Reducing versus discontinuing erythropoietin at high hemoglobin levels

A 2006 change in Medicare policy allowed reimbursement for erythropoietin (EPO) in dialysis patients whose most recent hemoglobin exceeded 13 g/dl. We investigated the effects of a change in dosing algorithm implemented in response to this policy, in which EPO dosages were reduced instead of temporarily discontinued for hemoglobin levels > or =13 g/dl. Among 1688 individuals in 18 hemodialysis units, the reduction protocol resulted in more hemoglobin levels > or =13 g/dl (P < 0.0001), fewer levels between 11 and 12.9 g/dl (P < or = 0.004), no difference in the proportion of levels <11 g/dl, and more EPO administered per session (P < 0.0001) than the discontinuation protocol. In view of the expense of erythropoiesis stimulating agents and the uncertainty of the safety of using EPO to achieve high hemoglobin targets, this study suggests that discontinuation, rather than reduction, of EPO treatment is appropriate when hemoglobin reaches 13 g/dl in hemodialysis patients.