Download anemia management orders

November 2011
Page 1 of 3
PHYSICIAN’S ORDERS
Date/Time/Initial
s
ANEMIA MANAGEMENT ORDERS
Blood Management
MD: Please indicate order selections with an “X” and sign at end.
LAB:
Minimum blood volume draws
Iron Panel (serum iron, TIBC, TSAT%) and Ferritin
Hemoglobin / Hematocrit
SUPPLEMENTAL MEDICATIONS
Ferrous Sulfate 325 mg po TID (one hour before meals)
Vitamin C 250 mg po TID with iron Multivitamin 1 po once daily Folate 1mg po once daily
Docusate stool softener 250 mg po daily PRN constipation ESP THERAPY: (ESP = erythropoetic stimulating protein)
Iron Administration Orders
Hold therapy if hemoglobin is greater than or equal to
IV Iron supplements are necessary when lab values are: Serum Ferritin
11 gm/dL:
less than 200 ng/ml and TSAT% less than 20%
**note:serum ferritin may be increased due to inflammatory factors, hold
INDICATIONS AND DOSAGE/SCHEDULE:
IV iron for ferritin above 500.
Chronic Renal Failure (with or without dialysis)
Sodium ferric gluconate complex (Ferrlecit)
Epoetin (Procrit) 150 units/kg subcutaneous per week
125 mg/100 ml NS IV daily over 60 minutes for 4 days
Darbepoetin (Aranesp) __________mcg subcutaneous
per week or per dialysis session. (circle schedule)
• (Recommended therapy 3 or 4 days.)
• Recommended beginning dose for dialysis patients is 25 mcg
with each dialysis session.
Chemotherapy Induced Anemia
Epoetin Alfa (Procrit) 10,000 units three times a week
• Equivalent to Darbepoetin 100 mcg weekly.
Epoetin Alfa (Procrit) 15,000 units three times a week
- Equivalent to Darbepoetin 150 mcg weekly
Presurgical/ Post Surgical Patients/Transfusion Refusal
Patients:
Epoetin (Procrit) 600 units/kg SQ or IV (see back)
Recommended dose is 600 units/ kg/ wk
Critically Ill Anemic Patients
Epoetin (Procrit) 40,000 units once a week
Other_________________________________
**Pharmacy will round dosage to nearest vial size
.
Practitioner: ___________
IV Iron Dextran:
Pretreat with Diphenhydramine 50 mg IV or po
Test dose: Iron Dextran 25 mg in 50 ml NS over 30 minutes
• Observe for 1 hour for signs of allergic reaction.
• Subtract test dose of 25 mg from full calculated replacement dose
Iron Dextran___________mg/500ml 0.9% NaCl
Infuse over 4 – 6 hours- watch for allergic reaction
IRON DEXTRAN DOSING:
To calculate dose in ml (50 mg/ml) of IV Iron Dextran the patient
should receive for iron deficient anemia:
Dose (ml) = 0.0442 (desired hgb – observed hgb) x LBW + (0.26 x LBW).
IF ANAPHYLACTIC ALLERGIC REACTION, SEE ANAPHYLACTIC
PROTOCOL.
*IF NON ANAPHYLACTIC ALLERGIC REACTION IS APPARENT:
(nausea, itching, joint pain):
1. Stop IV drip
2. Give: Diphenhydramine (Benadryl) 50 mg IV
3. Give: Hydrocortisone 125 mg IV
4. Wait 30 minutes
5. When symptoms subside: Restart iron dextran
Infusion at 50 ml per hour, then gradually increase
the infusion rate as tolerated.
A DRUG EQUIVALENT MAY BE DISPENSED UNLESS CHECKED
SIGNATURE IS REQUIRED FOLLOWING ENTRY OF EACH ORDER
PHYSICIAN’S ORDERS
Disclaimer: This content is covered by an important www.iron.sabm.org. Please read this disclaimer carefully before reviewing this content.
Blood Management Pre-Surgery Guidelines
(For surgeries that involve the risk of more than 2 units of
blood loss)
Required Baseline Labs
Total Iron, TIBC, % Transferrin Saturation, Ferritin, CBC
Oral Iron or IV Iron per
dosing protocol *
NO
Hb/Hct
13/39
Hb/Hct
10-12.9/30-38.9
Transferrin
saturation
more than
20%?
Transferrin
saturation
more than
20%?
Hb/Hct
Under 10/30
YES
YES
Proceed with
Surgery
Transferrin
saturation
more than
20%?
Hematology consult or
proceed to next step
NO
NO
Hematology consult or
proceed to next step
YES
325 mg Ferrous Sulfate TID
AND
EPO 600 units/Kg on days -21, -14, -7,
and day of surgery or EPO 300 units/Kg
daily for 10 days
NOTE :
IV Iron* is recommended if :
Transferrin saturation is less than 20%,
Ferritin is less than 100ng/ml** and/or
Total iron is less than 70 mcg/ dL
IV Iron per dosing protocol*
AND
EPO 600 units/Kg on days -21, -14, -7, and
day of surgery or EPO 300 units/Kg daily for
10 days
*Sodium Ferric Gluconate (Ferrlecit) IV Dosing Protocol: 125 mg in 100 ml normal saline infused over one hour, daily for 3 or 4 doses. May need to repeat cycle weekly for
cumulative dose of 1 gram. TSAT and serum iron levels may be drawn 24 hours after last infusion. If total dose of iron is necessary, refer to IV Iron Dextran dosing instructions on
page 2 of this guideline. For assistance in determining dosing, contact Pharmacy at 320-2181.
**Note: If patient’s ferritin is greater than 100 ng/ml but less than 600 ng/ml, iron studies need to be evaluated every four weeks if erythropoietin is initiated. The pre-existing iron
levels may be reduced by 50% within one week of erythropoietin therapy. For assistance in determining dosing, contact Pharmacy at 320-2181.
Disclaimer: This content is covered by an important www.iron.sabm.org. Please read this disclaimer carefully before reviewing this content.
Page 2 of 3
Additional Information for Anemia Management Orders
and Pre-Surgery Guidelines
Sodium Ferric Gluconate (Ferrlecit) Dosing: 125mg in 100 ml normal saline infused over one hour,
daily for 3 or 4 doses. May need to repeat cycle weekly for cumulative dose of 1 gram. TSAT and serum
iron levels may be drawn 24 hours after last infusion.
IV Iron Dextran (Infed) IV Iron Dextran is recommended for outpatient use or when the total dose of IV
iron needs to be given in one dose. Dosing Formula: Calculate dose in ml (50mg/ml) of Iron Dextran =
0.0442 (desired HGB - observed HGB) X LBW (lean body weight) + (0.26 X LBW). Test dose of 25mg is
given over 5 to 15 minutes followed by remaining infusion over 4 to 6 hours. (LBW in kg)
How does patient get EPO and/or iron injections?
1) Patient can receive EPO and iron through his primary care physician with surgeon’s orders. OR
2) Contact Blood Management Department for internal medicine or hematology physicians. OR
3) Patient can receive EPO and/or iron at Ambulatory Infusion Center (AIC) at Providence Campus or
Ambulatory Treatment center (ATC) at FH Campus.
a) Surgeon writes EPO and iron orders per above guidelines.
b) Surgeon’s office faxes orders to AIC at 320-3659 or ATC at 386-2238 or
Ballard MTC at 781-6107.
c) Patient calls AIC at 320-3158 or ATC at 386-3800 to schedule an appointment for injections.
d) Patient receives injections at the center.
Note on Self-Injecting: Some Insurance companies allow the patient to receive EPO at the pharmacy and self
inject. In that case, AIC at Providence, Ballard, and FH will teach the patient how to inject. All Iron Infusions must
be done under careful supervision and thus must be done in the AIC or other infusion center.
EPO coverage: Most major Insurance Carriers cover the cost of EPO under their pharmacy policy. Check with
patient’s insurance to verify coverage. Patients should be advised that the cost of EPO is high. (40,000 units cost
anywhere from $600 - $900 depending on the pharmacy.)
Medicare covers epo for
presurgery buildup under
the following conditions
1. Patient must be about
to undergo hip or knee
surgery, and
2. Must have HGB 13 or
below or HCT 39 or below,
and
3. Not be a candidate for
autologous blood
transfusion, and
4. Expected to lose more
than 2 units of blood.
Medicare covers EPO for the following non
ESRD anemias.(ICD-9 Codes in
parenthesis)
Note: Starting hct must by 33% or less or
Hgb 11 or less
1.
2.
3.
4.
5.
6.
7.
Unspecified Deficiency Anemia (281.9)
Anemia due to chronic disease (284.8)
Anemia of chronic illness (285.2)
Anemia of neoplastic disease (285.22)
Anemia of other chronic illness (285.29)
Other specified anemias (285.8)
Anemia unspecified (285.9)
Medicare covers IV Iron for
the following. This list is
abbreviated. For more
diagnosis codes that support
medical necessity see the
ICD9 Code Reference
Manual.
1. Iron deficiency anemia
secondary to blood loss
(chronic) (280.0)
2. Iron deficiency anemia
secondary to inadequate
dietary intake (280.1)
3. Other specified iron
deficiency anemias (280.8)
4. Iron deficiency anemia,
unspecified (280.9)
References and Resources:
Goodnough, LT, Skikne, B, Brugnara C. Erythropoietin, iron, and erythropoisis. Blood. 2000 Aug 1; 96(3):823-33
Faris, PM, Ritter, MA. Epoetin Alfa, A Bloodless Approach for the Treatment of Perioperative Anemia. Clinical Orthopaedics and Related
Research, Number 357;60-67
State Medicare Guidelines from http://www.procritline.com Washington, Part B Last revised 04/21/04
LMRP: Epoetin Alfa/EPO, Contractor’s Policy Number 2000-05, Contractor Name: Mutual of Omaha Insurance Company,
January 30, 2001.
LMRP: Intravenous Iron Therapy, Contractor Policy Number: 2002-06 Contractor Name: Mutual of Omaha Insurance Company, May 2002
Iron Administration Guidelines/SMC July 2003; Iron Administration Guidelines/SMC July 2003
Disclaimer: This content is covered by an important www.iron.sabm.org. Please read this disclaimer carefully before reviewing this
content.
Page 3 of 3