Evaluation of standardized pharmacist dosing approach of epoetin in acutely hospitalized patients with chronic kidney disease

Abstract

Background

Practice guidelines recommend an individualized dosing strategy approach for erythropoiesis-stimulating agent (ESA) therapy because of the narrow therapeutic range of target hemoglobin (Hb). Data on optimal dosing of ESA in acutely hospitalized patients with chronic kidney disease (CKD) is not well established.

Objectives

The study aimed to evaluate the impact of pharmacist-driven dosing standardization of ESA on efficacy, safety, and associated costs in acutely hospitalized non-dialysis and dialysis-dependent patients with CKD anemia.

Methods

The study was a single-center, retrospective cohort evaluating the impact of pharmacist-driven initial ESA dose optimization intervention compared to standard of care. Outcomes evaluated included ESA dosing characterization, clinical safety, and efficacy.

Results

The study included a total of 254 patients. Baseline characteristics were equally balanced for the majority. The intervention group favored a reduction in the primary outcome of median ESA dose: 100 units/kg/dose compared to 137 units/kg/dose (P < 0.001). The intervention group was associated with reduced ESA dosing characteristics: total dose of ESA per patient (30,000 units vs. 40,000 units, P = 0.047); total dose of ESA (5,659,000 units vs. 6,733,000 units, P = 0.047); and the total weekly dose of ESA used per patient (15,000 units vs. 20,000 units, P < 0.001). The intervention group yielded a total estimated drug-related savings of $19,267.56. There were no differences in clinical outcomes: the last known Hb (P = 0.096), relative change of Hb (P = 0.768), absolute change of Hb (P = 0.809), packed red blood cell transfusion (P = 0.167), hospitalization within 90 days due to thrombotic events (P = 0.271), proportion of patients experiencing hypertensive crisis (P = 0.132), and inpatient survival (P = 0.725). The intervention group was associated with a longer length of stay (15 days vs. 11 days, P = 0.009), a finding likely associated with confounders.

Conclusion

Pharmacist-driven dosing standardization protocol limited to initial ESA dose adjustment was associated with reduced ESA use in acutely hospitalized patients with CKD.