Anemia Related Cancer Guideline

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NCCN Clinical Practice Guidelines in Oncology

Cancer- and

Treatment-Related

Anemia

V.1.2008

www.nccn.org


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Version 1.2008, 12/17/07 2007 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.

Practice Guidelinesin Oncology v.1.2008

Guidelines Index

Anemia Table of Contents

ManuscriptCancer- and Treatment-Related Anemia

NCCN

NCCN Cancer- and Treatment-Related Anemia Panel Members

George M. Rodgers, III, MD, PhD/ChairHuntsman Cancer Institute at the

University of Utah

Pamela Sue Becker, MD, PhD

Fred Hutchinson Cancer Research

Center/Seattle Cancer Care Alliance

Charles L. Bennett, MD, PhD, MPPRobert H. Lurie Comprehensive Cancer

Center of Northwestern University

St. Jude Children's Research

Hospital/University of Tennessee

Cancer Institute

David Cella, PhDRobert H. Lurie Comprehensive Cancer

Center of Northwestern University

Asher Chanan-Khan, MDRoswell Park Cancer Institute

Carolyn Chesney, MD

Charles Cleeland, PhD

The University of Texas M. D. AndersonCancer Center

Victoria Mock, PhD #The Sidney Kimmel Comprehensive

Cancer Center at Johns Hopkins

Denise Reinke, APRN, BC, AOCN #University of Michigan Comprehensive

Cancer Center

Joseph Rosenthal, MDCity of Hope

Paul Sabbatini, MDMemorial Sloan-Kettering Cancer Center

Ravi Vij, MDSiteman Cancer Center at Barnes-

Jewish Hospital and WashingtonUniversity School of Medicine

*

Hematology/Hematology oncology

Medical oncology

Bone marrow transplantation

Internal medicine# Nursing

Psychiatry/Psychology

Pediatric oncology

* Writing Committee Member

Peter F. Coccia, MDUNMC Eppley Cancer Center at The

Nebraska Medical Center

Benjamin Djulbegovic, MD, PhDH. Lee Moffitt Cancer Center & Research

Institute at the University of South Florida

Jennifer L. Garst, MDDuke Comprehensive Cancer Center

Eric H. Kraut, MDArthur G. James Cancer Hospital &

Richard J. Solove Research Institute at

The Ohio State University

Weei-Chin Lin, MD, PhDUniversity of Alabama at Birmingham

Comprehensive Cancer Center

Ursula Matulonis, MDDana-Farber/Brigham and Womens

Cancer Center | Massachusetts General

Hospital Cancer Center

Michael Millenson, MDFox Chase Cancer Center

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http://contents.pdf/http://contents.pdf/


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Guidelines Index


ManuscriptCancer- and Treatment-Related Anemia

NCCN

This manuscript is being

updated to correspond

with the newly updated

algorithm.

Table of Contents

NCCN Anemia Panel Members

Guidelines Index

Print the Anemia Guideline

Order the Patient Version of the Cancer and Treatment-Related Anemia

Guidelines

Summary of the Guidelines Updates

Screening Evaluation and Risk Assessment (ANEM-1Cancer-Related AnemiaMyelosuppressive Chemotherapy-Related Anemia

)

))

)

Evaluation for Symptomatic Anemia Risk (ANEM-3Treatment and Evaluation (ANEM-4Response Assessment (ANEM-6

Erythropoietic Therapy - Dosing and Titration (ANEM-A

Patient Counseling Information Regarding the Use of ESAs (ANEM-B

Parenteral Iron Preparations (ANEM-C

)

)

)

These guidelines are a statement of consensus of the authors regarding their views of currently accepted approaches to treatment. Any clinicianseeking to apply or consult these guidelines is expected to use independent medical judgment in the context of individual clinical circumstances todetermine any patient's care or treatment. The National Comprehensive Cancer Network makes no representations nor warranties of any kindwhatsoever regarding their content, use, or application and disclaims any responsibility for their application or use in any way. These guidelines arecopyrighted by National Comprehensive Cancer Network. All rights reserved. These guidelines and the illustrations herein may not be reproduced inany form without the express written permission of NCCN. 2007.

For help using thesedocuments, please click here

Manuscript

Clinical Trials:

Categories of Evidence andConsensus:NCCN

Thebelieves that the best managementfor any cancer patient is in a clinicaltrial. Participation in clinical trials isespecially encouraged.

To find clinical trials online at NCCNmember institutions,

All recommendationsare Category 2A unless otherwisespecified.

See

NCCN

click here:nccn.org/clinical_trials/physician.html

NCCNCategories of Evidence

and Consensus
http://contents.pdf/http://contents.pdf/http://print/http://patient_gl_request_form.pdf/http://patient_gl_request_form.pdf/http://help.pdf/http://help.pdf/http://www.nccn.org/clinical_trials/physician.htmlhttp://www.nccn.org/clinical_trials/physician.htmlhttp://www.nccn.org/clinical_trials/physician.htmlhttp://patient_gl_request_form.pdf/http://www.nccn.org/clinical_trials/physician.htmlhttp://contents.pdf/http://help.pdf/http://contents.pdf/http://print/


4/19Version 1.2008, 12/17/07 2007 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.


Guidelines Index


ManuscriptCancer- and Treatment-Related AnemiaNCCN

Changes in the 1.2008 version of the Cancer- and Treatment-Related Anemia Guidelines from the 3.2007 version include:

UPDATES

Summary of the Guidelines updates

Follow-up therapy and symptom response were removed from the guidelines.

For asymptomatic anemia, risk factors present: the hemoglobin level 10 g/dL for considering treatment with erythropoietic therapy

was added.

Patient counseling regarding the risks and benefits of ESAs is now recommended prior to considering erythropoietic therapy.

Footnote i,

Footnote j was modified to indicate that IV iron can be considered for supplementation and a new reference was added throughout

the guidelines.

bjective physical symptoms and other subjective physical

symptoms.

is new throughout the guidelines.

ANEM-1

ANEM-2

ANEM-3

ANEM-4

See Patient Counseling Information Regarding the Use of ESAs (ANEM-B)

The pathways for myelosuppressive chemotherapy-related anemia and cancer-related anemia were separated.

Pulmonary symptoms was added to risk assessment.

Fatigue was removed from risk assessment

RT alone was added to n - -related anemia due to specific causes.

Footnote d was modified throughout the guidelines by adding ESAs should only be used in the setting of myelosuppressivechemotherapy and The risks of shortened survival and tumor progression have not been excluded when ESAs are dosed to a target

hemoglobin of < 12 g/dL. Patients with end stage cancer should not be treated with ESAs.

Footnote e was modified throughout the guidelines by separating the o

Cancer-related anemia pathway is new to the guidelines.

Complete symptom assessment was modified to include, Objective physical symptoms may include:

.

Footnote f, Other anemia related symptoms include: decreased activity level, and decreased performance status is new to the page.

Footnote g, If considering use of ESAs, evaluate the risk factors for thrombosis: history of thromboembolism, hypercoagulability,

hypertension, steroids, renal insufficiency, prolonged inactivity is new to the page.

omorbidities were added to .

on-cancer or non chemotherapy

Peripheral edema, sustained

tachycardia, tachypnea. Other subjective physical symptoms may include: Chest pain, dyspnea on exertion, orthostatic

lightheadedness/near syncope or syncope, and fatigue

Age was removed and c evaluation for symptomatic anemia risk

Continued on next page


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UPDATES

Summary of the Guidelines updates (Continued)

ANEM-5

ANEM-6

For symptomatic anemia: the hemoglobin level for considering treatment with erythropoietic therapy was clarified as Hb 10 g/dL. The

category 1 designation was clarified as for prevention of transfusion.

Patient counseling regarding the risks and benefits of ESAs is recommended prior to considering erythropoietic therapy.

References for footnote k were updated.

Cancer Patient Survival: The second bullet was added, The risks of shortened survival and tumor progression have not been excluded

when ESAs are dosed to a target hemoglobin of < 12 g/dL.

Thrombosis: Third bullet was revised, A recent analysis update on thrombotic complications confirms an increased thrombosis risk

with use of erythropoietic agents. This same study demonstrated a significant trend toward worse survival.

The statement, Patients receiving these drugs should also receive pretreatment with diphenhydramine and acetaminophen to minimize

adverse events was removed from the guidelines.

Titration of the ESA dose should be done to avoid transfusion. The hemoglobin range was changed from 11-12 g/dL to

10-


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Note: All recommendations are category 2A unless otherwise indicated.

Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.

aThe NCCN Cancer and Treatment-Related Anemia Guidelines were formulated in reference to adult patients.b

c

d

e

Transplant-related anemia is not included.

The following studies should have been completed if clinically indicated: reticulocyte count, iron studies, B12/folate, stool guaiac, LDH, fractionated bilirubin, bonemarrow examination, direct Coombs, Hb electrophoresis, creatinine and/or creatinine clearance. There is no clear evidence that erythropoietin levels are predictiveof response.

Erythropoiesis-stimulating agents (ESAs) should only be used in the setting of myelosuppressive chemotherapy-related anemia. ESAs have been mainly tested inthe setting of chemotherapy or radiation-related anemia. Several small trials indicate that ESAs may be useful in the treatment of anemia due to cancer, but recentstudies (see FDA warning and page )indicate that the use of ESAs in this setting may beineffective and harmful. The risks of shortened survival and tumor progression have not been excluded when ESAs are dosed to a target hemoglobin of < 12 g/dL.Patients with end stage cancer should not be treated with ESAs.

Objective physical symptoms may include peripheral edema, sustained tachycardia, and tachypnea and other subjective physical symptoms may include chest pain,

dyspnea on exertion, orthostatic lightheadedness/near syncope or syncope, and fatigue.

http://www.fda.gov/cder/drug/infopage/RHE/default.htm ANEM-A 3 of 5

PRESENTATION a,b

Hemoglobin

(Hb) < 11 g/dL

Myelosuppressive

chemotherapy-related

anemia d

Non-cancer or non

chemotherapy-related

anemia-specific cause:

Bleeding

HemolysisNutritional deficiency

Hereditary

Renal dysfunction

Iron deficiency

RT alone

Treat as

indicated

CBC with indices

Review of

peripheral smear,

as clinically

indicated

SCREENING

EVALUATIONc

ANEM-1

Cancer-related

anemia d See ANEM-2

RISK ASSESSMENT

AcuitySeverity

Mild

(Hb 10-11 g/dL)Moderate

(Hb 8-10 g/dL)Severe

(Hb < 8 g/dL)

Symptoms-physiologicalCardiac symptomsPulmonary symptoms

ComorbiditiesCardiac history/decompensationChronic pulmonary diseaseCerebral vascular disease

e

See SymptomAssessment

and Evaluationof Anemia Risk(ANEM-3)


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Inadequate data to make

recommendations:

clinical trials areespecially needed

Cancer-relatedanemia d

Myelodysplastic

syndromesSee NCCN MyelodysplasticSyndromes Guidelines

Solid tumors

Hematologic

malignancies

Transfuse as indicated based upon

symptoms and institutional guidelines

Erythropoiesis-stimulating agents (ESAs)

are not indicated

Treat underlying

hematologic malignancyTransfuse as indicated

based upon symptoms

and institutional

guidelines For patients with good

prognosis and

persistent transfusion-

dependent anemiafollowing response to

treatment

Anemia corrected Observe

Poor disease control

or fail therapy

Treat underlying diseaseper NCCN guidelineSee

NCCN Guidelines Table

of Contents

Other

hematologic

malignancies

dErythropoiesis-stimulating agents (ESAs) should only be used in the setting of myelosuppressive chemotherapy-related anemia. ESAs have been mainly tested in thesetting of chemotherapy or radiation-related anemia. Several small trials indicate that ESAs may be useful in the treatment of anemia due to cancer, but recentstudies (see FDA warning and page )indicate that the use of ESAs in this setting may beineffective and harmful. The risks of shortened survival and tumor progression have not been excluded when ESAs are dosed to a target hemoglobin of < 12 g/dL.

Patients with end stage cancer should not be treated with ESAs.




ANEM-2

TREATMENT

CANCER-RELATED ANEMIA

CANCER TYPE
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fOther anemia-related symptoms include: decreased activity level, and decreased performance status.gIf considering use of ESAs, evaluate the risk factors for thrombosis: history of thromboembolism, hypercoagulability, hypertension, steroids, renal insufficiency,

prolonged inactivity.

ANEM-3



Immediatecorrection

not required

Immediate

correction

required

Transfuse as indicated

based on institutional

guidelines

Complete symptom

assessment:

Peripheral edema

Sustained tachycardiaTachypnea

Other subjective physical

symptoms may include:Chest painDyspnea on exertionOrthostatic

lightheadedness/near

syncope or syncopeFatigue

f

Objective physical

symptoms may include:

SYMPTOM ASSESSMENT

Symptomatic

Asymptomatic

EVALUATION FOR SYMPTOMATIC

ANEMIA RISK

Evaluate risk factors for developingsymptomatic anemia:

History of prior myelosuppressive

therapy (e.g., bone marrow

transplant)

History of radiotherapy

> 20% of skeleton

Myelosuppression potential of

current therapy

ScheduleAgents

Hemoglobin level

Transfusion in past 6 mo

Duration

ComorbiditiesCardiac history/decompensationChronic pulmonary diseaseCerebral vascular disease

Risk factors

present g

Risk factors

not present

SeeTreatment

(ANEM-4)

SeeTreatment(ANEM-4)

SeeTreatment

(ANEM-5)

MYELOSUPPRESSIVE CHEMOTHERAPY-RELATED ANEMIA


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ANEM-4

TREATMENT

Asymptomatic;

Risk factors

present for

development of

symptomatic

anemia

Asymptomatic;

Risk factors

not present for

symptomatic

anemia

development of

Observation

or

Consider erythropoietic therapyHb 10 g/dL:

after patient counseling regardingrisks and benefits of ESAs

d,h

i

Observation

ADDITIONAL EVALUATION

Iron studies:Iron panel (serum iron,

total iron bindingcapacity, serum ferritin)

Periodic re-evaluation

for symptoms and risk

factors

dErythropoiesis-stimulating agents (ESAs) should only be used in the setting of myelosuppressive chemotherapy-related anemia. ESAs have been mainly tested in the

setting of chemotherapy or radiation-related anemia. Several small trials indicate that ESAs may be useful in the treatment of anemia due to cancer, but recent studies(see FDA warning and page )indicate that the use of ESAs in this setting may be ineffective andharmful. The risks of shortened survival and tumor progression have not been excluded when ESAs are dosed to a target hemoglobin of < 12 g/dL. Patients with endstage cancer should not be treated with ESAs.

alfa

h

j

i

Oral iron is more commonly used but IV iron appears to have superior efficacy and can be considered for supplementation. (Auerbach M, Ballard H, Trout JR et al.Intravenous iron optimizes the response to recombinant human erythropoietin in cancer patients with chemotherapy-related anemia: A multicenter, open-label,randomized trial. J Clin Oncol 2004;22:1301-1307. Henry DH, Dahl NV, Auerbach M, et al. Intravenous ferric gluconate significantly improves response to epoetin


See Adverse Effects of Erythropoietic Therapy (ANEM-A 3 of 5).

See Patient Counseling Information Regarding the Use of ESAs (ANEM-B).

TREATMENT REGIMEN

See Erythropoietic

Therapy - Dosing and

Titration (ANEM-A) iron

supplementation as

indicated (ferritin < 100,transferrin saturation

< 20%)

j

SeeResponse

AssessmentANEM-6( )

versus oral iron or no iron in anemic patients with cancer receiving chemotherapy. Oncologist 2007;12:231-242.) .See Parenteral Iron Preparations (ANEM-C)

Periodic re-evaluation

for symptoms and risk

factors
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ANEM-A1 of 5

ERYTHROPOIETIC THERAPY - DOSING AND TITRATION (1 of 5) 1,2,3,4,5

INITIAL DOSING TITRATION FOR NO RESPONSE

Epoetin alfa 150 units/kg 3 times weekly

by subcutaneous injection

Darbepoetin alfa 2.25 mcg/kg every

wk by subcutaneous injection

Increase dose of epoetin alfa to 300 units/kg

3 times weekly by subcutaneous injection

Increase darbepoetin alfa to up to 4.5 mcg/kg

every wk by subcutaneous injection

or

PACKAGE INSERT DOSING SCHEDULE

ALTERNATIVE REGIMENS

or

Darbepoetin alfa 200 mcg fixed dose

every 2 wks by subcutaneous injection 7Increase darbepoetin alfa to up to 300 mcg fixed

dose every 2 wks by subcutaneous injection 7

orEpoetin alfa 40,000 units every

wk by subcutaneous injection

Increase dose of epoetin alfa to 60,000 units


See Adverse Effects ofErythropoietic Therapy(ANEM-A 3 of 5)

See Footnotes and References (ANEM- A 2 of 5)

Darbepoetin alfa 500 mcg every 3 wks by subcutaneous injection

or

Darbepoetin alfa 300 mcg fixed doseevery 3 wks by subcutaneous injection

Increase darbepoetin alfa to up to 500 mcg fixeddose every 3 wks by subcutaneous injection 8

Darbepoetin alfa 100 mcg fixed dose


Increase darbepoetin alfa to up to 150-200 mcg

fixed dose every wk by subcutaneous injection 6

or


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ADVERSE EFFECTS OF ERYTHROPOIETIC THERAPY

Cancer Patient Survival

Thrombosis

Recent studies have reported decreased survival in cancer patients receiving erythropoietic drugs for correction of anemia.

Additional prospective clinical trials designed and powered to measure cancer patient survival are ongoing to provide clinicians with data

to guide optimal use of erythropoietic agents.

Early trials of recombinant human erythropoietin reported that a high target hematocrit (42 3%) was found to have an increased

mortality and an increased number of vascular events (arterial and venous).

A recent analysis update on thrombotic complications confirms an increased thrombosis risk with use of erythropoietic agents.

1,2,3,4

5

The risks of shortened survival and tumor progression have not been excluded when ESAs are dosed to a target hemoglobin of < 12 g/dL.

Analyses of five studies in patients with cancer found a higher chance of serious and life-threatening side effects and/or death with the

use of ESAs. Please refer to the FDA website for additional information:

Until new research evidence changes current benefit:risk estimates, physicians should be advised not to administer ESAs (darbepoetin

alfa, epoetin alfa) to patients outside of the treatment period of cancer-related therapy (radiation therapy, chemotherapy). A treatment

period is defined as anemia following initiation of therapy and continuing approximately 6 weeks after the completion of treatment.

Erythropoietin has a thrombogenic potential independent of hemoglobin levels. In patients receiving erythropoietic drugs, physicians

should be suspicious of signs and symptoms of thrombosis.

Hypertension/seizures

Blood pressure should be controlled in all patients prior to initiating therapy with erythropoietic drugs and must be monitored regularly in

treated patients.

Seizures have been reported in chronic renal failure patients receiving erythropoietic drugs.

Hemoglobin level should be monitored to decrease the risk of hypertension and seizures.

http://www.fda.gov/cder/drug/infopage/RHE/default.htm

( )See Titration for Response ANEM-A 1 of 5

ERYTHROPOIETIC THERAPY - DOSING AND TITRATION (3 OF 5)

See References(ANEM- A 5 of 5)

ANEM-A3 of 5

Adverse Effects of ErythropoieticTherapy continued (ANEM-A 4 of 5)

Guidelines Index
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ADVERSE EFFECTS OF ERYTHROPOIETIC THERAPY CONTINUED


ESA Neutralizing Antibodies (Pure red cell aplasia-PRCA)

Between 1998-2004, 197 cases of PRCA were reported in patients treated with erythropoietin. Over 90% of these cases occurred with

Eprex, an epoetin alfa product used outside of the United States. Patients who develop a loss of response to erythropoietic drugs

should be evaluated for possible PRCA, and if present, all erythropoietic drugs should be discontinued.

6

7

8 In 2005, the FDA's interpretation of anemia associated with neutralizing antibodies evolved to include both PRCA and severe anemia,

with or without other cytopenias, associated with neutralizing antibodies. This interpretation resulted in a class label change for all

ESAs. The toxicity has been reported predominantly in patients with chronic renal failure receiving ESAs by subcutaneousadministration. Any patient who develops a sudden loss of response to an ESA, accompanied by a severe anemia and low

reticulocyte count, should be evaluated for the etiology of loss of effect, including the presence of neutralizing antibodies to

erythropoietin. If anti-erythropoietin antibody-associated anemia is suspected, ESAs should be withheld and plasma should be sent

for evaluation of assays for binding and neutralizing antibodies. ESAs should be permanently discontinued in patients with antibody-

mediated anemia. Patients should not be switched to other ESA products as antibodies may cross-react.

See References(ANEM- A 5 of 5)



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ADVERSE EFFECTS OF ERYTHROPOIETIC THERAPY

ANEM-A5 of 5


1

2

Leyland-Jones B, BEST Investigators and Study Group. Breast cancer trial with erythropoietin terminated unexpectedly. Lancet Oncol2003;4:459-460.

Henke M, Laszig R, Rube C et al. Erythropoietin to treat head and neck cancer patients with anaemia undergoing radiotherapy:randomised, double-blind, placebo-controlled trial. Lancet 2003;362:1255-1260.

3

4

5

Wright JR, Ung YC, Julian JA et al. Randomized, double-blind, placebo-controlled trial of erythropoietin in non-small-cell lung cancerwith disease-related anemia. J Clin Oncol. 2007 Mar 20;25:1027-1032.

Hedenus M, Adriansson M, San Miguel J et al. Efficacy and safety of darbepoetin alfa in anaemic patients with lymphoproliferativemalignancies: a randomized, double-blind, placebo-controlled study. Br J Haematol 2003;122:394-403.

Gleason, K, Tigue C, Yarnold P et al. Recombinant erythropoietin (Epo)/darbepoetin (Darb) associated venous thromboembolism(VTE) in the oncology setting: Findings from the Research on Adverse Drug Events And Reports (RADAR) project. Journal of ClinicalOncology, 2007 ASCO Annual Meeting Proceedings Part I. Vol 25, No. 18S (June 20 Supplement): 2552.

Bennett CL, Luminari S, Nissenson, AR et al. Pure red-cell aplasia and epoetin therapy. N Eng J Med 2004;351:1403-1408.

Bennett CL, Cournoyer D, Carson KR, et al. Long-term outcome of individuals with pure red cell aplasia and aniterythropoietin

antibodies in patients treated with recombinant epoetin: a follow-up report from the Research on Adverse Drug Events and Reports(RADAR) Project. Blood 2005;106:3343-3347.

FDA MedWatch Web-site.

6

7

8 http://www.fda.gov/medwatch/SAFETY/2005/safety05.htm#epoetin

REFERENCES

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Physicians and other healthcare professionals should discuss the following with their patients:

The primary goal of treatment with erythropoiesis stimulating agents (ESA) is to increase the number of red

blood cells in order to avoid receiving blood transfusions.

ESAs require at least 2 weeks of treatment before there is an increase in the number of red blood cells and the

dose may be adjusted periodically but not more often than every 4 weeks.

ESAs increase their chance of blood clots and the risk of dying may be greater in certain circumstances

They should keep appointments for blood tests so hemoglobin levels can be monitored.

They need to monitor their blood pressure and to call you if there are any changes outside of the range that has

been established for them.

Call you if they experience any of the following symptoms:Pain and/or swelling in the legsWorsening in shortness of breathIncreases in blood pressureDizziness or loss of consciousnessExtreme tiredness

Blood clots in hemodialysis vascular access ports

PATIENT COUNSELING INFORMATON REGARDING THE USE OF ESAs1



ANEM-B

1Available at: Accessed November 26, 2007.http://www.fda.gov/cder/drug/InfoSheets/HCP/RHE200711HCP.htm

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PARENTERAL IRON PREPARATIONS 1,2

ANEM-C

Parenteral Iron PreparationsIron dextranFerric gluconateIron sucrose

These products are helpful in treating iron deficiency in patients intolerant or unresponsive to oral irontherapy, and in treating functional iron deficiency as seen in chronic renal failure patients, and cancer

patients who are receiving erythropoietic drugs.

Test doses are required for iron dextran, and strongly recommended for patients receiving ferric

gluconate or iron sucrose who are sensitive to iron dextran or who have other drug allergies.

1

2Silverstein SB, Rodgers GM. Parenteral iron therapy options. Am J Hematol 2004;76:74-78.

Henry D. The role of intravenous iron in cancer-related anemia. Oncology (Williston Park) 2006;20:21-24.

Guidelines Index

A i T bl f C t tP ti G id li

NCCN


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Version 1.2008, 12/17/07 2007 National Comprehensive Cancer Network, Inc. All rights reserved.These guidelines and this i llustration may not be reproduced in any form w ithout the express writt en permission of NCCN. MS-1


ManuscriptPractice Guidelinesin Oncology v.1.2008 Cancer- and Treatment-Related Anemia

NCCN

Manuscript

NCCN Categories of Evidence and Consensus

Category 1:There is uniform NCCN consensus, based on high-level

evidence, that the recommendation is appropriate.

Category 2A:There is uniform NCCN consensus, based on lower-

level evidence including clinical experience, that the recommendation

is appropriate.

Category 2B:There is nonuniform NCCN consensus (but no major

disagreement), based on lower-level evidence including clinical

experience, that the recommendation is appropriate.

Category 3:There is major NCCN disagreement that the

recommendation is appropriate.

Al l recommendations are category 2A un less otherwise noted.

This manuscript is being updated to correspond withthe newly updated algorithm.

Anemia Related Cancer Guideline

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