Study finds clinicians do not consistently use algorithms when dosing Mircera
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Key takeaways:
- Even with algorithms available, dosing for Mircera appears to vary widely among nephrologists.
- Dialysis clinics could save money by using a consistent dosing regimen.
LONG BEACH, Calif. — Clinicians do not consistently use algorithms for dosing methoxy polyethylene glycol-epoetin beta when treating patients with anemia, presented research shows.
“Multiple dosing algorithms exist for the use of [methoxy polyethylene glycol-epoetin beta] MPG-EPO [Mircera, Vifor Pharma],” Namrata Shrestha, MD, of the University of the Incarnate Word, San Antonio, and colleagues wrote in a poster presented at the National Kidney Foundation Spring Clinical Meetings. “However, the maximal dose used is usually an arbitrary single number (between 220 to 225 mcg per dose), not based on initial dose calculations or body weight.”
Shrestha and colleagues reviewed dosing at three large dialysis clinics in South Texas. Patients in the study were on in-center hemodialysis for more than 6 months between June 1, 2023, and July 15, 2023, and had been receiving MPG-EPO at high doses (defined as 100 g/dose or higher), the researchers wrote.
Review of data from 322 patients showed 219 were receiving MPG-EPO and 60 were on a high dose; 58 of the 60 patients were included in the analysis. “Recommended maximal dose based on package insert recommendations was calculated using the formula: 1.2 g/kg x 1.25 x 1.25 (recommended initial dose of 1.2 g/kg/month and two up titrations by 25% each). The calculated and actual dose that patients received were compared,” the authors wrote.
For the 58 patients, the average MPG-EPO dose was 2.45 g/kg/dose (range 0.9 kg/dose to 6 kg/dose) and mean hemoglobin was 10.38 g/dL (range 7 g/dL to 13.9 g/dL). Investigators found 12 patients (20.69%) were receiving lower than recommended doses and 46 patients (79.31%) were receiving doses higher than the recommended dose.
“In our study, the majority of patients on high-dose MPG-EPO were receiving doses higher than the recommended dose (mostly those with lower weights). By using an arbitrary single maximal dose, we may be causing potential harm to the patients receiving significantly higher than recommended doses and incurring unnecessary costs,” the authors wrote. “In contrast, those with higher weights may be underdosed.”
“The maximal dose of 220 [mcg] to 225 mcg is arbitrary and not supported by the literature,” Pablo E. Pergola, MD, PhD, of Renal Associates PA in San Antonio and a co-author of the poster, told Healio. “Here the actual problem is that we are following bad algorithms that push for continuous up-titration regardless of Hb response to the arbitrary maximal dose (putting patients at risk for complications like stroke, [myocardial infarction], thromboembolism) and stops others that could respond to higher doses (like many patients with higher body weights) from achieving goal Hb, exposing them to complications of untreated anemia and blood transfusions,” he said.
“The way to correct this is to adjust the protocols in use to prevent patients from additional up-titration if marginal or no Hb increments noted (must not aim to the arbitrary maximum as a goal) and to continue up-titration for those with significant Hb increases until they do not respond (and then stop titration) regardless of them reaching or surpassing the arbitrary maximum,” Pergola told Healio.
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Shrestha N, et al. Paper 222. Presented at: NKF Spring Clinical Meetings; May 14-18, 2024; Long Beach, Calif.
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