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ESA use declines for ESRD; IV iron, hypoxia-inducible factor prolyl hydroxylase inhibitors may serve as alternatives
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DALLAS — Use of IV iron in patients with anemia on hemodialysis reduces the need for erythropoiesis-stimulating agents and effectively increases hemoglobin, according to a speaker at the Annual Dialysis Conference. According to another speaker, hypoxia-inducible factor prolyl hydroxylase inhibitors may also provide similar benefits.
Daniel W. Coyne, MD, professor of medicine in the division of nephrology at Washington University in St. Louis, Missouri, cited the DRIVE study which found that in patients that were more difficult to treat, IV iron significantly raised the likelihood of hemoglobin increasing by a gram or more when compared to erythropoietin alone. Patients on IV iron also continued to maintain the hemoglobin higher than the no IV iron group, which was on large doses of ESAs.
Furthermore, due to the PIVOTAL trial, “the safety concerns about IV iron have largely been disproven,” Coyne said during the presentation. “We should pair this with placebo-controlled studies of heart failure.”
According to Coyne, when researchers randomized patients to either IV iron or no iron, IV iron significantly reduced the number of hospitalizations related to heart failure, improved functional status and did not increase infections.
In a subsequent presentation, Jay B. Wish, MD, medical director of the outpatient dialysis unit at Indiana University Hospital and professor of clinical medicine at Indiana University School of Medicine, discussed the decline in the use of ESAs and noted potential alternatives, saying that “the era of erythropoiesis-stimulating agents [may be] coming to a close.”
While ESAs are effective at raising hemoglobin, the FDA has advised that these also increase the risk of death, myocardial infarction and stroke, according to Wish.
As for alternatives to ESAs, Wish discussed hypoxia-inducible factor prolyl hydroxylase (HIF-PH) inhibitors, which stimulate endogenous erythropoietin production, enable more iron to be absorbed and reduce cholesterol levels.
“The HIF-PH inhibitors do offer some promise as alternatives to erythropoiesis-stimulating agents — they improve iron mobilization and produce a similar hemoglobin response — but their long-term safety has yet to be documented,” Wish said. - by Melissa J. Webb
Reference:
Coyne DW and Wish JB. Hemodialysis: Anemia Management. Presented at the Annual Dialysis Conference; March 16-19, 2018; Dallas.
Disclosures: Coyne reports being a consultant for and receiving speaker fees from Fresenius Medical Care. Wish reports having associations with and receiving speaker fees from Keryx Pharmaceuticals, Daiichi Sankyo and Pfizer.