title: Should the ASCO/ASH Guidelines for the use of intravenous iron in cancer- and chemotherapy-induced anemia be updated?
abstract: Coadministration of intravenous (IV) iron improves responses to erythropoiesis-stimulating agents (ESAs) in the treatment of cancer-associated (CAA) and chemotherapy-induced anemia (CIA). Twelve prospective studies have demonstrated synergy between parenteral iron and ESAs, with variable degrees of improved hemoglobin (Hgb) response rates, shorter times to target Hgb levels, and a lower ESA dose required for equivalent Hgb responses. Clinically significant adverse events (AEs) with currently available IV iron products are uncommon. Pretreatment serum hepcidin levels may predict response magnitude. Safety concerns among many oncologists are driven by reports of serious AEs from older IV iron formulations that are no longer available, and misinterpretation of the nature and frequency of minor infusion reactions. Premedication with antihistamines is of unproven benefit and can cause symptoms that mimic anaphylaxis, prompting intervention with vasopressors and converting self-limited reactions into hemodynamically significant AEs. Payer rules proscribing the administration of ESAs and IV iron on the same day also have limited the clinical adoption of IV iron and ESA coadministration. At a time when financial resources are scarce, the ability to reduce use of costly ESAs is beneficial. Despite a favorable risk/benefit ratio for IV iron in CAA and CIA, current IV iron recommendations in guidelines from ASCO/ASH, NCCN, and ESMO are inconsistent. The authors believe more routine use of IV iron for CAA and CIA is appropriate in view of existing evidence, and suggest reconsideration of the current ASCO/ASH guidelines, which state "there is insufficient evidence to consider the use of intravenous iron as a standard of care."
authors.affiliation: From aInstitute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva, and Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel; bDana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts; and cGeorgetown University School of Medicine, Washington, DC.
authors.forename: Anat
authors.initials: A
authors.lastname: Gafter-Gvili
authors.forename: David P
authors.initials: DP
authors.lastname: Steensma
authors.forename: Michael
authors.initials: M
authors.lastname: Auerbach
mesh_terms: D061605:Administration, Intravenous; D000740:Anemia / Q000139:chemically induced / Q000628:therapy*; D000970:Antineoplastic Agents / Q000009:adverse effects; D006801:Humans; D007501:Iron / Q000008:administration & dosage*; D009369:Neoplasms / Q000188:drug therapy*; D017410:Practice Guidelines as Topic
chemical_list: D000970:Antineoplastic Agents; D007501:Iron