Anemia Management Protocol: Home ... - BC Renal Agency

BCPRA HOME HEMODIALYSIS ANEMIA MANAGEMENT PROTOCOLUPDATED APRIL 2012The following protocol, on order of physician, transfers anemia management of home dialysis (peritoneal and hemodialysis) patients tononphysician staff (i.e. RNs and renal pharmacists). This protocol is intended to serve as a guide and cannot replace clinical judgment. Therecommendations included may be inappropriate for specific clinical situations (e.g. patients with hemochromatosis, thalassemia, PRCA,allergy to IV iron or an erythropoiesis stimulating agent (ESA), history of stroke, active malignancy, history of malignancy, etc.). The lowestESA dosage to achieve acceptable Hgb range should be used. This algorithm is based on the assumption that the patient is compliant tomedication and bloodwork. Note: ESA refers to both epoetin alpha (Eprex®) and darbepoetin (Aranesp®).Notify MD if Hgb increased by≥ 20 g/L from last bloodworkor if Hgb >140 g/L on ESAHgb > 120 g/LAssess Hemoglobin (Hgb) StatusTarget Hgb: 110 g/LAcceptable Hgb Range: 100 to 120 g/LHgb 100 to 120 g/L and stable(no change > 20 g/L from last Hgb level)Notify MD if Hgb < 80 g/L or ifHgb has fallen ≥ 20 g/L fromlast bloodworkHgb < 100 g/LNONo ESA required.Continue routine Hgbmonitoring as perusual order.ReceivingESA?YESHgb 121to 130 g/L• If there has been no dosagereduction in the past 5 weeks,reduce ESA dosage as perprotocol ESA Dosage AdjustmentTables.• If there have been dosagereductions in the past 5 weeks,maintain current dose.• Measure Hgb once monthly.Hgb >130 g/LESA on hold ordiscontinuedHgb 121to 130 g/L• Consult MDto hold ESA orreduce dose.*• Measure Hgbin 4 weeks andreassess Hgbstatus and ESAdosage.NONo ESArequired.Continueroutine Hgbmonitoringonce monthly.ReceivingESA?YESMaintain ESAdose andcontinue Hgbmonitoring oncemonthly.< less than≤ less than or equal to> greater than≥ greater than or equal to*Unless directed by program to hold ESA and follow protocol without MD notification.ESA on hold ordiscontinued• Restart ESA at areduced dosebased on thedose before hold.Refer to protocolESA DosageAdjustmentTables.• Continue Hgbmonitoring oncemonthly.• If Hgb hasdropped morethan 20 g/L whileESA was on hold,notify MD.NOCheck ironstudies.Ensure ironrepleted. Referto page 2.Consider startingESA. Suggestedinitial dose:epoetin100 units/kg/wkor darbepoetin0.9 mcg/kg/2weeks. Obtain anorder from MDto start anemiaprotocol.AFTER Hgb STATUS ASSESSMENT ABOVE, ASSESS IRON STATUS. Refer to page 2 for ferrous fumarate or intravenous iron protocol.ReceivingESA?YESCheck ironstudies.Ensure ironrepleted. Referto page 2.• If TSAT < 20%, consider ironload instead of increasingESA dosage.• If no dosage increase inpast 5 weeks, increase ESAdosage as per protocolESA Dosage AdjustmentTables.• If dose was increased inpast 5 weeks, maintainthat dose until nextbloodwork.• Continue Hgb monitoringonce monthly.• Notify MD if Hgb is notin target range after3 consecutive doseincreases. Refer to ESAHyporesponsivenessFlowchart.

BCPRA HOME HEMODIALYSIS ANEMIA MANAGEMENTPROTOCOL ESA DOSAGE ADJUSTMENT TABLESUPDATED APRIL 2012The following tables provide guidance for most dosage adjustments. If a patient’s Hgb cannot bemaintained within the desired range with 3 consecutive dose modifications using the dosage schedulebelow, contact a nephrologist or renal pharmacist for advice. If a patient’s erythropoiesis stimulatingagent (ESA) dosage is not available in the tables below, please contact a nephrologist for ESA dosagemodification. The lowest ESA dosage to maintain Hgb within acceptable range should be used.Darbepoetin (Aranesp®) Dosage Adjustment TablePre-filled syringes available in CKD patients include: 10 mcg, 20 mcg, 30 mcg, 40 mcg, 50 mcg,60 mcg, 80 mcg, 100 mcg, 130 mcg and 150 mcg.Current Dose Increase Dose* Decrease Dose*10 mcg every 2 weeks20 mcg every 2 weeks30 mcg every 2 weeks40 mcg every 2 weeks50 mcg every 2 weeks60 mcg every 2 weeks80 mcg every 2 weeks100 mcg every 2 weeks130 mcg every 2 weeks150 mcg every 2 weeks100 mcg every 1 week130 mcg every 1 week150 mcg every 1 week20 mcg every 2 weeks30 mcg every 2 weeks40 mcg every 2 weeks50 mcg every 2 weeks60 mcg every 2 weeks80 mcg every 2 weeks100 mcg every 2 weeks130 mcg every 2 weeks150 mcg every 2 weeks100 mcg every 1 week130 mcg every 1 week150 mcg every 1 weekNo further increase, check with nephrologistD/C, check Hgb in 2 weeks10 mcg every 2 weeks20 mcg every 2 weeks30 mcg every 2 weeks40 mcg every 2 weeks50 mcg every 2 weeks60 mcg every 2 weeks80 mcg every 2 weeks100 mcg every 2 weeks130 mcg every 2 weeks150 mcg every 2 weeks100 mcg every 1 week130 mcg every 1 week* For dosage increase or decrease, change interval to use up current syringes before starting new dosage.Refer to ESA Dosing Interval Adjustment Table.Epoetin alpha (Eprex®) Dosage Adjustment TablePrefilled syringes available in CKD patients include: 1000 units, 2000 units, 3000 units, 4000 units,5000 units, 6000 units, 8000 units and 10,000 units.Current Dose Increase Dose* Decrease Dose*1000 units every 1 week2000 units every 1 week3000 units every 1 week4000 units every 1 week5000 units every 1 week6000 units every 1 week8000 units every 1 week10,000 units every 1 week6000 units twice per week8000 units twice per week10,000 units twice per week8000 units 3 times per week10,000 units 3 times per week2000 units every 1 week3000 units every 1 week4000 units every 1 week5000 units every 1 week6000 units every 1 week8000 units every 1 week10,000 units every 1 week6000 units twice per week8000 units twice per week10,000 units twice per week8000 units 3 times per week10,000 units 3 times per weekNo further increase, check with nephrologistD/C, check Hgb in 2 weeks1000 units every 1 week2000 units every 1 week3000 units every 1 week4000 units every 1 week5000 units every 1 week6000 units every 1 week8000 units every 1 week10,000 units every 1 week6000 units twice per week8000 units twice per week10,000 units twice per week8000 units 3 times per week* For dosage increase or decrease, change interval to use up current syringes before starting new dosage. Refer to ESADosing Interval Adjustment Table.

ESA DOSING INTERVAL ADJUSTMENT TABLESUPDATED APRIL 2012FOR HOME DIALYSIS PATIENTSDarbepoetin (Aranesp ® ) Dosing Interval Adjustment Table(to use up current supplies at home)CURRENT DOSE10 mcg every 2 weeks20 mcg every 2 weeks30 mcg every 2 weeks40 mcg every 2 weeks50 mcg every 2 weeks60 mcg every 2 weeks80 mcg every 2 weeks100 mcg every 2 weeks130 mcg every 2 weeks150 mcg every 2 weeks100 mcg every 1 week130 mcg every 1 week150 mcg every 1 weekINCREASED DOSECHANGE INTERVAL TOEvery 10 daysEvery 5 daysCheck with MDDECREASED DOSECHANGE INTERVAL TOHoldEvery 21 DaysEvery 10 daysEpoetin alpha (Eprex ® ) Dosing Interval Adjustment Table(to use up current supplies at home)CURRENT DOSE1000 units every 1 week2000 units every 1 week3000 units every 1 week4000 units every 1 week5000 units every 1 week6000 units every 1 week8000 units every 1 week10,000 units every 1 week6000 units twice per week8000 units twice per week10,000 units twice per week8000 units 3 times per week10,000 units 3 times per weekINCREASED DOSECHANGE INTERVAL TOEvery 5 daysEvery 3 daysEvery 2 daysCheck with MDDECREASED DOSECHANGE INTERVAL TOHoldEvery 10 daysEvery 5 daysEvery 3 days