Epoetin alfa

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Epoetin alfa
Clinical data
Pronunciation/ɛˈpoʊ.ɪtɪn/
Trade namesEpogen, Retacrit
Other namesepoetin alfa-epbx
AHFS/Drugs.comMonograph
MedlinePlusa692034
License data
subcutaneous
ATC code
Legal status
Legal status
Identifiers
CAS Number
DrugBank
ChemSpider
  • none
UNII
KEGG
ChEMBL
Chemical and physical data
FormulaC815H1317N233O241S5
Molar mass18396.19 g·mol−1
 ☒NcheckY (what is this?)  (verify)

Epoetin alfa is a human

chronic kidney failure and cancer chemotherapy
.

Epoetin is manufactured and marketed by

Janssen Biotech (formerly Ortho Biotech Products, LP), sells the same drug under the name Procrit, pursuant to a product license agreement. The average cost per patient in the U.S. was $8,447 in 2009.[7] Darbepoetin alfa (rINN) /dɑːrbəˈpɔɪtɪn/ is a glycosylation analog of erythropoietin containing two additional N-linked carbohydrate chains,[8] also manufactured and marketed by Amgen, with a brand name of Aranesp. The Food and Drug Administration
(FDA) warnings and safety precautions for Procrit, Epogen and Aranesp are identical.

For several years, epoetin alfa has accounted for the single greatest drug expenditure paid by the U.S. Medicare system; in 2010, the program paid $2 billion for the drug.[9][10] Raising hemoglobin levels has been found in some studies to be associated with higher risks of thrombotic events, strokes and death.[11]

It is on the World Health Organization's List of Essential Medicines.[12]

Medical uses

Erythropoietin is available as a therapeutic agent produced by

myelodysplasia, from the treatment of cancer (chemotherapy and radiation).[citation needed
]

Anemia caused by kidney disease

For people who require dialysis or have chronic kidney disease, iron should be given with erythropoietin, depending on some laboratory parameters such as ferritin and transferrin saturation.[13] Dialysis patients in the U.S. are most often given Epogen; other brands of epoetin may be used in other countries.[citation needed]

Erythropoietin is also used to treat anemia in people, and cats and dogs, with chronic kidney disease who are not on dialysis (those in Stage 3 or 4 disease and those living with a kidney transplant). There are two types of erythropoietin for people, and cats and dogs, with anemia due to chronic kidney disease (not on dialysis).[14][15]

Anemia caused by cancer

In March 2008, a panel of advisers for the

tumor growth in chemotherapy patients taking the anti-anemia drugs.[citation needed
]

Anemia in critically ill people

Erythropoietin is used to treat people with anemia resulting from critical illness.

In a randomized controlled trial,[16] erythropoietin was shown to not change the number of blood transfusions required by critically ill patients. A surprising finding in this study was a small mortality reduction in patients receiving erythropoietin. This result was statistically significant after 29 days but not at 140 days. The mortality difference was most marked in patients admitted to the ICU for trauma. The authors provide several hypotheses for potential etiologies of this reduced mortality, but, given the known increase in thrombosis and increased benefit in trauma patients as well as marginal nonsignificant benefit (adjusted hazard ratio of 0.9) in surgery patients, it could be speculated that some of the benefit might be secondary to the procoagulant effect of erythropoietin. Regardless, this study suggests further research may be necessary to see which critical care patients, if any, might benefit from administration of erythropoietin. Any benefit of erythropoietin use must be weighed against the increased likelihood of thrombosis, which has been demonstrated in numerous trials.[citation needed]

Neurological diseases

Erythropoietin has been hypothesized to be beneficial in treating certain neurological diseases such as schizophrenia and stroke.

cerebral malaria, which is caused by the malaria parasite's blockage of blood vessels in the brain.[18][19][20] However, the possibility that erythropoietin may be neuroprotective is inconsistent with the poor transport of the chemical into the brain[21]
and the low levels of erythropoietin receptors expressed on neuronal cells.

Psychiatric diseases

Randomized clinical control trials have shown promising results of EPO in improving cognition which is often intractable with the current treatment of mood disorders and schizophrenia.These domains include speed of complex cognitive processing across attention,memory and executive function.[22]

Preterm infants

Infants born early often require transfusions with red blood cells and have low levels of erythropoietin. Erythropoietin has been studied as a treatment option to reduce anemia in preterm infants. Treating infants less than 8 days old with erythropoietin may slightly reduce the need for red blood cell transfusions, but increases the risk of retinopathy. Due to the limited clinical benefit and increased risk of retinopathy, early or late erythropoietin treatment is not recommended for preterm infants.[23][24]

Adverse effects

Epoetin alfa is generally well tolerated. Common side effects include high blood pressure, headache, disabling cluster migraine (resistant to remedies), joint pain, and clotting at the injection site. Rare cases of stinging at the injection site, skin rash, and

dyspnea and abdominal pain.[25]

Erythropoietin is associated with an increased risk of adverse cardiovascular complications in patients with kidney disease if it is used to target an increase of hemoglobin levels above 13.0 g/dl.[26]

Early treatment (before an infant is 8 days old) with erythropoietin correlated with an increase in the risk of retinopathy of prematurity in premature and anemic infants, raising concern that the angiogenic actions of erythropoietin may exacerbate retinopathy.[23][24] Since anemia itself increases the risk of retinopathy, the correlation with erythropoietin treatment may be incidental.[citation needed]

Safety advisories in anemic cancer patients

Amgen sent a "dear doctor" letter in January 2007 that highlighted results from a recent anemia of cancer trial, and warned doctors to consider use in that off-label indication with caution.[citation needed]

Amgen advised the

U.S. Food and Drug Administration (FDA) regarding the results of the DAHANCA 10 clinical trial. The DAHANCA 10 data monitoring committee found that three-year loco-regional cancer control in subjects treated with Aranesp was significantly worse than for those not receiving Aranesp (p=0.01).[citation needed
]

In response to these advisories, the FDA released a Public Health Advisory[27] on 9 March 2007, and a clinical alert

darbepoetin
. The advisory recommended caution in using these agents in cancer patients receiving chemotherapy or off chemotherapy, and indicated a lack of clinical evidence to support improvements in quality of life or transfusion requirements in these settings.

In addition, on 9 March 2007, drug manufacturers agreed to new

black box warnings
about the safety of these drugs.

On 22 March 2007, a congressional inquiry into the safety of erythropoietic growth factors was reported in the news media. Manufacturers were asked to suspend drug rebate programs for physicians and to also suspend marketing the drugs to patients.

Several publications and FDA communications have increased the level of concern related to adverse effects of ESA therapy in selected groups. In a revised black box warning, the FDA notes significant risks, advising that ESAs should be used only in patients with cancer when treating anemia specifically caused by chemotherapy, and not for other causes of anemia. Further, the warning states that ESAs should be discontinued once the patient's chemotherapy course has been completed.[29][30][31][32]

Interactions

Drug interactions with erythropoietin include:

  • Major: lenalidomide—risk of thrombosis
  • Moderate:
    cyclosporine
    —risk of high blood pressure may be greater in combination with EPO. EPO may lead to variability in blood levels of cyclosporine.
  • Minor:
    ACE inhibitors may interfere with hematopoiesis by decreasing the synthesis of endogenous erythropoietin or decreasing bone marrow production of red blood cells.[33]

Society and culture

The publication of an editorial questioning the benefits of high-dose epoetin was canceled by the marketing branch of a journal after being accepted by the editorial branch highlighting concerns of conflict of interest in publishing.[34]

In 2011, author Kathleen Sharp published a book, Blood Feud: The Man Who Blew the Whistle on One of the Deadliest Prescription Drugs Ever,[35] alleging drug maker Johnson & Johnson encouraged doctors to prescribe epoetin in high doses, particularly for cancer patients, because this would increase sales by hundreds of millions of dollars. Former sales representatives Mark Duxbury and Dean McClennan, claimed that the bulk of their business selling epoetin to hospitals and clinics was Medicare fraud, totaling US$3 billion.[36]

Biosimilars

See also:
Biosimilars

In August 2007, Binocrit, Epoetin Alfa Hexal, and Abseamed were approved for use in the European Union.[37][38][4]

References

  1. FDA
    . Retrieved 22 October 2023.
  2. ^ "Epogen- epoetin alfa solution". DailyMed. 25 July 2018.
  3. ^ "Retacrit- epoetin alfa-epbx injection, solution". DailyMed. 29 January 2020.
  4. ^ a b "Abseamed EPAR". European Medicines Agency (EMA). 17 September 2018. Retrieved 2 April 2020.
  5. ^ "Abseamed". Union Register of medicinal products. Retrieved 14 January 2021.
  6. ISBN 978-0-415-26368-9
    .
  7. PMID 19828525
    .
  8. S2CID 7214868
    .
  9. ^ "Testimony Before the Subcommittee on Health, Committee on Energy and Commerce, House of Representatives.] Medicare. Information on Highest-Expenditure Part B Drugs." (PDF), United States Government Accountability Office (GAO), 28 June 2013, retrieved 29 June 2015
  10. doi:10.1001/jama.2013.192555
  11. ^ Anemia drugs made billions, but at what cost? By Peter Whoriskey, The Washington Post, 19 July 2012
  12. hdl:10665/345533
    . WHO/MHP/HPS/EML/2021.02.
  13. PMID 8914038
    .
  14. ^ Fitzsimons, Helen (14 November 2020). "ERYTHROPOIESIS STIMULATING AGENTS (ESAs) FOR SEVERE ANAEMIA". Tanya's Feline CKD Website. Retrieved 17 September 2023.
  15. ^ Ruben, Dr. Dawn (6 August 2015). "Erythropoietin (Epogen®, Procrit®) for Dogs and Cats". PetPlace. Retrieved 17 September 2023.
  16. PMID 17804841
    .
  17. S2CID 22595839
    .
  18. PMID 19008152
    .
  19. PMID 21044627
    .
  20. ^ McKie R (17 February 2008). "Kidney drug could save children from malaria brain damage". The Guardian. London.
  21. PMID 15556141
    .
  22. S2CID 2335208
    .
  23. ^
    PMID 32048730
    .
  24. ^
    PMID 32048729
    .
  25. ^ R. Baselt, Disposition of Toxic Drugs and Chemicals in Man, 8th edition, Biomedical Publications, Foster City, CA, 2008, pp. 547-549.
  26. PMID 17108342
    .
  27. ^ "FDA Public Health Advisory: Erythropoiesis-Stimulating Agents (ESAs): Epoetin alfa (marketed as Procrit, Epogen), Darbepoetin alfa (marketed as Aranesp)". Food and Drug Administration. Archived from the original on 28 May 2007. Retrieved 5 June 2007.
  28. ^ "Information for Healthcare Professionals: Erythropoiesis Stimulating Agents (ESA)". Food and Drug Administration. Archived from the original on 15 May 2007. Retrieved 5 June 2007.
  29. ^ "Erythropoiesis Stimulating Agents: Aranesp (darbepoetin alfa), Epogen (epoetin alfa), and Procrit (epoetin alfa)". MedWatch - 2007 Safety Information Alerts. U.S. Food and Drug Administration. 3 January 2008. Archived from the original on 9 April 2009. Retrieved 9 April 2009.
  30. ^ "Procrit (Epoetin alfa) for injection" (PDF). U.S. Food and Drug Administration. 11 August 2007. Archived from the original (PDF) on 18 January 2009. Retrieved 9 April 2009.
  31. ^ "Aranesp (darbepoetin alfa) for Injection" (PDF). U.S. Food and Drug Administration. 8 November 2007. Archived from the original (PDF) on 18 January 2009. Retrieved 9 April 2009.
  32. ^ "Information on Erythropoiesis Stimulating Agents (ESA) (marketed as Procrit, Epogen, and Aranesp)". U.S. Food and Drug Administration. 26 January 2009. Retrieved 9 April 2009.
  33. ^ "Epoetin alfa Interactions Checker". Drugs.com.
  34. PMID 17086516
    .
  35. ^ Maryann Napoli (5 October 2011), Whistleblower's story: New book reviewed, Center for Medical Consumers, archived from the original on 5 January 2012, retrieved 12 February 2012{{citation}}: CS1 maint: bot: original URL status unknown (link)| archive-url= | archive-date=5 January 2012
  36. ^ Edwards J (17 August 2009). "Drug Rep in $3B Procrit Case: "80% of My Sales Were Medicare Fraud"; Carried $400K in "Cash"". CBS news. Retrieved 12 February 2012.
  37. ^ "Binocrit EPAR". European Medicines Agency (EMA). 17 September 2018. Retrieved 2 April 2020.
  38. ^ "Epoetin Alfa Hexal EPAR". European Medicines Agency (EMA). 17 September 2018. Retrieved 2 April 2020.
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