Value of ESAs in Avoiding Transfusion Questionable

The annual cost for preventing a patient from being transfused varied from $61,188 to $317,988.
The annual cost for preventing a patient from being transfused varied from $61,188 to $317,988.

Erythropoiesis stimulating agents (ESAs) have limited benefit in decreasing the need for transfusion in patients with chronic kidney disease (CKD) and anemia, and are associated with risk that may outweigh therapeutic benefit, researchers concluded in a poster presented at the National Kidney Foundation's 2014 Spring Clinical Meetings in Las Vegas.

Anubha Mutneja, MD, and Daniel W. Coyne, MD, of Washington University School of Medicine in St. Louis, Mo., examined red blood cell (RBC) transfusion rates in three randomized trials: the Trial to Reduce Cardiovascular Events with Aranesp Therapy (TREAT), normal hematocrit trial (NHT), and the left ventricular volume index (LVVI) trial.

TREAT included diabetic patients with stage 3-4 CKD, whereas the NHT and LVVI trial included dialysis patients with and without cardiac disease, respectively. The trial treatment periods were 29 months, 14 months, and 17 months, respectively.

The annual ESA dose in TREAT was 2,288 mcg in the treatment arm with a high hemoglobin goal and 65 mcg in the placebo arm, with annual cost of therapy of $13,248 and $376, respectively.

In the NHT, the annual dose was 1,794,000 units and 585,000 units in the high and low hemoglobin goal arms, for an annual cost of $23,546 and $7,678, respectively. In the LVVI study, the annual dose was 624,000 units and 288,600 units in the high and low hemoglobin goal arms, for an annual cost of $8,190 and $3,788, respectively.

In all three trials, the vast majority of patients in either the low or high hemoglobin target arms did not receive a transfusion during the trial period. The researchers calculated that in TREAT, NHT, and the LVVI trial, 10.3, 9.7, and 9.8 patients, respectively, would need to be treated with ESAs to prevent 1 transfusion. This translated into an annual net cost of $317,988, $179,308, and $61,188, respectively, to prevent 1 transfusion.

“Most CKD patients in these trials never required transfusions,” the researchers concluded. “These results highlight the questionable efficacy and the cost effectiveness of targeting higher hemoglobin [levels] to avoid transfusions, especially repeated transfusions. Without the ability to identify patients likely to receive transfusions in the near term, treatment will be given mostly to patients unlikely to ever require transfusion.

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