Preoperative Epoetin-α with Intravenous or Oral Iron for Major Orthopedic Surgery

Abstract

Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background Preoperative administration of epoetin-α with iron is commonly used in anemic patients undergoing major orthopedic surgery, but the optimal route of iron intake is controversial. The aim of this study was to compare the clinical effects of erythropoietin in combination with oral or intravenous iron supplementation. Methods This study was a prospective, randomized, single-blinded, parallel arm trial. Patients scheduled for elective hip or knee arthroplasty with hemoglobin 10 to 13 g/dl received preoperative injections of erythropoietin with oral ferrous sulfate or intravenous ferric carboxymaltose. The primary endpoint was the hemoglobin value the day before surgery. Results One hundred patients were included in the analysis. The day before surgery, hemoglobin, increase in hemoglobin, and serum ferritin level were higher in the intravenous group. For the intravenous and oral groups, respectively, hemoglobin was as follows: median, 14.9 g/dl (interquartile range, 14.1 to 15.6) versus 13.9 g/dl (interquartile range, 13.2 to 15.1), group difference, 0.65 g/dl (95% CI, 0.1 to 1.2; P = 0.017); increase in hemoglobin: 2.6 g/dl (interquartile range, 2.1 to 3.2) versus 1.9 g/dl (interquartile range, 1.4 to 2.5), group difference, 0.7 g/dl (95% CI, 0.3 to 1.1; P < 0.001); serum ferritin: 325 µg/l (interquartile range, 217 to 476) versus 64.5 µg/l (interquartile range, 44 to 107), group difference, 257 µg/l (95% CI, 199 to 315; P < 0.001). The percentage of patients with nausea, diarrhea, or constipation was higher in the oral group, 52% versus 2%; group difference, 50% (95% CI, 35 to 64%; P < 0.0001). Conclusions After preoperative administration of erythropoietin, body iron stores and stimulation of the erythropoiesis were greater with intravenous ferric carboxymaltose than with oral ferrous sulfate supplementation.

Efficacy and safety of erythropoietin and iron therapy to reduce red blood cell transfusion in surgical patients: a systematic review and meta-analysis

“…It is also possible that the addition of ESAs to intravenous iron did not further reduce the incidence of RBC transfusion, as the increased efficacy of intravenous iron relative to oral iron may have negated any further therapeutic effect of ESA on optimal erythropoiesis. 17,19 Data from our analysis that refutes this argument include the finding that oral or intravenous iron alone did not dramatically increase the reticulocyte count (1% change with treatment). This suggests that inadequate time was allowed for the maximal therapeutic effect of iron or inadequate drug dosing prevented optimal erythropoiesis in patients treated with intravenous iron alone.…”

“…[16][17][18] These clinical studies and a recently published small randomizedcontrolled trial (RCT) also support the finding that intravenous iron may be more effective than oral iron at restoring iron homeostasis. 17,19 Previous systematic reviews and meta-analyses have directly assessed the efficacy of ESAs with respect to RBC avoidance. [20][21][22] Nevertheless, these studies were limited in that: 1) all relevant RCTs that assessed the efficacy of preoperative ESA therapy on RBC transfusion avoidance were not included [20][21][22] ; 2) they included studies that utilized preoperative autologous donation (PAD), which may have confounded the impact of ESAs on RBC utilization and Hb outcomes 20,21 ; 3) one study did not perform a formal meta-analysis 22 ; 4) data on all cardiac and non-cardiac surgical patient populations were not included; and 5) complete data on serious adverse effects associated with ESA therapy were not included [20][21][22] (available as Electronic Supplementary Material [ESM] eAppendix, eTable 2 and eTable 3).…”

Management of Perioperative Iron Deficiency Anemia

“…Several observational studies and a recent RCT have also reported on the beneficial effects of fewer rHuEPO doses in orthopedic patients, especially when combined with intravenous iron within a patient blood management program [25, 27, 44, 45] (see online suppl. Table 2).…”

Development of a Resource Impact Model for Clinics Treating Pre-Operative Iron Deficiency Anemia in Ireland

“…The study showed a significant reduction in the median number of red blood cell units transfused from 1 to 0, with a corresponding increase in hemoglobin concentration, reticulocyte count, and a reticulocyte hemoglobin content [19]. Similarly, a 2018 study by Biboulet and colleagues demonstrated the superior efficacy of IV iron in combination with erythropoietin relative to oral iron in patients undergoing major orthopedic surgery, showing a 0.7-g/dl larger increase in preoperative hemoglobin (p \ 0.001) [20].…”