CONCORD INTERNAL MEDICINE ANEMIA OF CHRONIC DISEASE PROTOCOL. Douglas G. Kelling, Jr, MD Carmella Gismondi-Eagan, MD, FACP George C.

Transcription

1 CONCORD INTERNAL MEDICINE ANEMIA OF CHRONIC DISEASE PROTOCOL Douglas G. Kelling, Jr, MD Carmella Gismondi-Eagan, MD, FACP George C. Monroe, III, MD Revised, May 1, 2012 The information contained in this protocol should never be used as a substitute for clinical judgment. The clinician and the patient need to develop and individual treatment plan tailored to the specific needs and circumstances of the patient.

2 Protocol Table of Contents PAGE(S) FERRITIN > FERRITIN < VENOFER PROTOCOL 5

3 Page 1 Ferritin > 60 Measure erythropoietin level Erythropoietin level < 500 Erythropoietin level > 500 Begin oral iron sulfate, 325 mg once daily, one hour before or two hours after meals Begin erythropoietin, 40,000 units s.c. weekly Treatment with erythropoietin not indicated Intolerance of iron sulfate Measure Hemoglobin (Hgb) and Hematocrit (Hct) weekly x 4 weeks Consider referral to Hematologist Continue iron sulfate, 325mg once daily one hour before or two hours after meals See Page 2 Intolerant of ferrous fumarate Begin ferrous fumarate once daily, one hour before or two hours after meals Rise in Hgb < 1g/dl In 4 weeks Increase erythropoietin to 60,000 units s.c. weekly Measure Hgb/Hct before each dose of erythropoietin Rise in Hgb > 1g/dl In 4 weeks Rise in Hgb > 3 g/dl or > 11 Continue ferrous fumarate (Tandem) Refer to Page 2 Begin Elixir of Feosol, 7.5 ml daily, one hour before or two hours after meals Intolerant of Feosol? Refer to physician for reevaluation Measure Hgb/Hct before each dose of erythropoietin Hgb < 11 Continue Feosol Consider IV Iron Refer to Page 2 Refer to page 4 Continue present dose erythropoietin Hold erythropoietin until Hgb < 11 then resume at present dose

4 Page 2 Patient on: Iron Sulfate 325 mg once a day Or Ferrous fumarate once a day Or Feosol 7.5 ml once a day Hct one month after starting Erythropoietin Hct < 35 Hct >35 Measure 8 AM iron, iron binding capacity TSAT and Ferritin monthly Measure Hgb/Hct before each dose of erythropoietin Ferritin > 60 Ferritin < 60 Hct < 35 Hct > 35 Reevaluate Hct monthly Stop Erythropoietin until Ferritin > 60, and Hct < 35 then resume at present dose per protocol See Page 3 Hct < 35 Hct > 35 for 3 consecutive months Measure 8 AM iron, iron binding capacity, TSAT, and Ferritin every 3 months Hct < 35 Hct > 35 Ferritin < 60 Ferritin > 60 Stop Erythropoietin until, Ferritin > 60 and Hct < 35 then resume at present dose Refer to Page 3

5 Page 3 Ferritin < 60 Is patient on iron sulfate once a day? Increase iron sulfate to 325 three times a day Is patient on ferrous fumarate once a day? Patient intolerant? Begin/Increase ferrous fumarate to 325 twice a day Begin/Increase Feosol to 7.5 three times a day Patient intolerant? Patient intolerant? Refer to Page 4 Consider IV iron Refer to Page 5

6 Page 4 Ferritin < 60 Measure 8 AM iron, iron binding capacity, TSAT and Ferritin in one month Ferritin < 60 Ferritin > 60 Reevaluate patient for: 1. Patient not taking iron 2. Iron not being absorbed (malabsorption) 3. Iron (blood) loss or need in excess of amount ingested (such as hemolytic anemia) Resume Erythropoietin at present dose per protocol It patient unwilling to take iron, iron not being absorbed or iron loss in excess of amount ingested begin IV iron Refer to Page 5

7 Page 5 VENOFER PROTOCOL Pre-medicate with: Famotidine 20 mg IV Diphenhydramine 50 mg IV Hydrocortisone 100 mg IV Venofer 300 mg in 250 ml normal saline IV over 1 ½ hrs 2 weeks later Pre-medicate with: Famotidine 20 mg IV Diphenhydramine 50 mg IV Hydrocortisone 100 mg IV Venofer 300 mg in 250 ml normal saline IV over 1 ½ hrs 2 weeks later Pre-medicate with: Famotidine 20 mg IV Diphenhydramine 50 mg IV Hydrocortisone 100 mg IV Venofer 400 mg in 250 ml normal saline IV over 2 ½ hrs 2 weeks later draw CBC with diff and Ferritin, Iron and Iron Binding Capacity