Effective utilization of erythropoietin with intravenous iron therapy

Current misconceptions in diagnosis and management of iron deficiency

The prevention and treatment of iron deficiency is a major public health goal. Challenges in the treatment of iron deficiency include finding and addressing the underlying cause and the selection of an iron replacement product which meets the needs of the patient. However, there are a number of non-evidence-based misconceptions regarding the diagnosis and management of iron deficiency, with or without anaemia, as well as inconsistency of terminology and lack of clear guidance on clinical pathways. In particular, the pathogenesis of iron deficiency is still frequently not addressed and iron not replaced, with indiscriminate red cell transfusion used as a default therapy. In our experience, this imprudent practice continues to be endorsed by non-evidence-based misconceptions. The intent of the authors is to provide a consensus that effectively challenges these misconceptions, and to highlight evidence-based alternatives for appropriate management (referred to as key points). We believe that this approach to the management of iron deficiency may be beneficial for both patients and healthcare systems. We stress that this paper solely presents the Authors' independent opinions. No pharmaceutical company funded or influenced the conception, development or writing of the manuscript.

A randomized, open-label trial of iron isomaltoside 1000 (Monofer®) compared with iron sucrose (Venofer®) as maintenance therapy in haemodialysis patients

BACKGROUND

Iron deficiency anaemia is common in patients with chronic kidney disease, and intravenous iron is the preferred treatment for those on haemodialysis. The aim of this trial was to compare the efficacy and safety of iron isomaltoside 1000 (Monofer®) with iron sucrose (Venofer®) in haemodialysis patients.

METHODS

This was an open-label, randomized, multicentre, non-inferiority trial conducted in 351 haemodialysis subjects randomized 2:1 to either iron isomaltoside 1000 (Group A) or iron sucrose (Group B). Subjects in Group A were equally divided into A1 (500 mg single bolus injection) and A2 (500 mg split dose). Group B were also treated with 500 mg split dose. The primary end point was the proportion of subjects with haemoglobin (Hb) in the target range 9.5-12.5 g/dL at 6 weeks. Secondary outcome measures included haematology parameters and safety parameters.

RESULTS

A total of 351 subjects were enrolled. Both treatments showed similar efficacy with >82% of subjects with Hb in the target range (non-inferiority, P = 0.01). Similar results were found when comparing subgroups A1 and A2 with Group B. No statistical significant change in Hb concentration was found between any of the groups. There was a significant increase in ferritin from baseline to Weeks 1, 2 and 4 in Group A compared with Group B (Weeks 1 and 2: P < 0.001; Week 4: P = 0.002). There was a significant higher increase in reticulocyte count in Group A compared with Group B at Week 1 (P < 0.001). The frequency, type and severity of adverse events were similar.

CONCLUSIONS

Iron isomaltoside 1000 and iron sucrose have comparative efficacy in maintaining Hb concentrations in haemodialysis subjects and both preparations were well tolerated with a similar short-term safety profile.

Intravenous iron administration is associated with reduced platelet counts in patients with chronic kidney disease

WHAT IS KNOWN AND OBJECTIVE

In the management of anaemia associated with chronic kidney disease (CKD), optimal use of intravenous (i.v.) iron has a central role. It minimizes reliance on erythropoiesis-stimulating agents (ESAs) and may be beneficial in reducing overall cardiovascular risks through its effects on platelet counts (PLT). We have examined the effects of i.v. iron on PLT in patients with CKD.

METHODS

Two hundred and three patients with CKD, referred to a single teaching hospital in UK for i.v. iron therapy, received low molecular-weight iron dextran at a median dose of 1000 milligrams given over a median time of 2 h and 40 min. PLT at baseline were compared with the measurements taken during a 4-month follow-up period post-infusion.

RESULTS

PLT were checked at various points following i.v. iron treatment. Compared with baseline, mean reduction in PLT ranged between 10.1 and 23.6 (×10(9) /L) during consecutive 15-days intervals post-treatment. At the reference point of 90-days post-infusion, the drop in PLT was statistically significant (P < 0.001).

WHAT IS NEW AND CONCLUSION

Low molecular-weight iron dextran in patients with CKD leads to reduction in PLT. This reduction appears soon after treatment and is maximal after 3 months. Prospective data are required to confirm these findings and examine whether this translates to a reduction in thrombotic episodes.

Health economic assessment of ferric carboxymaltose in patients with iron deficiency and chronic heart failure based on the FAIR-HF trial: an analysis for the UK

AIMS

The purpose of this study was to evaluate the cost-effectiveness of iron repletion using intravenous (i.v.) ferric carboxymaltose (FCM) in chronic heart failure (CHF) patients with iron deficiency with or without anaemia. Cost-effectiveness was studied from the perspective of the National Health Service in the UK.

METHODS AND RESULTS

A model-based cost-effectiveness analysis was used to compare iron repletion with FCM with no iron treatment. Using data from the FAIR-HF trial and publicly available sources and publications, per patient costs and clinical effectiveness of FCM were estimated compared with placebo. Cost assessment was based on study drug and administration costs, cost of CHF treatment, and hospital length of stay. The incremental cost-effectiveness ratio (ICER) of FCM use was expressed as cost per quality-adjusted life year (QALY) gained, and sensitivity analyses were performed on the base case. The time horizon of the analysis was 24 weeks. Mean QALYs were higher in the FCM arm (difference 0.037 QALYs; bootstrap-based 95% confidence interval 0.017-0.060). The ICER of FCM compared with placebo was €4414 per QALY gained for the FAIR-HF dosing regimen. Sensitivity analyses confirmed the base case result to be robust.

CONCLUSION

From the UK payers' perspective, managing iron deficiency in CHF patients using i.v. FCM was cost-effective in this analysis. The base case ICER was clearly below the threshold of €22 200-€33 300/QALY gained (£20 000-£30 000) typically used by the UK National Institute for Health and Clinical Excellence and proved to be robust in sensitivity analysis. Improved symptoms and better quality of life contributed to this result.

Efficacy and tolerability of accelerated-dose low-molecular-weight iron dextran (Cosmofer) in patients with chronic kidney disease

INTRODUCTION

The Renal NSF advocates correction of anaemia in chronic kidney disease patients. Oral iron is often insufficient, while intravenous supplementation replenishes and maintains iron stores. There is a need to administer high doses of iron in a single rapid infusion to enable efficient costs, effective utilisation of time for patients and staff and optimal use of resources.

METHODS

We performed a prospective study of consecutive patients referred for iron dextran (Cosmofer) therapy. This was administered over 2 h 40 min compared with the normal regime of 4-6 h. Blood pressure was recorded throughout administration. Adverse drug reactions were recorded over 2 weeks. Serum ferritin, haemoglobin and estimated glomerular filtration rate were measured at baseline and 3 months.

RESULTS

One hundred patients (59 male, mean age 69 years), received a median dose of 1,000 mg Cosmofer in a median time of 2 h 40 min. Mean serum ferritin rose from 178 at baseline to 413 μg/l (p < 0.001). Mean haemoglobin rose by 1.5 g/dl (p < 0.001). There was no decline in estimated glomerular filtration rate after 3 months. No adverse reactions were noted.

CONCLUSION

We demonstrated that accelerated administration of iron dextran is safe and effective with no short-term effects on renal function. This resulted in a time saving of approximately 67 hours.

Update of a comparative analysis of cost minimization following the introduction of newly available intravenous iron therapies in hospital practice

Background

The clinical need to be able to administer high doses of intravenous iron conveniently as a rapid infusion has been addressed by the recent introduction of ferric carboxymaltose and subsequently iron isomaltoside 1000. Neither requires a test dose. The maximum dose of ferric carboxymaltose is 1000 mg. The maximum dose of iron isomaltoside 1000 is based on 20 mg/kg body weight without a specified ceiling dose, thereby increasing the scope of being able to achieve total iron repletion with a single infusion. This ability to give high doses of iron is important in the context of managing iron deficiency anemia, which is associated with a number of clinical conditions where demands for iron are high. It is also an important component of the strategy as an alternative to blood transfusion. Affordability is a key issue for health services. Recent price changes affecting iron sucrose and ferric carboxymaltose, plus modifications to the manufacturers’ prescribing information, have provoked this update.

Methods

This study is a comparative analysis of the costs of acquiring and administering the newly available intravenous iron formulations against standard treatments in the hospital setting. The costs include the medication, nursing costs, equipment, and patient transportation. Three dosage levels (600 mg, 1000 mg, and 1600 mg) are considered.

Results and conclusion

The traditional standard treatments, blood and iron sucrose, cost more than the alternative intravenous iron preparations across the dose spectrum and sensitivities. Low molecular weight iron dextran is the least expensive option at the 1600 mg dose level but has the caveat of a prolonged administration time and requirement for a test dose. At 600 mg and 1000 mg dose levels, both iron isomaltoside 1000 and ferric carboxymaltose are more economical than low molecular weight iron dextran. Iron isomaltoside 1000 is less expensive than ferric carboxymaltose at all dose levels. Newly available iron preparations appear to be clinically promising, cost effective, and practical alternatives to current standards of iron repletion.

Reliance on credibility to prioritise interventions can lead to sub-optimal management strategies

When there is more than one possible intervention, clinicians have to decide which intervention to offer first. This paper hypothesises that where there is more than one intervention for which the evidence indicates there is similar effectiveness that selecting the intervention with the lowest credibility first may lead to optimal long-term results.

Beyond efficacy and safety-the need for convenient and cost-effective iron therapy in health care

The National Service Framework advocates correction of anaemia in patients with chronic kidney disease (CKD). Oral iron is insufficient, while intravenous (IV) supplementation replenishes and maintains iron stores. Previously, effective delivery of iron therapy using available parenteral preparations has been hampered by dosing schedules and the need in some cases of a test dose. The introduction in Europe of newer iron preparations, including iron isomaltoside 1000 (Monofer) and iron carboxymaltose (Ferinject), now offers a potentially safe, effective and time-efficient method of outpatient iron repletion. This may potentially lead to better cost-effectiveness in a resource-limited service.

A hospital-based cost minimization study of the potential financial impact on the UK health care system of introduction of iron isomaltoside 1000

Background:

The clinical need to be able to administer high doses of intravenous iron conveniently in a single rapid infusion has been addressed by the recent introduction of ferric carboxymaltose and subsequently iron isomaltoside 1000. Neither requires a test dose. Ferric carboxymaltose can be administered at 15 mg/kg body weight to a maximum dose of 1000 mg, whereas iron isomaltoside 1000 can be administered at 20 mg/kg body weight. The ability to give high doses of iron is important in the context of managing iron deficiency anemia in a number of clinical conditions where demands for iron are high (including chronic blood loss associated with inflammatory bowel disease, menorrhagia, and chronic kidney disease). It is also an important component in the strategy as an alternative to a blood transfusion. Affordability is a key issue for health services.

Methods:

This study was a comparative analysis of the costs of administering the newly available intravenous iron formulations against standard practice (blood transfusion, intravenous iron sucrose) by considering the cost of this treatment option plus nursing costs associated with administration, equipment for administration, and patient transportation in the secondary care (hospital) setting across three dosage levels (600 mg, 1000 mg, and 1600 mg).

Results and conclusion:

The analysis indicates that the use of iron isomaltoside 1000 results in a net saving when compared with iron sucrose, blood, and ferric carboxymaltose. At 600 mg and 1000 mg doses, it is cheaper than low-molecular-weight iron dextran but more expensive at a dose of 1600 mg. However, it takes six hours to administer low-molecular-weight iron dextran at this dose level, which is inconvenient and reduces patient throughput (productivity).

Improving efficiency and value in health care. Intravenous iron management for anaemia associated with chronic kidney disease: linking treatment to an outpatient clinic, optimizing service provision and patient choice

RATIONALE

The National Service Framework advocates correction of anaemia in patients with chronic kidney disease (CKD). Oral iron is insufficient, while intravenous (IV) supplementation replenishes and maintains iron stores. In Yorkshire numerous peripheral clinics exist to reduce travel for patients, but patients must travel to the main unit for IV iron therapy. Therefore an outpatient service in tandem with a routine clinic for administration of IV CosmoFer was created.

PURPOSE

To evaluate the feasibility and benefits of IV iron therapy in the outpatient clinic during active patient review for CKD patients.

DESIGN

A cross-sectional study of patients attending for total dose IV iron (n = 57) at a peripheral clinic. Iron was administered and monitored according to protocol by one of the clinic nurses with medical staff available in the adjoining room. Haemoglobin, ferritin and renal function were recorded pre-infusion and after 4-6 months. Results are given as medians/means +/- standard error.

RESULTS

A total of 76 IV infusions were carried out with no reported side effects or haemodynamic instability. Haemoglobin (median 10.9 vs. 11.3 g dL(-1), P = NS), creatinine and estimated glomerular filtration rate (eGFR) over the 6-month period remained stable. Serum ferritin rose significantly [80.9 +/- 6.2 vs. 186.4 +/- 18.2 g L(-1) (P < 0.001)]. Hospital time saved 380 day case bed hours, doctor hours saved 76 hours, and patient hours saved 3 hours/patient. Cost savings for TDI CosmoFer in peripheral clinic versus in centre therapy and versus sucrose, respectively, for 76 treatments was pound 5749.40 and pound 46,320.80 respectively.

CONCLUSION

We have demonstrated, in a resource-limited service, the feasibility and cost-effectiveness of a management care pathway for patients with CKD, in a peripheral clinic, to receive total dose IV CosmoFer without disruption of a functioning renal clinic.

Predictors of the response to treatment in anemic hemodialysis patients with high serum ferritin and low transferrin saturation

Treating hemodialysis patients to combat anemia corrects hemoglobin but exacerbates iron deficiency by utilizing iron stores. Patients needing iron should receive this by intravenous (i.v.) means. The Dialysis patients' Response to IV iron with Elevated ferritin (DRIVE) trial investigated the role of i.v. iron in anemic patients with high ferritin, low transferrin saturation, and adequate epoetin doses. We examined whether baseline iron and inflammation markers predict the response of hemoglobin to treatment. Patients (134) were randomized to no added iron or to i.v. ferric gluconate for eight consecutive hemodialysis sessions spanning 6 weeks with epoetin increased by 25% in both groups. The patients started with hemoglobin less than or equal to 11 g/dl, ferritin between 500 and 1200 ng/ml, and transferrin saturation of less than 25%. Significantly, patients with a reticulocyte hemoglobin content greater than or equal to 31.2 pg were over five times more likely to achieve a clinically significant increase in hemoglobin of greater than 2 g/dl. Lower reticulocyte hemoglobin contents did not preclude a response to i.v. iron. Significantly higher transferrin saturation or lower C-reactive protein but not ferritin or soluble transferrin receptor levels predicted a greater response; however their influence was not clinically significant in either group. We conclude that none of the studied markers is a good predictor of response to anemia treatment in this patient sub-population.

Advances in Anemia Management in Chronic Kidney Disease

The prevalence of chronic kidney disease (CKD) is increasing in the United States. Efforts to promote earlier intervention to screen for CKD and manage secondary complications are of paramount importance to improve overall care of this population. Anemia is a secondary complication of CKD that develops as kidney function declines. Historically, anemia management efforts have been primarily emphasized in patients with end-stage renal disease; however, early detection and treatment of anemia in the early stages of the disease are essential to prevent negative consequences of anemia such as reduced quality of life, left ventricular hypertrophy and mortality. With the increased prevalence of CKD and efforts focused on identifying this disorder early in its course, it is likely that more pharmacists will be involved in the management of CKD and secondary complications such as anemia. Treatment approaches must also be based on the more recently advocated guidelines from the National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative (NKF-K/DOQI). This article reviews therapeutic issues of anemia of CKD, new agents for management, and the NKF-K/DOQI anemia management guidelines from a clinical perspective that will assist pharmacists involved in the care of these patients.

Risk of bacterial infection in patients under intravenous iron therapy: dose versus length of treatment

Some studies have suggested that intravenous iron therapy may be associated with an increased risk of infection. We analyzed the incidence of bacterial infection in 111 hemodialysis patients. Group 1 (n = 39, transferrin saturation <20%) received 10 doses of 100 mg of intravenous iron saccharate, 3 doses per week (28 treatment days); Group 2 (n = 13, transferrin saturation <20%) received 20 doses, 3 doses per week (70 treatment days); and Group 3 (n = 59, transferrin saturation 20-50%) received 10 doses, 1 dose per week (70 treatment days). The follow-up was 150 days for all groups, and all infectious episodes were recorded. Pulmonary infection was the most frequent event observed in all of the groups. In an incidence-density analysis, Group 2, which received a total of 20 doses, presented a significantly higher incidence of infection than Group 3, which received only 10 doses over the same period (0.13 versus 0.06 infections per patient per month, p = 0.04). No difference was observed between Groups 1 and 2 suggesting that the risk of infection during iron therapy is dose dependent rather than time length dependent.