Use of epoetin and darbepoetin in patients with cancer: 2007 American Society of Hematology/American Society of Clinical Oncology clinical practice guideline update

Purpose: To update the American Society of Clinical Oncology/American Society of Hematology (ASCO/ASH) recommendations for the use of epoetin. The guideline was expanded to address use of darbepoetin and thromboembolic risk associated with these agents. Method: An Update Committee ("Committee") reviewed and analyzed data published since 2002 through July 2007. MEDLINE and the Cochrane Collaboration Library databases were searched. Recommendations: For patients with chemotherapy-associated anemia, the Committee continues to recommend initiating an erythropoiesis-stimulating agent (ESA) as hemoglobin (Hb) approaches, or falls below, 10 g/dL, to increase Hb and decrease transfusions. ESA treatment continues to be recommended for patients with low-risk myelodysplasia for similar reasons. There is no evidence showing increased survival as a result of ESA treatment. Conclusive evidence is lacking that, absent clinical circumstances necessitating earlier treatment, initiating ESAs at Hb levels greater than 10 g/dL either spares more patients from transfusion or substantially improves their quality of life. Starting doses and dose modifications based on response or lack thereof should follow the package insert. Continuing ESAs beyond 6 to 8 weeks in the absence of response, assuming appropriate dose increase has been attempted in nonresponders as per US Food and Drug Administration–approved label, does not seem to be beneficial, and ESA therapy should be discontinued. The Committee recommends monitoring iron stores and supplementing iron intake for ESA-treated patients. ESAs should be used cautiously with chemotherapy, or in clinical states, associated with elevated risk for thromoembolic complications. The Committee also cautions against ESA use for patients with cancer who are not receiving chemotherapy, since recent trials report increased thromboembolic risks and decreased survival under these circumstances.      

Use of epoetin in patients with cancer: evidence-based clinical practice guidelines of the American Society of Clinical Oncology and the American Society of Hematology

Anemia resulting from cancer or its treatment is an important clinical problem increasingly treated with the recombinant hematopoietic growth factor erythropoietin. To address uncertainties regarding indications and efficacy, the American Society of Clinical Oncology and the American Society of Hematology developed an evidence-based clinical practice guideline for the use of epoetin in patients with cancer. The guideline panel found good evidence to recommend use of epoetin as a treatment option for patients with chemotherapy-associated anemia with a hemoglobin (Hgb) concentration below 10 g/dL. Use of epoetin for patients with less severe anemia (Hgb level below 12 g/dL but never below 10 g/dL) should be determined by clinical circumstances. Good evidence from clinical trials supports the use of subcutaneous epoetin thrice weekly (150 U/kg) for a minimum of 4 weeks. Less strong evidence supports an alternative weekly (40 000 U/wk) dosing regimen, based on common clinical practice. With either administration schedule, dose escalation should be considered for those not responding to the initial dose. In the absence of response, continuing epoetin beyond 6-8 weeks does not appear to be beneficial. Epoetin should be titrated once the hemoglobin concentration reaches 12 g/dL. Evidence from one randomized controlled trial supports use of epoetin for patients with anemia associated with low-risk myelodysplasia not receiving chemotherapy; however, there are no published high-quality studies to support its use for anemia in other hematologic malignancies in the absence of chemotherapy. Therefore, for anemic patients with hematologic malignancies it is recommended that physicians initiate conventional therapy and observe hematologic response before considering use of epoetin.     

American Society of Hematology/American Society of Clinical Oncology clinical practice guideline update on the use of epoetin and darbepoetin in adult patients with cancer

Purpose: To update American Society of Hematology/American Society of Clinical Oncology recommendations for use of erythropoiesis-stimulating agents (ESAs) in patients with cancer. Methods: An Update Committee reviewed data published between January 2007 and January 2010. MEDLINE and the Cochrane Library were searched. Results: The literature search yielded one new individual patient data analysis and four literature-based meta-analyses, two systematic reviews, and 13 publications reporting new results from randomized controlled trials not included in prior or new reviews. Recommendations: For patients undergoing myelosuppressive chemotherapy who have a hemoglobin (Hb) level less than 10 g/dL, the Update Committee recommends that clinicians discuss potential harms (eg, thromboembolism, shorter survival) and benefits (eg, decreased transfusions) of ESAs and compare these with potential harms (eg, serious infections, immune-mediated adverse reactions) and benefits (eg, rapid Hb improvement) of RBC transfusions. Individual preferences for assumed risk should contribute to shared decisions on managing chemotherapy-induced anemia. The Committee cautions against ESA use under other circumstances. If used, ESAs should be administered at the lowest dose possible and should increase Hb to the lowest concentration possible to avoid transfusions. Available evidence does not identify Hb levels ≥ 10 g/dL either as thresholds for initiating treatment or as targets for ESA therapy. Starting doses and dose modifications after response or nonresponse should follow US Food and Drug Administration-approved labeling. ESAs should be discontinued after 6 to 8 weeks in nonresponders. ESAs should be avoided in patients with cancer not receiving concurrent chemotherapy, except for those with lower risk myelodysplastic syndromes. Caution should be exercised when using ESAs with chemotherapeutic agents in diseases associated with increased risk of thromboembolic complications. Table 1 lists detailed recommendations.     

Immunotherapy highlights from the 2011 meeting of the American Society of Hematology

The world's largest hematology society, the American Society for Hematology, meets annually, gathering physicians, scientists, administrators, medical students, graduate students, allied health professionals and exhibitors. The meeting this year was held in San Diego, CA, USA, and included a plethora of basic, translational and clinical research.     

Investment analysts and the American Society of Hematology

Investment analysts are a growing presence at the Annual Meeting of the American Society of Hematology (ASH), and financial professionals frequently contact ASH members for information and perspective on drugs, devices, and scientific developments. Recent incidents have raised concerns about consulting relationships between physicians and the investment industry; the appropriate role of medical societies in influencing these relationships is unclear. In this essay, I summarize the current situation, discuss potential risks and benefits from interactions between physicians and investment analysts, and outline issues that all individuals involved in investment industry consulting should consider. I also propose changes in ASH policy that may help safeguard public trust as well as preserve the access of clinicians and scientists to clinically relevant data presented at the Annual Meeting.     

Moxibustion for primary dysmenorrhea: A protocol for evidence-based clinical practice guideline

Background:Primary dysmenorrhea (PD) is a common gynecological disease characterized by lower abdominal pain. Moxibustion as a traditional Chinese treatment, can effectively treat PD with few adverse reactions. Nowadays, there is still no standard guideline for moxibustion treatment of PD, so related clinical practice guidelines need to be developed.Methods:This guideline will be developed in line with the latest guideline definition from Institute of Medicine, and that applies the GRADE system as well as the World Health Organization handbook to appraise the quality of evidence and develop recommendations. We will set up a Guideline working group, put forward the corresponding problems based on the principle of Population, Intervention, Comparison, Outcomes (PICO), and complete the literature retrieval. After achieving consensus through evidence syntheses and 2 to 3 rounds of Delphi process, we will also consider patients values and preferences and implement peer review in the guideline.Result:We will put forward evidence-based best practice recommendations and moxibustion standard to improve the symptoms caused by primary dysmenorrhea in a more efficient way. At present, the research is still in progress, and there is no result to report.Conclusions:This guideline will be helpful to clinical acupuncturists and other professionals to further improve clinical efficacy in treating PD with moxibustion. Moreover, we will also constantly update and evaluate the evidence to both support recommendations and identify gap areas for future research.Systematic Review registrations:registration number: IPGRP-2020CN021     

The American Society of Hematology: a success at age 50

The American Society of Hematology (ASH) turns 50 years old in 2008, and we have much to celebrate. Over those years the Society established its principles: to promote both the art and science of hematology and to hold a high-quality Educational Meeting. ASH membership has grown from a few hundred curious attendees at a planning meeting in 1957 to more than 15,000 members today, and the annual meeting has grown from a scientific session of 5 papers at the planning meeting to more than 500 oral presentations and nearly 2,500 poster presentations at the 2007 meeting. The modern ASH promotes cutting-edge science, sponsors research by scholars from all over the globe, helps train the next generation of clinician-scientists, lobbies Congress and several other governmental agencies on behalf of its clinician and scientist members, and publishes the foremost scholarly journal in the field of hematology, Blood, designed to provide its readership with timely reviews, expert opinion on clinical hematology, practice-changing clinical trials, and insightful basic science. The next 50 years of ASH are likely to see many profound changes, but one thing is almost certain-our dedication to fostering clinical and scientific excellence in hematology will continue as the Society's raison d'etre.     

Management of alcohol withdrawal delirium. An evidence-based practice guideline

BACKGROUND: Alcohol withdrawal delirium is the most serious manifestation of alcohol withdrawal. Evidence suggests that appropriate care improves mortality, but systematic reviews are unavailable. METHODS: Articles with original data on management of alcohol withdrawal delirium underwent structured review and meta-analysis. RESULTS: Meta-analysis of 9 prospective controlled trials demonstrated that sedative-hypnotic agents are more effective than neuroleptic agents in reducing duration of delirium and mortality, with a relative risk of death when using neuroleptic agents of 6.6. Statistically significant differences among various benzodiazepines and barbiturates were not found. No deaths were reported in 217 patients from trials using benzodiazepines or barbiturates. CONCLUSIONS: Control of agitation should be achieved using parenteral rapid-acting sedative-hypnotic agents that are cross-tolerant with alcohol. Adequate doses should be used to maintain light somnolence for the duration of delirium. Coupled with comprehensive supportive medical care, this approach is highly effective in preventing morbidity and mortality.     

Summary of the Updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons

The following article is a summary of the American Geriatrics Society/British Geriatrics Society Clinical Practice Guideline for Prevention of Falls in Older Persons (2010). This article provides additional discussion of the guideline process and the differences between the current guideline and the 2001 version and includes the guidelines' recommendations, algorithm, and acknowledgments. The complete guideline is published on the American Geriatrics Society's Web site (http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recommendations/2010/).     

Use of eltrombopag for secondary immune thrombocytopenia in clinical practice

Eltrombopag is a second‐line treatment in primary immune thrombocytopenia (ITP). However, its role in secondary ITP is unknown. We evaluated the efficacy and safety of eltrombopag in secondary ITP in daily clinical practice. Eighty‐seven secondary ITP patients (46 with ITP secondary to autoimmune syndromes, 23 with ITP secondary to a neoplastic disease subtype: lymphoproliferative disorders [LPDs] and 18 with ITP secondary to viral infections) who had been treated with eltrombopag were retrospectively evaluated. Forty‐four patients (38%) had a platelet response, including 40 (35%) with complete responses. Median time to platelet response was 15 days (95% confidence interval, 7–28 days), and was longer in the LPD‐ITP group. Platelet response rate was significantly lower in the LPD‐ITP than in other groups. However, having achieved response, there were no significant differences between the durable response of the groups. Forty‐three patients (49·4%) experienced adverse events (mainly grade 1–2), the commonest being hepatobiliary laboratory abnormalities. There were 10 deaths in this case series, all of which were related to pre‐existing medical conditions. In routine clinical practice, eltrombopag is effective and well‐tolerated in unselected patients with ITP secondary to both immune and infectious disorders. However, the response rate in LPD‐ITP is low.     

Clinical practice guideline for emergency department ketamine dissociative sedation: 2011 update

We update an evidence-based clinical practice guideline for the administration of the dissociative agent ketamine for emergency department procedural sedation and analgesia. Substantial new research warrants revision of the widely disseminated 2004 guideline, particularly with respect to contraindications, age recommendations, potential neurotoxicity, and the role of coadministered anticholinergics and benzodiazepines. We critically discuss indications, contraindications, personnel requirements, monitoring, dosing, coadministered medications, recovery issues, and future research questions for ketamine dissociative sedation.