Darbepoetin alfa – Uses, Dosage, Side Effects, Interactions

Darbepoetin alfa is a recombinant form of human erythropoietin used to increase the differentiation of progenitor cells to red blood cells in the treatment of anemia. Human erythropoietin with 2 aa substitutions to enhance glycosylation (5 N-linked chains), 165 residues (MW=37 kD). Produced in Chinese hamster ovary (CHO) cells by recombinant DNA technology.

Darbepoetin alfa injection is used to treat anemia (a lower-than-normal number of red blood cells) in people with chronic kidney failure (a condition in which the kidneys slowly and permanently stop working over a period of time). Darbepoetin alfa injection is also used to treat anemia caused by chemotherapy in people with certain types of cancer. Darbepoetin alfa cannot be used in place of a red blood cell transfusion to treat severe anemia and has not been shown to improve tiredness or poor well-being that may be caused by anemia. Darbepoetin alfa is in a class of medications called erythropoiesis-stimulating agents (ESAs). It works by causing the bone marrow (soft tissue inside the bones where blood is made) to make more red blood cells.

Mechanism of action

Darbepoetin alfa stimulates erythropoiesis by the same mechanism as endogenous erythropoietin. Erythropoietin interacts with progenitor stem cells to increase red cell production. The binding of erythropoietin to the erythropoietin receptor leads to receptor dimerization, which facilitates the activation of JAK-STAT signaling pathways within the cytosol. Activated STAT (signal transducers and activators of transcription) proteins are then translocated to the nucleus where they serve as transcription factors that regulate the activation of specific genes involved in cell division or differentiation.

Darbepoetin alfa is used in the treatment of anemia. It is involved in the regulation of erythrocyte differentiation and the maintenance of a physiological level of circulating erythrocyte mass.

Indications

• For the treatment of anemia (from renal transplants or certain HIV treatments)
• Anemia

Use in Cancer

Darbepoetin alfa is approved to treat:

• Anemia is caused by myelosuppressive chemotherapy used for certain types of cancer.

Contraindications

The following conditions are contraindicated with this drug. Check with your physician if you have any of the following:

• are allergic to darbepoetin alfa or any ingredients of the medication
• are allergic to medications made from mammalian cells
• have developed a condition called pure red cell aplasia (PRCA), after using erythropoiesis-stimulating proteins (e.g., darbepoetin alfa, epoetin alfa)
• have uncontrolled high blood pressure
• inadequate folic acid
• inadequate vitamin B12
• porphyria
• anemia from inadequate iron
• high blood pressure
• significant uncontrolled high blood pressure
• a heart attack
• a clot in the lung
• sudden and serious symptoms of heart failure called acute decompensated heart failure
• a stroke
• obstruction of a blood vessel by a blood clot
• a blood clot
• blood clot in a deep vein of the extremities
• seizures
• visible water retention
• a blood clot in a vascular access device
• pure red cell aplasia

Dosage

Strengths: 25 mcg/mL; 40 mcg/mL; 60 mcg/mL; 100 mcg/mL; 200 mcg/mL; 300 mcg/mL; 40 mcg/0.4 mL; 60 mcg/0.3 mL; 100 mcg/0.5 mL; 150 mcg/0.3 mL; 200 mcg/0.4 mL; 500 mcg/mL; 300 mcg/0.6 mL; 150 mcg/0.75 mL; 25 mcg/0.42 mL; 10 mcg/0.4 mL

Anemia Associated with Chronic Renal Failure

Chronic Kidney Disease (CKD) Patients Not on Dialysis

• Initial dose: 0.45 mcg/kg IV or subcutaneously once every 4 weeks as appropriate
• Initiate treatment only when hemoglobin is less than 10 g/dL, the rate of hemoglobin decline indicates the likelihood of requiring RBC transfusion, and reducing the risk of alloimmunization and/or other RBC transfusion-related risks is a goal.

CKD Patients on Dialysis

• Initial dose: 0.45 mcg/kg IV or subcutaneously once a week or 0.75 mcg/kg once every 2 weeks as appropriate
• Initiate treatment when hemoglobin is less than 10 g/dL.
• IV route is recommended for patients on hemodialysis.

Anemia Associated with Chemotherapy

• Initial dose: 2.25 mcg/kg subcutaneously once a week or 500 mcg subcutaneously once every 3 weeks
• Duration of therapy: Until completion of the chemotherapy course
• Initiate treatment if hemoglobin is less than 10 g/dL and a minimum of 2 additional months of chemotherapy is planned.
• Use the lowest dose necessary to avoid RBC transfusions.

Usual Pediatric Dose

Anemia Associated with Chronic Renal Failure

Less than 18 Years:
Initial dose:

• Chronic Kidney Disease (CKD) Patients Not on Dialysis: 0.45 mcg/kg IV or subcutaneously once a week or 0.75 mcg/kg once every 2 weeks
• CKD Patients on Dialysis: 0.45 mcg/kg IV or subcutaneously once a week
• Initiate treatment when hemoglobin is less than 10 g/dL.

Dose Adjustments

All chronic kidney disease (CKD) patients

• May increase dose no more than every 4 weeks; may decrease dose more frequently. Avoid frequent dose adjustments.
• If hemoglobin increases by more than 1 g/dL in 2 weeks, reduce the dose by 25% or more as needed to reduce rapid responses.
• If hemoglobin has not increased by more than 1 g/dL after 4 weeks of therapy, increase the dose by 25%.
• For patients who do not respond adequately over a 12-week escalation period, further dose increases are unlikely to improve response and may increase risks. Use the lowest dose that will maintain a hemoglobin level sufficient to reduce the need for RBC transfusions. Evaluate other causes of anemia. Discontinue if responsiveness does not improve.

CKD patients on dialysis

• If hemoglobin approaches or exceeds 11 g/dL, reduce or interrupt the dose of this drug.

CKD patients not on dialysis

• If hemoglobin exceeds 10 g/dL, reduce or interrupt the dose and use the lowest dose sufficient to reduce need for RBC transfusions.

Pediatric CKD patients

• If hemoglobin approaches or exceeds 12 g/dL, reduce or interrupt the dose of this drug.

Conversion from epoetin alfa to this drug in CKD patients on dialysis

• Maintain the route of administration when converting.
• Administer this drug once weekly in patients who were receiving epoetin alfa 2 to 3 times weekly; administer once every 2 weeks in patients who were receiving epoetin alfa once weekly.
• Previous weekly epoetin alfa dose (units/week): Darbepoetin alfa dose (mcg/week)
• Less than 1500: Adults: 6.25; Pediatric: Unknown
• 1500 to 2499: Adults: 6.25; Pediatric: 6.25
• 2500 to 4999: Adults: 12.5; Pediatric: 10
• 5000 to 10999: Adults: 25; Pediatric: 20
• 11000 to 17999: Adults: 40; Pediatric: 40
• 18000 to 33999: Adults: 60; Pediatric: 60
• 34000 to 89999: Adults: 100; Pediatric: 100
• 90000 or greater: Adults: 200; Pediatric: 200

Conversion from epoetin alfa to this drug in CKD patients not on dialysis

• Refer to doses for CKD patients on dialysis. Dose conversion does not accurately estimate the once-monthly dose of this drug.

All chemotherapy patients

• If hemoglobin increases greater than 1 g/dL in 2 weeks or reaches a level needed to avoid RBC transfusion, reduce the dose by 40%.
• If hemoglobin exceeds a level needed to avoid RBC transfusion, withhold the dose until hemoglobin approaches a level where RBC transfusions may be required and reinitiate at a dose 40% below the previous dose.
• If hemoglobin increases by less than 1 g/dL and remains below 10 g/dL after 6 weeks of therapy, increase the dose to 4.5 mcg/kg/week, if on the weekly dosing schedule. If on the every 3 week dosing schedule, no dose adjustment is recommended.
• If there is no response as measured by hemoglobin levels or if RBC transfusions are still required after 8 weeks of therapy, or if the chemotherapy course is complete, discontinue this drug.

Side Effects

The Most Common

• cough
• stomach pain
• redness, swelling, bruising, itching, or a lump at the spot where you injected darbepoetin alfa
• heart attack symptoms–chest pain or pressure, shortness of breath, pain spreading to your jaw or shoulder, nausea, sweating;
• signs of a stroke–sudden numbness or weakness (especially on one side of the body), confusion, sudden severe headache, slurred speech, problems with vision or balance;
• signs of a blood clot–pain, swelling, warmth, redness, cold feeling, or pale appearance of an arm or leg; or
• increased blood pressure–severe headache, blurred vision, pounding in your neck or ears, anxiety, nosebleed.
• rash
• itching
• difficulty breathing or swallowing
• wheezing
• hoarseness
• swelling of the face, throat, tongue, lips, eyes, hands, feet, ankles, or lower legs
• fast pulse
• excessive tiredness
• lack of energy
• dizziness
• fainting
• pale skin

More Common

• a general feeling of tiredness or weakness
• pain, stinging, redness, or swelling around the injection site
• clotting of the vascular access site (for people on hemodialysis)
• dehydration
• diarrhea
• edema (swelling of the face, fingers, ankles, feet, or lower legs)
• headache
• increased or decreased blood pressure, dizziness, or feeling faint
• muscle aches and pain
• nausea
• signs of infection (symptoms may include fever or chills, severe diarrhea, shortness of breath, prolonged dizziness, headache, stiff neck, weight loss, or listlessness)

Rare

• chest pain
• signs of an allergic reaction (symptoms may include skin rash or hives, trouble breathing, sweating, abnormal heart rate, or decreased blood pressure)
• signs of blood clots (pain or swelling in the legs, worsening shortness of breath)
• signs of severe skin reactions (blistering, peeling, a rash covering a large area of the body, a rash that spreads quickly, or a rash combined with fever or discomfort)
• signs of stroke (confusion, severe headache, sudden weakness, dizziness, trouble speaking, or vision problems)
• a light-headed feeling, like you, might pass out;
• unusual weakness or tiredness;
• a seizure (convulsions); or
• shortness of breath (even with mild exertion), swelling, and rapid weight gain.

Drug Interactions

There may be an interaction between darbepoetin alfa and any of the following:

DRUG	INTERACTION
Abemaciclib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Abemaciclib.
Abiraterone	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Abiraterone.
Afatinib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Afatinib.
Aldesleukin	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Aldesleukin.
Alectinib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Alectinib.
Alemtuzumab	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Alemtuzumab.
Alitretinoin	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Alitretinoin.
Alpelisib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Alpelisib.
Altretamine	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Altretamine.
Aminoglutethimide	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Aminoglutethimide.
Aminolevulinic acid	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Aminolevulinic acid.
Amsacrine	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Amsacrine.
Anagrelide	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Anagrelide.
Anastrozole	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Anastrozole.
Apalutamide	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Apalutamide.
Arsenic trioxide	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Arsenic trioxide.
Artesunate	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Artesunate.
Asciminib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Asciminib.
Asparaginase Erwinia chrysanthemi	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Asparaginase Erwinia chrysanthemi.
Asparaginase Escherichia coli	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Asparaginase Escherichia coli.
Atezolizumab	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Atezolizumab.
Avelumab	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Avelumab.
Axicabtagene ciloleucel	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Axicabtagene ciloleucel.
Axitinib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Axitinib.
Azacitidine	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Azacitidine.
Belinostat	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Belinostat.
Belzutifan	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Belzutifan.
Bendamustine	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Bendamustine.
Bevacizumab	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Bevacizumab.
Bexarotene	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Bexarotene.
Bicalutamide	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Bicalutamide.
Binimetinib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Binimetinib.
Bleomycin	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Bleomycin.
Blinatumomab	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Blinatumomab.
Bortezomib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Bortezomib.
Bortezomib D-mannitol	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Bortezomib D-mannitol.
Bosutinib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Bosutinib.
Brentuximab vedotin	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Brentuximab vedotin.
Brexucabtagene autoleucel	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Brexucabtagene autoleucel.
Brigatinib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Brigatinib.
Buserelin	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Buserelin.
Busulfan	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Busulfan.
Cabazitaxel	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Cabazitaxel.
Cabergoline	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Cabergoline.
Cabozantinib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Cabozantinib.
Capecitabine	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Capecitabine.
Capmatinib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Capmatinib.
Carboplatin	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Carboplatin.
Carfilzomib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Carfilzomib.
Carmustine	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Carmustine.
Catumaxomab	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Catumaxomab.
Cemiplimab	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Cemiplimab.
Ceritinib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Ceritinib.
Cetuximab	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Cetuximab.
Chlorambucil	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Chlorambucil.
Cisplatin	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Cisplatin.
Cladribine	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Cladribine.
Clofarabine	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Clofarabine.
Cobimetinib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Cobimetinib.
Copanlisib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Copanlisib.
Crizotinib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Crizotinib.
Curcumin	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Curcumin.
Cyclophosphamide	The risk or severity of pulmonary toxicity can be increased when Darbepoetin alfa is combined with Cyclophosphamide.
Cyproterone acetate	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Cyproterone acetate.
Cytarabine	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Cytarabine.
Dabrafenib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Dabrafenib.
Dacarbazine	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Dacarbazine.
Dacomitinib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Dacomitinib.
Dactinomycin	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Dactinomycin.
Daratumumab	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Daratumumab.
Darolutamide	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Darolutamide.
Dasatinib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Dasatinib.
Daunorubicin	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Daunorubicin.
Decitabine	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Decitabine.
Degarelix	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Degarelix.
Denileukin diftitox	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Denileukin diftitox.
Dexamethasone	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Dexamethasone.
Dienogest	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Dienogest.
Dinutuximab	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Dinutuximab.
Docetaxel	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Docetaxel.
Dostarlimab	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Dostarlimab.
Doxorubicin	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Doxorubicin.
Durvalumab	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Durvalumab.
Duvelisib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Duvelisib.
Elotuzumab	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Elotuzumab.
Enasidenib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Enasidenib.
Encorafenib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Encorafenib.
Enfortumab vedotin	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Enfortumab vedotin.
Entrectinib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Entrectinib.
Enzalutamide	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Enzalutamide.
Epirubicin	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Epirubicin.
Erdafitinib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Erdafitinib.
Eribulin	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Eribulin.
Erlotinib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Erlotinib.
Estramustine	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Estramustine.
Etoposide	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Etoposide.
Everolimus	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Everolimus.
Exemestane	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Exemestane.
Fedratinib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Fedratinib.
Floxuridine	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Floxuridine.

Fludarabine	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Fludarabine.
Fluorouracil	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Fluorouracil.
Flutamide	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Flutamide.
Formestane	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Formestane.
Fulvestrant	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Fulvestrant.
Futibatinib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Futibatinib.
Gallium nitrate	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Gallium nitrate.
Gefitinib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Gefitinib.
Gemcitabine	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Gemcitabine.
Gemtuzumab ozogamicin	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Gemtuzumab ozogamicin.
Gilteritinib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Gilteritinib.
Glasdegib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Glasdegib.
Goserelin	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Goserelin.
Hydroxyprogesterone caproate	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Hydroxyprogesterone caproate.
Hydroxyurea	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Hydroxyurea.
Ibrutinib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Ibrutinib.
Idarubicin	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Idarubicin.
Idecabtagene vicleucel	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Idecabtagene vicleucel.
Idelalisib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Idelalisib.
Ifosfamide	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Ifosfamide.
Imatinib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Imatinib.
Infigratinib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Infigratinib.
Inotuzumab ozogamicin	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Inotuzumab ozogamicin.
Interferon alfa-2a	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Interferon alfa-2a.
Interferon alfa-2b	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Interferon alfa-2b.
Ipilimumab	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Ipilimumab.
Irinotecan	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Irinotecan.
Isatuximab	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Isatuximab.
Ivosidenib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Ivosidenib.
Ixabepilone	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Ixabepilone.
Ixazomib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Ixazomib.
Lanreotide	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Lanreotide.
Lapatinib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Lapatinib.
Larotrectinib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Larotrectinib.
Lenalidomide	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Lenalidomide.
Lenvatinib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Lenvatinib.
Letrozole	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Letrozole.
Leuprolide	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Leuprolide.
Lisocabtagene maraleucel	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Lisocabtagene maraleucel.
Lomustine	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Lomustine.
Loncastuximab tesirine	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Loncastuximab tesirine.
Lorlatinib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Lorlatinib.
Lurbinectedin	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Lurbinectedin.
Margetuximab	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Margetuximab.
Masoprocol	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Masoprocol.
Mechlorethamine	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Mechlorethamine.
Medroxyprogesterone acetate	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Medroxyprogesterone acetate.
Megestrol acetate	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Megestrol acetate.
Melphalan	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Melphalan.
Mercaptopurine	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Mercaptopurine.
Methotrexate	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Methotrexate.
Methylprednisolone	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Methylprednisolone.
Methylprednisolone hemisuccinate	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Methylprednisolone hemisuccinate.
Methyltestosterone	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Methyltestosterone.
Midostaurin	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Midostaurin.
Miltefosine	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Miltefosine.
Mitomycin	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Mitomycin.
Mitotane	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Mitotane.
Mitoxantrone	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Mitoxantrone.
Mogamulizumab	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Mogamulizumab.
Mosunetuzumab	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Mosunetuzumab.
Moxetumomab pasudotox	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Moxetumomab pasudotox.
Nandrolone decanoate	The therapeutic efficacy of Darbepoetin alfa can be increased when used in combination with Nandrolone decanoate.
Nandrolone phenpropionate	The therapeutic efficacy of Darbepoetin alfa can be increased when used in combination with Nandrolone phenpropionate.
Necitumumab	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Necitumumab.
Nedaplatin	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Nedaplatin.
Nelarabine	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Nelarabine.
Neratinib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Neratinib.
Nilotinib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Nilotinib.
Nilutamide	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Nilutamide.
Nintedanib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Nintedanib.
Niraparib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Niraparib.
Nivolumab	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Nivolumab.
Obinutuzumab	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Obinutuzumab.
Octreotide	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Octreotide.
Ofatumumab	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Ofatumumab.
Olaparib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Olaparib.
Olaratumab	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Olaratumab.
Omacetaxine mepesuccinate	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Omacetaxine mepesuccinate.
Osimertinib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Osimertinib.
Oxaliplatin	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Oxaliplatin.
Paclitaxel	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Paclitaxel.
Palbociclib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Palbociclib.
Pamidronic acid	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Pamidronic acid.
Panitumumab	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Panitumumab.
Panobinostat	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Panobinostat.
Pazopanib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Pazopanib.
Pegaspargase	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Pegaspargase.
Peginterferon alfa-2a	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Peginterferon alfa-2a.
Pembrolizumab	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Pembrolizumab.
Pemetrexed	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Pemetrexed.
Pemigatinib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Pemigatinib.
Pentostatin	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Pentostatin.
Pertuzumab	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Pertuzumab.
Pexidartinib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Pexidartinib.
Pipobroman	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Pipobroman.
Pirfenidone	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Pirfenidone.
Pixantrone	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Pixantrone.
Plicamycin	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Plicamycin.
Polatuzumab vedotin	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Polatuzumab vedotin.

Pomalidomide	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Pomalidomide.
Ponatinib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Ponatinib.
Porfimer sodium	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Porfimer sodium.
Pralatrexate	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Pralatrexate.
Pralsetinib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Pralsetinib.
Prednisolone	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Prednisolone.
Prednisone	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Prednisone.
Prednisone acetate	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Prednisone acetate.
Procarbazine	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Procarbazine.
Radium Ra 223 dichloride	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Radium Ra 223 dichloride.
Raltitrexed	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Raltitrexed.
Ramucirumab	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Ramucirumab.
Regorafenib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Regorafenib.
Ribociclib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Ribociclib.
Ripretinib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Ripretinib.
Rituximab	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Rituximab.
Romidepsin	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Romidepsin.
Roxadustat	The risk or severity of adverse effects can be decreased when Roxadustat is combined with Darbepoetin alfa.
Rucaparib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Rucaparib.
Ruxolitinib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Ruxolitinib.
Sacituzumab govitecan	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Sacituzumab govitecan.
Selinexor	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Selinexor.
Selpercatinib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Selpercatinib.
Selumetinib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Selumetinib.
Siltuximab	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Siltuximab.
Sonidegib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Sonidegib.
Sorafenib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Sorafenib.
Sotorasib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Sotorasib.
Streptozocin	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Streptozocin.
Sunitinib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Sunitinib.
Tafasitamab	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Tafasitamab.
Tagraxofusp	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Tagraxofusp.
Talazoparib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Talazoparib.
Talimogene laherparepvec	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Talimogene laherparepvec.
Tamoxifen	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Tamoxifen.
Taurolidine	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Taurolidine.
Tebentafusp	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Tebentafusp.
Tegafur	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Tegafur.
Temoporfin	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Temoporfin.
Temozolomide	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Temozolomide.
Temsirolimus	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Temsirolimus.
Teniposide	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Teniposide.
Tepotinib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Tepotinib.
Testolactone	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Testolactone.
Thalidomide	The risk or severity of thromboembolism can be increased when Thalidomide is combined with Darbepoetin alfa.
Thiotepa	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Thiotepa.
Tioguanine	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Tioguanine.
Tisagenlecleucel	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Tisagenlecleucel.
Tisotumab vedotin	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Tisotumab vedotin.
Tivozanib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Tivozanib.
Topotecan	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Topotecan.
Toremifene	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Toremifene.
Tositumomab	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Tositumomab.
Trabectedin	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Trabectedin.
Trametinib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Trametinib.
Trastuzumab	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Trastuzumab.
Trastuzumab deruxtecan	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Trastuzumab deruxtecan.
Trastuzumab emtansine	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Trastuzumab emtansine.
Treosulfan	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Treosulfan.
Tretinoin	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Tretinoin.
Trifluridine	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Trifluridine.
Trilostane	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Trilostane.
Trimetrexate	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Trimetrexate.
Triptorelin	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Triptorelin.
Tucatinib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Tucatinib.
Umbralisib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Umbralisib.
Uracil mustard	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Uracil mustard.
Urethane	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Urethane.
Valproic acid	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Valproic acid.
Valrubicin	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Valrubicin.
Vandetanib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Vandetanib.
Vemurafenib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Vemurafenib.
Venetoclax	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Venetoclax.
Vinblastine	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Vinblastine.
Vincristine	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Vincristine.
Vindesine	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Vindesine.
Vinflunine	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Vinflunine.
Vinorelbine	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Vinorelbine.
Vismodegib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Vismodegib.
Vorinostat	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Vorinostat.
Zanubrutinib	The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Zanubrutinib.

Pregnancy and Lactation

FDA Pregnancy Category C

Pregnancy

This medication should not be used during pregnancy unless the benefits outweigh the risks. If you become pregnant while taking this medication, contact your doctor immediately. Limited available data on pregnant women are insufficient to determine a drug-associated risk of major birth defects or miscarriage; in animal reproductive and developmental toxicity studies, the drug increased early post-implantation loss at doses approximating clinical recommended starting doses; consider benefits and risks for the mother and possible risks to a fetus when prescribing to a pregnant woman

Breast-feeding

It is not known if darbepoetin alfa passes into breast milk. If you are a breastfeeding mother and are taking this medication, it may affect your baby. Talk to your doctor about whether you should continue breastfeeding. The safety and effectiveness of using this medication have not been established for children.

Warning

• Allergies: This medication can cause severe allergic and skin reactions. Contact your doctor immediately if you experience signs of an allergic reaction, such as skin rash, itching, difficulty breathing, or swelling of the face and throat.
• Blood clots: This medication may increase the chance of blood clot formation, causing a reduction of blood flow to organs or the extremities, and which in some cases can cause death. Your doctor will monitor your hemoglobin level closely with blood tests during treatment with this medication. If you experience symptoms such as sharp pain and swelling in the leg, or difficulty breathing, contact your doctor immediately.
• Cancer: Darbepoetin alfa is used to treat anemia caused by the chemotherapy treatment of non-myeloid cancers. It is not used to treat anemia that is due to cancer itself. Under some conditions, this medication may cause tumors to progress or reoccur more quickly than for people who are not using darbepoetin alfa. It may also increase the chances of cardiovascular complications (e.g., heart attack, stroke, blood clots, and death). The lowest possible dose needed to avoid blood transfusion should be used for cancer patients.
• Cardiovascular disease: This medication often affects blood pressure and can contribute to symptoms of heart disease. If you have high blood pressure, heart disease such as heart failure, angina, or a previous heart attack, discuss with your doctor how this medication may affect your medical condition, how your medical condition may affect the dosing and effectiveness of this medication, and whether any special monitoring is needed. If you are taking blood pressure pills to control blood pressure, it is important to continue taking them regularly while you are on darbepoetin alfa. Your doctor will monitor your hemoglobin (the protein in red blood cells that carry oxygen) until an appropriate dose of darbepoetin alfa has been determined.
• Kidney disease: This medication may be used by people with chronic kidney disease who are receiving dialysis and who are not receiving dialysis – the dose may be different for each. Your doctor will monitor you closely for your response to the medication.
• Pure red cell aplasia: Cases of pure red cell aplasia (PRCA) have been reported among people treated with darbepoetin alfa. PRCA is a condition in which a person’s bone marrow stops producing red blood cells, leading to severe anemia. People who develop PRCA may experience a new or worsening feeling of tiredness or shortness of breath. If you are experiencing such symptoms, call your doctor as soon as possible. Do not stop your medication without contacting your doctor first.
• Seizure: This medication may contribute to an increase in seizures although the relationship between darbepoetin and seizures is not clear. If you experience seizures or have a history of seizure disorder, discuss with your doctor how this medication may affect your medical condition, how your medical condition may affect the dosing and effectiveness of this medication, and whether any special monitoring is needed.
• Stroke: Darbepoetin can increase the risk of blood clots forming in the blood vessels. If you have a past history of stroke, discuss with your doctor how this medication may affect your medical condition, how your medical condition may affect the dosing and effectiveness of this medication, and whether any special monitoring is needed.
• Increased mortality, myocardial infarction, stroke, and thromboembolism: Using ESAs to target a hemoglobin level of greater than 11 g/dL increases the risk of serious adverse cardiovascular reactions and has not been shown to provide additional benefit (see Black Box Warnings)
• Hypertensive encephalopathy and seizures reported in patients with CKD; appropriately control hypertension before initiation of and during treatment; reduce or withhold Aranesp if blood pressure becomes difficult to control; advise patients of the importance of compliance with antihypertensive therapy and dietary restrictions
• For lack or loss of hemoglobin response to therapy, initiate a search for causative factors (eg, iron deficiency, infection, inflammation, bleeding); if typical causes of lack or loss of hemoglobin response are excluded, evaluate for PRCA; in absence of PRCA, follow dosing recommendations for the management of patients with insufficient hemoglobin response to therapy
• Use caution in known porphyria, sickle cell anemia, thalassemia
• Serious allergic reactions, including anaphylactic reactions, angioedema, bronchospasm, skin rash, and urticaria may occur; immediately and permanently discontinue therapy and administer appropriate therapy if a serious allergic or anaphylactic reaction occurs
• Decrease dose if Hgb increase exceeds 1 g/dL in any 2 wk period
• Increased mortality and/or increased risk of tumor progression or recurrence in patients with cancer
• Increases the risk for seizures in patients with CKD; increases monitoring of these patients for changes in seizure frequency or premonitory symptoms
• If severe anemia and low reticulocyte count develop during treatment, withhold therapy and evaluate for pure red cell aplasia
• Blistering and skin exfoliation reactions including erythema multiforme and Stevens-Johnson Syndrome (SJS)/Toxic Epidermal Necrolysis (TEN), reported in the post-marketing setting; discontinue therapy immediately if a severe cutaneous reaction, such as SJS/TEN, suspected
• Two different excipients are available: polysorbate 80 or human albumin
• May use supplemental iron if serum ferritin  is less than 100 mcg/L [0.225 pmol/L] or serum transferrin saturation is less than 20%
• IV route preferred for patients on hemodialysis
• Patients may require adjustments in their dialysis prescriptions after initiation of therapy; patients receiving treatment may require increased anticoagulation with heparin to prevent clotting of the extracorporeal circuit during hemodialysis
• Autoinjector for SC administration only
• The dose increase no more frequently than once monthly
• Cases of PRCA and severe anemia, with or without other cytopenias that arise following the development of neutralizing antibodies to erythropoietin reported predominantly in patients with CKD receiving ESAs by subcutaneous administration; also reported in patients receiving therapy for anemia related to hepatitis C treatment (indication not approved)
• If severe anemia and low reticulocyte count develop during treatment, withhold therapy and evaluate patients for neutralizing antibodies to erythropoietin; contact Amgen (1-800-77-AMGEN) to perform assays for binding and neutralizing antibodies
• Permanently dhttps://www.webmd.com/drugs/2/drug-144492/darbepoetin-alfa-in-polysorbate-injection/details/list-contraindicationsiscontinue therapy in patients who develop PRCA following treatment; do not switch patients to other ESA.

References

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