Guidelines for the treatment of preoperative anaemia with epoetin

Recombinant human erythropoietin (epoetin) has been approved for use in patients undergoing autologous blood donation (ABD) in Japan, the European Union and Canada since 1993, 1994 and 1996 respectively, and for perisurgical adjuvant therapy without ABD in Canada and the US since 1996. Early clinical trials of epoetin therapy in the setting of ABD have provided important information with respect to clinical safety, dose and erythropoietic response. Later trials of perisurgical epoetin therapy without ABD provided data on efficacy (i.e. reduced allogeneic blood exposure) that led to approval of epoetin in this setting. However, the epoetin doses (300 U/kg subcutaneously x 14 days) used in these trials, and their subsequent inclusion in labelling for the use of this product, are costly to administer. A recent study has indicated that weekly administration of epoetin 600 U/kg over 4 weeks is just as effective but less costly than a daily regimen over 2 weeks. The most cost-effective regimen that has been shown to minimise allogeneic exposure is preoperative epoetin therapy with 600 U/kg/ week x 2 plus 300 U/kg on the day of surgery, coupled with acute normovolaemic haemodilution in patients undergoing radical retropubic prostatectomy. A similar regimen of epoetin therapy in patients undergoing coronary artery bypass grafting (2500 U/kg in divided doses over 2 weeks preoperatively) coupled with 'blood pooling', has also been described. 'Low dose' epoetin therapy coupled with acute normovolaemic haemodilution is cost-equivalent to the predonation of 3 autologous blood units, and may replace this strategy as a standard of care in the elective surgical setting.