Treating critically ill anemic patients with erythropoietin: less is more
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CORRESPONDENCE
Treating critically ill anemic patients with erythropoietin: less is more Simon Oczkowski1,2,3, Akshay Shah4,5, Cécile Aubron6, Marije Wijnberge7,8 and Alexander P. J. Vlaar7* on behalf of The ESICM Transfusion Guideline Part 1 Task force © 2020 Springer-Verlag GmbH Germany, part of Springer Nature
Dear Editor, We read with interest Lasocki et al.’s letter [1]. We agree with many points, especially their call for further research into the clinical effects of erythropoietin (EPO) in critically ill patients. However, the ESICM Taskforce stands by its “less is more” approach and conditionnel recommendation against widespread use of EPO in anemic critically ill patients [2]. First, while identifying a possible reduction in mortality (Relative Risk (RR) 0.80, 95% CI 0.61–1.05, absolute risk reduction (ARR) 3.1%), this was disproportionate to the modest effects upon transfusion (RR 0.89, 95% CI − 9.1 to − 2.7, ARR 5.9%, a mean of 0.65 units of blood fewer per patient), resulting in uncertainty in the purported mortality benefit and the value of EPO in anemic critically ill patients. With increasingly widespread adoption of restrictive transfusion practices [2] the benefits of EPO are likely even smaller than those identified in our metaanalysis and will need to be reassessed if transfusion triggers other than hemoglobin become routine. Second, while the cost of EPO is decreasing, it varies between regions and currently, not cost-effective (assuming our estimates of its effect on mortality are true). Costutility analyses from the UK have shown that EPO was not cost-effective in reducing transfusion requirements, with very high incremental cost-effectiveness ratios *Correspondence: [email protected] 7 Department of Intensive Care Medicine, Amsterdam UMC, Location AMC, Room, C3‑430, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands Full author information is available at the end of the article
The members of the ESICM Transfusion Guideline Part 1 Task force are listed in acknowledgements.
ranging from £1,020,000 per quality-adjusted life year (QALY) and £21,193,000 per QALY [3]. Third, data from the TRACE survey [4] indicate that the use of EPO is uncommon. A recommendation for use of EPO would represent a shift in practice for most clinicians. Taking a “less is more” approach, the burden of proof is on the intervention to demonstrate its worth before widespread adoption. A “why not” approach results in propagation of questionable therapies with the potential for harm and detracts from high-quality, evidence-based practice. EPO has not met the high standard of proof to recommend a change in practice which would impact the majority of critically ill patients; similarly, in centers where EPO use is well-established, the current evidence base is unlikely to support widespread deadoption. More evidence is necessary before any strong recommendations for the use or non-use of EPO can be made. Fourth, we emphasize that in GRADE, a conditional recommendation against EPO does not mean it should never be
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