Treating critically ill anaemic patients with erythropoietin: why not?
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CORRESPONDENCE
Treating critically ill anaemic patients with erythropoietin: why not? Sigismond Lasocki1* , Antoine Kimmoun2, Gerald Chanques3, Lionel Velly4,5 and Frédéric Pène6 © 2020 Springer-Verlag GmbH Germany, part of Springer Nature
Dear Editor, We read with great interest the clinical practice guidelines on transfusion strategies recently published in the journal [1]. Although it followed a well designed and robust methodology, we are concerned by the recommendation against the use of erythropoietin (EPO, with or without iron) in critically ill patients. Following a similar methodology, we ended up with different conclusions in our national guidelines under the aegis of the French society of anaesthesiology and critical care (SFAR) and the French intensive care society (SRLF) [2, 3]. Indeed, recent meta-analyses report a decrease in red blood cell transfusion and a reduction in mortality (relative risk for hospital mortality 0.82, 95% CI 0.71–0.94, p = 0.006, I2 = 0.1%) [4], without evidence for increased morbidity, neither for thromboembolic events nor for cardiovascular complications [4, 5]. This is why we recommended the use of erythropoietin to treat anaemia in the critically ill patients. Because the use of EPO is not widely admitted for critically ill patients and because morbidity is not well described in all the randomized controlled trials (RCTs), we choose to downgrade the recommendation to a grade 2 level (optional recommendation). We also mentioned that anaemic and trauma patients may draw a greater benefit from this treatment because the evidence of a reduction in mortality comes mainly from these subpopulations. We agree that one should remain cautious about the potential risk of adverse event (mainly thrombosis), and we also recommended to target reasonable haemoglobin levels (not higher than 12 g/dl), since higher targets are associated with worse outcomes *Correspondence: [email protected] 1 Département Anesthésie Réanimation, Université d’Angers, CHU Angers, 4 rue Larrey, 49933 Angers Cedex 9, France Full author information is available at the end of the article
Table 1 Hospital cost for 40,000 UI of epoietin alpha and estimated cost for “one saved life”
Australia
Cost for 40,000 UI epoietin a lphaa
Estimated cost for one life savedb (K€)
AUD 965 (€ 588) (Cost for the patient: AUD 41 or 6.6 = € 25 or 4)
65.2
Canada
CDN 426 (€ 296)
32.8
Denmark
€ 400
44.4
France
€ 61
6.8
Germany
€ 35
3.9
Italy
€ 120
13.3
Spain
€ 49
5.4
UK
£ 193 (€ 222)
11.3
USA
USD 685 (€ 632)
70.1
Mean cost
€ 267
13.7
a
Costs of epoietin (mostly biosimilars) were obtained from one hospital in each country and may vary across the country.
b
This cost was estimated using the data from the published meta-analysis from Litton et al. showing that 37 patients had to be treated to save one life (using the reported hospital mortality) [4] and assuming that patients received a mean of 3 injections (estimated cost = 37 × 3 × cost of 1 injection).
in patients with chronic kidney
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