Practical use of erythropoietin-stimulating agents in lower-risk MDS
| Indication | IPSS-R very low, low, or intermediate risk MDS |
| Reasons to consider other treatment | IPSS-Mol ≥ moderate high risk |
| Primary eligible for curative treatment (HSCT) | |
| Serum erythropoietin levels >200 to 500 U/L | |
| When to initiate treatment | At onset of symptomatic anemia (patient-reported symptoms) |
| Transfusion-dependent anemia at diagnosis | |
| Prerequisites for response | Adequate iron reserves |
| Initial dosing∗ (1 dose per week) | Epoetin: 30 000 U/wk and darbepoetin: 150-240 μg/wk |
| Reason for lower starting dose | Small body weight. Subnormal renal function (individual dosing) |
| Maximal dose | Epoetin: 60 000 to 80 000 U/wk (2 doses) Darbepoetin: 300 μg/wk |
| Duration before decision about response | 16 wk at the highest dose |
| Action if no response† | If very low/low-risk disease, consider addition of G-CSF for up to 12 wk |
| If intermediate-risk disease or signs of progression, new diagnostic evaluation | |
| Action if supranormal hemoglobin levels‡ | If Hb levels are greater than upper normal level, stop treatment and restart at lower Hb levels |
| If complete erythroid response, less frequent dosing (1 dose per 2-3 weeks) | |
| Administration | Depends on national legal and reimbursement rules. Self-administration is common. |
| Indication | IPSS-R very low, low, or intermediate risk MDS |
| Reasons to consider other treatment | IPSS-Mol ≥ moderate high risk |
| Primary eligible for curative treatment (HSCT) | |
| Serum erythropoietin levels >200 to 500 U/L | |
| When to initiate treatment | At onset of symptomatic anemia (patient-reported symptoms) |
| Transfusion-dependent anemia at diagnosis | |
| Prerequisites for response | Adequate iron reserves |
| Initial dosing∗ (1 dose per week) | Epoetin: 30 000 U/wk and darbepoetin: 150-240 μg/wk |
| Reason for lower starting dose | Small body weight. Subnormal renal function (individual dosing) |
| Maximal dose | Epoetin: 60 000 to 80 000 U/wk (2 doses) Darbepoetin: 300 μg/wk |
| Duration before decision about response | 16 wk at the highest dose |
| Action if no response† | If very low/low-risk disease, consider addition of G-CSF for up to 12 wk |
| If intermediate-risk disease or signs of progression, new diagnostic evaluation | |
| Action if supranormal hemoglobin levels‡ | If Hb levels are greater than upper normal level, stop treatment and restart at lower Hb levels |
| If complete erythroid response, less frequent dosing (1 dose per 2-3 weeks) | |
| Administration | Depends on national legal and reimbursement rules. Self-administration is common. |
Considerable variation in dosing between studies, no fixed recommendation can be given.
Important to explain to the patient that treatment will be stopped in case no response has been confirmed.
Overdosing of darbepoetin leading to supranormal Hb levels may require venesectio for patients at risk of thromboembolic events.