Algorithm-managed dosing and pharmacist-managed dosing of erythropoietin stimulating agents in renal anaemia: a systematic review

Clinical Snapshot

Key Findings

• P Value: Not reported

• Effect Size: Haemoglobin target range: 3.5% lower to 32.0% higher; ESA dose reduction: 5.45% to 49.97%

• Primary Outcome: Haemoglobin target range achievement and ESA dose reduction

• Nnt Or Sensitivity: Cannot be calculated due to heterogeneity and lack of meta-analysis

• Confidence Interval: Haemoglobin: 95% CI -18.67% to +49.93%; ESA dose: 95% CI -7.97% to +79.61%

Clinical Application

Pharmacist-managed dosing is feasible in Australian hospitals with clinical pharmacy services Relevant to Australian nephrology practice; ESAs are PBS-listed for renal anaemia; aligns with RACGP chronic kidney disease guidelines emphasising multidisciplinary care Adult patients with chronic kidney disease and renal anaemia requiring ESA therapy

Abstract

OBJECTIVES: The goal of this systematic review was to identify and summarise algorithm-managed and pharmacist-managed dosing of erythropoietin stimulating agents (ESA) in patients with renal anaemia and to determine the effects on available outcome parameters. METHODS: We followed the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines for systematic reviews. Studies investigating algorithm-managed and pharmacist-managed dosing of ESA in adult patients with renal anaemia were evaluated for inclusion. No restrictions were set on outcome parameters. Observational and interventional studies available as full-text articles with a control group and follow-up ≥6 months were eligible for inclusion. Relevant databases were searched from their inception through August 2024. Two independent reviewers evaluated all studies. The risk of bias was assessed by the ROBINS-I and RoB1 tools. The protocol of this study was registered in PROSPERO (CRD42021243678). RESULTS: After screening 140 articles, 17 articles and 4313 patients could be included. Available evidence was of low to moderate quality with a high risk of bias. Data were summarised and tabulated. Meta-analysis was not possible due to the substantial heterogeneity in participants, study design, interventions, comparisons, and outcome parameters. However, standardised metrics could be identified and calculated for haemoglobin and ESA dose. The percentage in target range for haemoglobin varied between 3.5% lower (95% CI -18.67% to +11.67%) to 32.0% higher (95% CI 14.07% to 49.93%) in the pharmacist-managed group versus the control group (n=1401). The range in reduction in ESA dose was 5.45% (95% CI -7.97% to +18.87%) to 49.97% (95% CI 20.32% to 79.61%) in the pharmacist-managed group versus the control group (n=2115). CONCLUSION: Low-quality data with high risk of bias suggest that pharmacist-managed renal anaemia may improve the percentage of haemoglobin within target range and reduce the ESA dose. However, meta-analysis was impossible due to substantial heterogeneity. Therefore, no definite conclusions could be drawn on the effectiveness of pharmacist-managed dosing of ESA in renal anaemia. PROSPERO REGISTRATION NUMBER: CRD42021243678.

References

1. 1.van den Oever, F. J., Dekker, M. J. E., Vasbinder, E. C., van Gelder, T., & Van den Bemt, P. M. L. A. (2024). Algorithm-managed dosing and pharmacist-managed dosing of erythropoietin stimulating agents in renal anaemia: a systematic review. European Journal of Hospital Pharmacy. https://doi.org/10.1136/ejhpharm-2024-004366