Clinical and practical perspectives on the use of intravenous vs. subcutaneous Epoetin alfa in hemodialysis patients

Background. The route of Epoetin alfa (EPO) administration has become a controversial issue in recent years. Despite the National Kidney Foundation Dialysis Outcomes Quality Initiative (NKF-DOQI) guidelines recommending subcutaneous (SC) EPO for all dialysis patients, only 12% of hemodialysis patients in the U.S. receive EPO by the SC route. Methods. A telephone survey was undertaken to gather opinions and clinical practice information regarding the choice of EPO route of administration. Sixteen people from several different vantage points within the dialysis community were interviewed about a variety of factors related to route of EPO therapy including clinical outcomes, financial aspects, impact on staff workload, and patient preferences. Six interviewees were specifically chosen to represent programs in which SC EPO was deemed unsuccessful in order to gain more insight into the issues causing a negative experience with this route of administration. Results. As expected, the majority of programs represented by the interviewees use intravenous (IV) EPO - a choice that, in many cases, appears to be linked to the financial reimbursement structure present in the particular dialysis program. However, some programs have tried SC administration with unsuccessful outcomes, citing a significant increase in staff workload as the primary reason. Other programs have successfully implemented the use of SC EPO through a carefully planned, unit-wide approach that includes staff and patient education. Conclusions. Dialysis staff and patients generally prefer IV EPO with regard to workload issues, ease of use, and avoidance of the discomfort associated with SC injections. The choice of EPO route of administration is a complex issue involving consideration of all of these factors.