Patient Encounter 2

A 65-year-old male with a diagnosis of metastatic colon cancer being treated with iri-notecan presents with chemotherapy-induced anemia, with a Hgb of 8.3 g/dL (83 g/L or 5.14 mmol/L).

What discussion must be presented to the patient before ESA therapy can be initiated?

What laboratory parameters and symptoms should be assessed prior to initiating ESA therapy?

If after 4 weeks of ESA therapy, the Hgb is 9.3 g/dL (93 g/L or 5.3 mmol/L), what action should be taken?

When should ESA therapy be stopped?

• Monitor the CBC to ensure the correct Hgb titration.

• A 1 g/dL (10 g/L or 0.62 mmol/L) per week titration is desirable in patients with IDA. Reevaluate patients with an increase of less than 2 g/dL (20 g/L or 1.24 mmol/ L) in 3 weeks.

• In patients with folic acid deficiency, methylmalonic acid may be normal, and homocysteine may be high. Monitor Hgb periodically, and reevaluate patients who fail to normalize Hgb levels after 2 months of therapy.

• In patients with vitamin B12 deficiency, methylmalonic acid and homocysteine levels may be high. Monitor for resolution of neurologic symptoms (i.e., confusion and paresthesias), if applicable, and Hgb levels periodically until the levels normalize.

• Do not exceed more than 1 g/dL (10 g/L or 0.62 mmol/L) every 2 weeks when using ESAs to increase Hgb. Decrease the dose of the ESA if this occurs.

• When using ESAs, do not exceed Hgb of greater than 10 g/dL (10 g/L or 6.2 mmol/ L) in cancer patients because of an increased risk of death and adverse effects.

• Monitor other laboratory tests, such as mean cell volume (MCV), iron studies, and presence of reticulocytosis.

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