Recommendations for the Use of Erythropoietic Factors

Anemia is a problem in up to 50-60% of patients with lung cancer, especially if they are treated with platinum-based chemotherapy. Despite its well-documented profound impact on QOL, many clinicians only treat with transfusion, once severe anemia (Hb concentration < 8 g/dL) is present. Much evidence supports the use of rHuEPO for chemotherapy-induced anemia, if the Hb concentration decreases by <10 g/dL (79). Although recent data suggest that QOL may be preserved better if rHuEPO is started when the Hb concentration is <12 g/dL, there is at present not enough evidence to make an overall recommendation for this strategy, but rather clinical evidence in particular circumstances.

Based on randomized data, the standard prescription is 150 U/kg rHuEPO three times a week for a minimum of 4 wk (90). With this schedule, it takes at least 4 wk for a response to occur, and only 50-60% of patients will have an increase of Hb of 2.0 g/dL. In case of insufficient response after 4 wk, the dose may be doubled. If there is no response after 8 wk, rHuEPO should be stopped. Less robust clinical practice evidence suggests an alternative weekly dosing of 40,000 U.

Darbepoetin alfa has a threefold longer half-life than rHuEPO, which allows less frequent dosing. The benefits of less frequent administration for patients are obvious in terms of reduced injections. In addition, other benefits to patients and their caregivers

include reduced time missed from work for physician visits and potentially better patient compliance. In a large randomized, placebo-controlled, phase 3 study in patients with lung cancer, using an administrations schedule of 2.25 ^g/kg once weekly, darbepoetin alfa showed a statistically significant and clinically meaningful reduction > 50% in both the proportion of transfused patients and number of RBC units transfused, as well as significantly reduced fatigue (88). The data suggested that darbepoetin alfa may overcome some of the limitations of rHuEPO, such as the lag time before onset of action, and may further improve our current management of cancer-related anemia.

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