the cells. Basically all I gathered was that the research is too new to have any conclusion. From reading the papers I thought the research was more in favor of the epo not having any effect...

 

[Adelaide]

😀

Thanks you all for the info. I knew I could count on my peers!

One missing info to this puzzle: the patient has Refractory anemia with excess blasts (RAEB)

PHARMAVIXEN, thanks a lot, I went to the NCCN and they recommend erythropoietin use for this type of cancer (TREATMENT OF SYMPTOMATIC ANEMIA).
The answer is there: rHU EPO 40,000 to 60,000 units/1-3 x week subcutaneously + G-CSF 1-2 mcg/Kg 1-3 x/week subcutaneously (So it might be better to divide the weekly dose of epogen 120,000 units into 3 doses of 40,000 units. Or use Darbepoetin!
Now I have to go back to the patient profile and analyse all the labs and see if the epogen can be considered a failure or not. I know he still receiving blood.

npgae148,
I heard of this neutralizing antibodies as an contraindication to Epo. But how to identify the antibodies? Is there such such kind of lab procedure already?

Thanks a lot!

 

[Omegadramon]

Somebody did an in-service about the use of ESAs. They said recent data suggest that the goal of ESAs should not be to normalize Hb, but to elevate it, because of side effects at high doses.

 

[AvocadoLover]

I can't comment on the appropriate use of Epo in this pt without knowing all the info but in most cases Epo is not indicated in oncology. However, assuming your patient is eligible for Epo here is what I think:

We often see HD patients who have similar labs to your patient.

In general they are requiring really high doses of Epo and Hgb is not improving. In these patients if you check retics it will give you an idea if the pt is responding to Epo. If your patient's retics are elevated then they are responding. (if not you can cont to inc Epo). If pt is a responder, and has high ferritin but low transferrin you can infer the patient has enough iron stores but the iron is not being "mobilized." We usually refer to this as functional anemia. There is some literature to support using IV Vitamin C in these patients and we do this regularly. However, there is currently not enough literature for KDOQI to support the use of it.

Hope this helps!

 

[AvocadoLover]

Oops! Just realized you said transferrin is HIGH. Hmm... your pt might actually be iron deficient. What is the TSAT and Ferritin?? In HD pt we give 1g of IV iron over 5-10d for any pt with Ferritin <200 and/OR TSAT<20%. If TSAT is between 20-50 and/OR Ferritin btw 200-500 we give IV or po iron supplements. If >50 AND >500 than no iron is indicated.