Back Back
Anemia of CKD Questions
Questions on Patient-Centered, Equitable Care in Anemia of CKD

Released: April 06, 2023

Branden D. Nemecek
Branden D. Nemecek, PharmD, BCPS
Michelle M. Richardson
Michelle M. Richardson, PharmD, BCPS
Activity Information

Activity

Progress
1
Course Completed
Continue
Key Takeaways
  • Having a regular quality improvement process will help improve outcomes regarding ESA usage.
  • Although daprodustat is approved by FDA for dialysis patients, it will take some time before it is regularly used in practice.
  • ESAs and HIF-PH inhibitors have not been studied to be used simultaneously for the treatment of anemia of CKD.

What recommendations do you have for a pharmacist who wants to have better outcomes at the hospital institution regarding erythropoiesis-stimulating agent (ESA) use?

Michelle Richardson, PharmD, BCPS:
When you want to have better outcomes at your institution, first look at your patient population and understand why your outcomes are not where you want them to be and where the breakdown is occurring. Reach out to other institutions to look at their policies and guidelines. Also, use updated national guidelines like Kidney Disease Improving Global Outcomes (KDIGO) as a reference for recommendations. Ultimately, it is best to take it through a regular quality improvement process and get input from the entire organization to improve.

Branden D. Nemecek, PharmD, BCPS:
In addition, review the transitions of care process from a hospital perspective. At my institution, a patient will get started on darbepoetin, but they were on epoetin at their dialysis facility. It is important to focus on the transition of care and try to optimize therapy when you can. Understanding the local dialysis centers and their policies and procedures can improve quality for a patient.

Can ESAs and HIF inhibitors be on a treatment plan simultaneously?

Branden D. Nemecek, PharmD, BCPS:
Mechanistically, it might be possible. However, according to the literature, the two have not been studied simultaneously.

Michelle Richardson, PharmD, BCPS:
When they are studied simultaneously, mechanisms of compounded efficacy and mechanisms of compounded adverse effects will need to be evaluated.

How quickly do you think daprodustat will be implemented in the treatment process, and would it be implemented more than darbepoetin?

Branden D. Nemecek, PharmD, BCPS:
I believe they will be incorporated into the ambulatory care setting initially. I do not believe daprodustat will replace ESAs soon, especially since there are standard treatment pathways with ESAs. It will take some time for medications like daprodustat to be used regularly.

Michelle Richardson, PharmD, BCPS:
With the FDA approval limiting daprodustat to patients on hemodialysis, it makes incorporation complicated. As a new medication, it could be more expensive than generic ESAs. Medicare reimbursement may also be a limitation to prescribers.

How can we increase education for patients without access to care?

Michelle Richardson, PharmD, BCPS:
It is important to be creative, and our colleagues in rural areas do this very well. Telehealth is an excellent tool that can help to teach patients who live far from care. If someone needs IV iron, you are going to have to go to them or vice versa. But with technology today, there are so many things that can be done via a computer in terms of monitoring and education.

Can you address iron sequestration? If transferrin saturation is less than 20% (plan criteria for prior authorization approval) and ferritin is continually >1000, is initiation or continuation of ESA therapy appropriate?

Michelle Richardson, PharmD, BCPS:
This is a gray area with a lot of differences in practice. In my experience, the nephrologists whom I work with think that a ferritin >1000 is probably an inflammatory response and will use that as a prompt to look for infection or other inflammatory diseases.

In broader terms, the transferrin saturation being low is what we usually think of as anemia or iron deficiency in patients, especially those with advanced chronic kidney disease (CKD) or on dialysis. I would try some extra iron and then an ESA. It also does depend on the patient and if they are symptomatic. Typically, it is not appropriate to continue an ESA.

Branden D. Nemecek, PharmD, BCPS:
When the ferritin is that high, you must consider that an inflammatory process is driving it. Yes, dialysis is an inflammatory process, but when there is iron sequestration, it is important to look at other factors.

Your Thoughts?
How do you see daprodustat being incorporated into the treatment options for anemia of CKD? Please leave your thoughts in the comments box.

Continue

Poll

1.

How likely are you to use daprodustat in your dialysis patients with anemia of CKD?

Submit