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‘Ultra-Short’ Iron Boost Day Before Cardiac Surgery Reduces RBC Transfusions

NEW YORK (Reuters Health) – A combination treatment given to patients with anemia or iron deficiency the day before cardiac surgery significantly reduces their need for red blood cell (RBC) transfusions, according to new findings in The Lancet.

The treatment consists of an iron complex, erythropoietin, vitamin B12 and folic acid.

“Even if you treat the patient late…you can make a difference,” Dr. Donat R. Spahn of the University of Zurich, the study’s lead author, told Reuters Health in a telephone interview. “The treated patients received less blood transfusions than the placebo-treated patients and at the same time the actively treated patients had higher hemoglobin levels throughout the first week after their operation.”

Patients undergoing elective cardiac surgery often have anemia, and preoperative treatment of iron deficiency is recommended by many expert groups, Dr. Spahn and his team note in their April 25 report. But most health care systems do not have a system in place for assessing patients’ iron status and treating deficiency and anemia, they add.

The researchers enrolled 253 patients with anemia (hemoglobin concentration <120 g/L in women and <130 g/L in men) and 252 patients with isolated iron deficiency (ferritin <100 ug/L, no anemia). The patients were randomly assigned to receive – on the day before surgery – either placebo or a slow infusion of ferric carboxymaltose, 20 mg/kg along with subcutaneous erythropoietin alpha, 40,000 U; subcutaneous vitamin B12, 1 mg; and oral folic acid, 5 mg.

During the first seven days after surgery, untreated patients required a median of one unit of RBC, compared to zero for treated patients. Treated patients required significantly fewer combined allogeneic transfusions up to 90 days after surgery.

The treated patients had higher hemoglobin concentrations, higher reticulocyte count and higher reticulocyte hemoglobin content during the seven days after treatment.

Serious adverse events were reported by 30% of the treatment group and 33% of the placebo group.

In the real world, Dr. Spahn said, many patients with iron deficiency or anemia aren’t assessed or treated because clinicians believe treatment must begin weeks before surgery. “It’s a logistical challenge to get a handle on all patient hemoglobin and iron status as early as possible prior to the procedure and then the patient may not necessarily be already at the hospital,” he added.

“This is the beauty of our concept, that you can treat the patient one or two days prior to surgery, and at that time many patients who need relatively urgent cardiac surgery are hospitalized already, therefore treatment is not difficult,” Dr. Spahn said.

“Earlier treatment is of course better, because then you can really increase the hemoglobin level from anemic levels up to a normal level before the operation,” he said.

Dr. Spahn and his colleagues are planning to investigate whether the ultra-short treatment could benefit elderly patients with hip fracture undergoing surgery and patients undergoing surgery for colorectal cancer.

“This new study provides evidence that pragmatic approaches to treating anemia and iron deficiency can reduce the use of allogeneic RBC transfusion and increase postoperative Hb concentration,” Dr. Gregory M. T. Hare and Dr. C. David Mazer of the University of Toronto write in an editorial accompanying the study.

“Whether such approaches can reduce adverse effects associated with anemia in patients undergoing cardiac surgery remains to be confirmed. In addition, with the development of additional novel treatments of anemia, including small peptide prolyl hydroxylase inhibitors, ongoing trials will be needed to assess the relative efficacy and safety of both new and older therapies,” they conclude.

Vifor Pharma and the Swiss Foundation for Anesthesia Research funded the study.


Lancet 2019.

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