(darbepoetin alfa and methoxy polyethylene glycol-
epoetin beta).
Patients and their carers should be advised of the signs
and symptoms of severe skin reactions when starting
treatment and instructed to stop treatment and seek
immediate medical attention if they develop widespread
rash and blistering; these rashes often follow fever or
flu-like symptoms—discontinue treatment permanently
if such reactions occur.
ERYTHROPOIETINS—HAEMOGLOBIN CONCENTRATION
In chronic kidney disease, the use of erythropoietins can
be considered in a child with anaemia. The aim of
treatment is to relieve symptoms of anaemia and to
avoid the need for blood transfusion. The optimum
haemoglobin concentration is dependent on the child’s
age and factors such as symptoms, comorbidities, and
patient preferences. The haemoglobin concentration
should not be increased beyond that which provides
adequate control of symptoms of anaemia. Inadults,
overcorrection of haemoglobin concentration with
erythropoietins in those with chronic kidney disease may
increase the risk of serious cardiovascular events and
death; haemoglobin concentrations higher than
12 g/ 100 mL should be avoided in children.lCONTRA-INDICATIONSAvoid injections containing benzyl
alcohol in neonates.pure red cell aplasia following
erythropoietin therapy.uncontrolled hypertension
lCAUTIONSAluminium toxicity (can impair the response to
erythropoietin).concurrent infection (can impair the
response to erythropoietin).correct factors that
contribute to the anaemia of chronic renal failure, such as
iron or folate deficiency, before treatment..during dialysis
(increase in unfractionated or low molecular weight
heparin dose may be needed).epilepsy.inadequately
treated or poorly controlled blood pressure—interrupt
treatment if blood pressure uncontrolled.ischaemic
vascular disease.malignant disease.other inflammatory
disease (can impair the response to erythropoietin).
sickle-cell disease (lower target haemoglobin
concentration may be appropriate).sudden stabbing
migraine-like pain (warning of a hypertensive crisis).
thrombocytosis (monitor platelet count forfirst 8 weeks)
lSIDE-EFFECTS
▶Common or very commonArthralgia.embolism and
thrombosis.headache.hypertension (dose-dependent).
influenza like illness.skin reactions.stroke
▶UncommonHypertensive crisis (in isolated patients with
normal or low blood pressure).respiratory tract
congestion.seizure
▶Rare or very rareThrombocytosis
▶Frequency not knownPure red cell aplasia (more common
following subcutaneous administration in patients with
chronic renal failure)
SIDE-EFFECTS, FURTHER INFORMATION
Hypertensive crisisIn isolated patients with normal or
low blood pressure, hypertensive crisis with
encephalopathy-like symptoms and generalised tonic-
clonic seizures requiring immediate medical attention has
occured with epoetin.
Pure red cell aplasiaThere have been very rare reports of
pure red cell aplasia in patients treated with
erythropoietins. In patients who develop a lack of efficacy
with erythropoietin therapy and with a diagnosis of pure
red cell aplasia, treatment with erythropoietins must be
discontinued and testing for erythropoietin antibodies
considered. Patients who develop pure red cell aplasia
should not be switched to another form of erythropoietin.
lMONITORING REQUIREMENTS
▶Monitor closely blood pressure, reticulocyte counts,
haemoglobin, and electrolytes—interrupt treatment if
blood pressure uncontrolled.▶Other factors, such as iron or folate deficiency, that
contribute to the anaemia of chronic renal failure should
be corrected before treatment and monitored during
therapy. Supplemental iron may improve the response in
resistant patients and in preterm neonates.eiiiiF 563Darbepoetin alfa
lINDICATIONS AND DOSE
Symptomatic anaemia associated with chronic renal
failure in patients on dialysis
▶BY SUBCUTANEOUS INJECTION, OR BY INTRAVENOUS INJECTION
▶Child 11–17 years:Initially 450 nanograms/kg once
weekly, dose to be adjusted according to response by
approximately 25 % at intervals of at least 4 weeks,
maintenance dose to be given once weekly or once
every 2 weeks, reduce dose by approximately 25 %if
rise in haemoglobin concentration exceeds 2 g/ 100 mL
over 4 weeks or if haemoglobin concentration exceeds
12 g/ 100 mL; if haemoglobin concentration continues
to rise, despite dose reduction, suspend treatment until
haemoglobin concentration decreases and then restart
at a dose approximately 25 % lower than the previous
dose, when changing route give same dose then adjust
according to weekly or fortnightly haemoglobin
measurements, adjust doses not more frequently than
every 2 weeks during maintenance treatment
Symptomatic anaemia associated with chronic renal
failure in patients not on dialysis
▶BY SUBCUTANEOUS INJECTION
▶Child 11–17 years:Initially 450 nanograms/kg once
weekly, alternatively initially 750 nanograms/kg every
2 weeks, dose to be adjusted according to response by
approximately 25 % at intervals of at least 4 weeks,
maintenance dose can be given once weekly, every
2 weeks, or once a month, subcutaneous route
preferred in patients not on haemodialysis, reduce
dose by approximately 25 % if rise in haemoglobin
concentration exceeds 2 g/ 100 mL over 4 weeks or if
haemoglobin concentration exceeds 12 g/ 100 mL; if
haemoglobin concentration continues to rise, despite
dose reduction, suspend treatment until haemoglobin
concentration decreases and then restart at a dose
approximately 25 % lower than the previous dose, when
changing route give same dose then adjust according to
weekly or fortnightly haemoglobin measurements,
adjust doses not more frequently than every 2 weeks
during maintenance treatment
Symptomatic anaemia associated with chronic renal
failure in patients not on dialysis
▶BY INTRAVENOUS INJECTION
▶Child 11–17 years:Initially 450 nanograms/kg once
weekly, dose to be adjusted according to response by
approximately 25 % at intervals of at least 4 weeks,
maintenance dose given once weekly, subcutaneous
route preferred in patients not on haemodialysis,
reduce dose by approximately 25 % if rise in
haemoglobin concentration exceeds 2 g/ 100 mL over
4 weeks or if haemoglobin concentration exceeds
12 g/ 100 mL; if haemoglobin concentration continues
to rise, despite dose reduction, suspend treatment until
haemoglobin concentration decreases and then restart
at a dose approximately 25 % lower than the previous
dose, when changing route give same dose then adjust
according to weekly or fortnightly haemoglobin
measurements, adjust doses not more frequently than
every 2 weeks during maintenance treatmentlINTERACTIONS→Appendix 1 : darbepoetin alfa564 Anaemias BNFC 2018 – 2019
Blood and nutrition9