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A Perspective on the Evolution of Management of Cancer- and Chemotherapy-Induced Anemia

George M. Rodgers

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Treatment Strategies for Myeloid Growth Factors and Intravenous Iron: When, What, and How?

Jeffrey Crawford and George M. Rodgers

Myeloid growth factors can reduce the risk of chemotherapy-induced neutropenia (CIN) and thus impact the survival of patients with cancer. Patients should be assessed for risk, taking into consideration patient-related risk factors and chemotherapy regimens. Patients stratified as having at least a 20% risk for CIN should be considered for prophylactic growth factors. The NCCN Guidelines for Myeloid Growth Factors provide category 1 recommendations for the daily use of filgrastim, tbo-filgrastim, and pegfilgrastim. Cancer-related anemia can be treated with erythropoiesis-stimulating agents, red blood cell transfusion, or intravenous iron.

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Current Quandaries in Cancer-Associated Anemia

Jeffrey A. Gilreath and George M. Rodgers

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Parenteral Iron Therapy: A Single Institution's Experience Over a 5-Year Period

Christopher A. Laman, Scott B. Silverstein, and George M. Rodgers

Many patients require parenteral iron therapy for optimal correction of anemia, including cancer patients who require erythropoietic drugs. Available parenteral iron therapy options include iron dextran, iron gluconate, and iron sucrose. The purpose of this study is to summarize our institution's experience with parenteral iron therapy over a 5-year period, with a focus on comparative safety profiles. All patients receiving parenteral iron therapy over this period were included in the analysis. Chi-squared test and Fisher's exact test were used to compare the adverse event rates of each product. A total of 121 patients received 444 infusions of parenteral iron over this period. Iron dextran was the most commonly used product (85 patients) and iron sucrose was the least used (2 patients). Iron gluconate was used by 34 patients. Overall adverse event rates per patient with iron dextran and iron gluconate were 16.5% and 5.8%, respectively (P = .024). Premedication with diphenhydramine and acetaminophen before infusions of iron dextran reduced adverse event rates per infusion from 12.3% to 4.4% (P = .054). Test doses of iron dextran were used 88% of the time for initial infusions of iron dextran. All adverse events for all parenteral iron products were mild or moderate. There were no serious adverse events and no anaphylaxis was observed. Our results suggest that, if test doses and premedications are used, iron dextran is an acceptable product to treat iron deficiency.

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Establishing an Anemia Clinic for Optimal Erythropoietic-Stimulating Agent Use in Hematology-Oncology Patients

Jeffrey A. Gilreath, Daniel S. Sageser, James A. Jorgenson, and George M. Rodgers

Erythropoietic-stimulating agent (ESA) therapy has significantly impacted the management of chemotherapy-induced anemia (CIA) by decreasing the number of red blood cell transfusions required by patients with cancer. However, managing these patients with ESA therapy has become increasingly difficult since the release of the Centers for Medicare & Medicaid Services' new National Coverage Determination document because of the disparities between this document and recommendations from expert-reviewed national clinical guidelines on the treatment of anemia. This article describes a collaborative practice agreement between pharmacists and physicians as one approach to managing CIA in hematology-oncology patients in an anemia clinic. The goal of the pharmacist-managed anemia clinic is to improve patient satisfaction and clinical outcomes associated with the treatment of CIA. This article describes the rationale for the clinic and discusses its design and implementation in managing ESA, iron, folate, and vitamin B12 therapy for CIA in hematology-oncology patients. The pharmacist's role is justified in this clinic model through increased adherence to evidence-based practice guidelines and decreased costs associated with ESA therapy.

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Total Dose Iron Dextran Infusion in Cancer Patients: Is it SaFe2+?

Jeffrey A. Gilreath, David D. Stenehjem, and George M. Rodgers

The feasibility of the large, single-dose intravenous iron repletion method, which is known today as total dose infusion (TDI), has been demonstrated over decades. However, this method of iron repletion was chiefly developed for patients with large iron deficits, such as those with pregnancy-induced anemia, chronic bleeding disorders, and absolute iron-deficiency anemia (serum ferritin < 30 ng/mL, transferrin saturation < 15%) who were unable to receive frequent small doses of intravenous iron. Today, 50 years after the advent of TDI, more is known about iron metabolism and storage, but the optimal dosing strategy for intravenous iron in patients with cancer is still not well defined. The proinflammatory state of cancer, or its treatment, may influence the response to intravenous iron therapy. Additionally, the long-term adverse effects of large single doses or smaller more frequent doses have yet to be studied in the oncology population. Historically, safety concerns surrounding the administration of intravenous iron have centered on anaphylaxis. Newer concerns are being raised, such as oxidative stress, iron overload, venous thromboembolism, infection risk, and tumor growth. Therefore, with the original premise of TDI assuming low levels of inflammation, coupled with the recent data surrounding the adverse effects of blood transfusions and erythropoietic-stimulating agents, this article reviews the risks and benefits of TDI administration specifically for patients with cancer.

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Cancer- and Chemotherapy-Induced Anemia

George M. Rodgers III, Pamela Sue Becker, Morey Blinder, David Cella, Asher Chanan-Khan, Charles Cleeland, Peter F. Coccia, Benjamin Djulbegovic, Jeffrey A. Gilreath, Eric H. Kraut, Ursula A. Matulonis, Michael M. Millenson, Denise Reinke, Joseph Rosenthal, Rowena N. Schwartz, Gerald Soff, Richard S. Stein, Gordana Vlahovic, and Alva B. Weir III

Anemia is prevalent in 30% to 90% of patients with cancer. Anemia can be corrected through either treating the underlying cause or providing supportive care through transfusion with packed red blood cells or administration of erythropoiesis-stimulating agents (ESAs), with or without iron supplementation. Recent studies showing detrimental health effects of ESAs sparked a series of FDA label revisions and a sea change in the perception of these once commonly used agents. In light of this, the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Cancer- and Chemotherapy-Induced Anemia underwent substantial revisions this year. The purpose of these NCCN Guidelines is twofold: 1) to operationalize the evaluation and treatment of anemia in adult cancer patients, with an emphasis on those who are receiving concomitant chemotherapy, and 2) to enable patients and clinicians to individualize anemia treatment options based on patient condition.