New paradigms for managing preoperative anemia

Abstract

To the Editor, In the Continuing Professional Development article, Assessment and treatment of preoperative anemia, Hare et al. present very interesting concepts and hypotheses. Despite the important concepts, implementation of the proposed protocol would inevitably result in delays as well as logistical and financial implications related to the supervised administration of intravenous iron and erythropoietic stimulating agents (ESAs). Also, it is questionable whether the evidence is sufficiently strong to incorporate the proposed protocol into routine clinical practice. The protocol in the article appears to be based on the Network for Advancement of Transfusion Alternatives (NATA) guidelines, which were directed specifically toward elective orthopedic surgical patients. The authors of the NATA guidelines made five recommendations graded as strong or weak according to the risk/benefit ratio, and they classified the respective quality of evidence as high, moderate, or low/very low. There are three strong recommendations regarding the timing of testing, laboratory tests, and the treatment of nutritional deficiency anemia, yet the recommendations are based on low/very low-quality evidence. Also, a weak recommendation regarding the target hemoglobin level is based on low/very low-quality evidence. The only recommendation based on high-quality evidence is the final weak recommendation regarding the use of ESAs in anemia where nutritional deficiency has been ruled out. The same group also produced a consensus statement regarding the use of intravenous iron wherein they concluded that intravenous iron may be indicated in the perioperative period in orthopedic patients who are expected to develop severe postoperative anemia. Again, this is a weak recommendation based on moderate/ lowquality evidence, and no evidence-based recommendations could be made for other types of surgery. With regard to the use of ESAs in cancer patients, the European Medicines Agency recommends that transfusion be the preferred method for correcting anemia in cancer patients, especially those with a long life expectancy. The Food and Drug Administration changed the product label for ESAs by adding a black box warning which specifies that ESAs are not indicated to treat cancer-induced anemia in patients not on chemotherapy or in patients with potentially curable cancer. These recommendations were echoed by the American Society of Clinical Oncology clinical practice guidelines.