ESAs (Erythropoesis Stimulating Agents)

What is Erythropoietin?

Erythropoietin is a natural hormone made in the kidney. It is the main ingredient that controls the number of red blood cells made in the bone marrow. Red blood cells (hemoglobin) carry oxygen to the body’s cells, giving the body’s organs energy to work properly.

Erythropoesis stimulating agents (ESAs) are man-made medications that work just like your body’s own erythropoietin. 

Which patients are given ESAs?

Since the late 1980’s, ESAs are used throughout the world for patients with kidney disease who often have low hemoglobin or anemia. ESAs are also used for patients with low hemoglobin due to cancer treatments or AIDS.

The ESA, Epotein Alfa (also called Eprex or EPO) has been approved by Health Canada to be given to patients having an operation since the mid 1990’s. Eprex is given to increase hemoglobin before the operation.

If your hemoglobin is less than 130 g/L, Eprex treatment is considered. 


What are the benefits of Eprex?

Eprex, by increasing the hemoglobin level before an operation, makes it easier for the body to adjust to the blood that may be lost during the operation.

Going into an operation with a higher hemoglobin means your hemoglobin does not become as low after the operation. You are less likely to need a blood transfusion.

Like all medications, Eprex treatment does not have a 100% guarantee. Some patients might not respond to Eprex as well or may lose more blood than usual and may still need a blood transfusion.

What does the doctor need to know about me?

It is important for the patient blood management team to know your medical history, allergies and medications that you take.

If Eprex treatment is being considered for you, it is very important to tell us if you have high blood pressure, seizures, a stroke or a blood clot.

Eprex treatment is not appropriate for some patients. If your high blood pressure is not well controlled or if you have had a stroke or blood clot in the past 3 months, the patient blood management team will carefully consider the best option for you.

If you are treated with Eprex, your family doctor will be given information.

What are the side effects of Eprex?

Allergic reactions are very unlikely, but seek medical attention if you have: trouble breathing, chest tightness, swelling of your throat, face, mouth or tongue, hives, itching.

You might feel a burning discomfort in the area where the Eprex needle was given (this can last up to 6 hours). You might feel tired, have muscle or joint aches, feel as if you have the flu or have a headache for 12 - 24 hours after the Eprex needle.

If your symptoms continue, visit your family doctor, a walk-in clinic or the closest emergency department.

Sometimes blood pressure might increase while having Eprex treatment; your blood pressure will be checked before each dose of Eprex is given.

Tell us if you have shortness of breath, chest tightness, racing of the heart, lightheadedness or have increased or unusual headaches while having Eprex treatment.

A very, very rare but serious side effect, pure red cell aplasia (PRCA) has occurred in a very small number of kidney disease patients who had been taking Eprex for long periods of time (months, years). With PRCA, the bone marrow does not respond to Eprex and severe anemia develops. The treatment for PRCA might include regular blood transfusions, medications, or a bone marrow transplant. The exact cause of PRCA is not clearly known.

The patient blood management team should be notified of any side effects.

What else do I need to do?

You must take extra iron while having Eprex treatment. Eprex will not work by itself. The Eprex and iron work together to increase your hemoglobin.

The patient blood management nurse will give you information about iron.

How is Eprex given?

Eprex is a clear liquid given to patients by a needle under the skin. The most common dose is one needle per week for 2 to 4 weeks before your operation.

Who will give me the Eprex needles?

The patient blood management nurse at LHSC or your family doctor’s office can give you the Eprex needles, depending on what is easiest for you.

How do I get the Eprex?

The patient blood management nurse will arrange for your Eprex prescription. It can be arranged with your own pharmacy. Most pharmacies do not keep Eprex in stock but can order it within 1-2 days. Eprex is in stock at the Prescription Centre, the LHSC retail pharmacy (locations at University Hospital and Victoria Hospital).

How do I store Eprex?

Eprex must be kept refrigerated. Make sure it doesn’t freeze. If you need to take your Eprex with you, carry it in a cooler with an ice pack.

Eprex needs to be at room temperature for 10 to 15 minutes before the needle is given to you. If Eprex is at room temperature for longer than 60 minutes, it should not be used.

Eprex should not be shaken. Eprex should be protected from light by storing it in its box or a brown bag.

How much does Eprex cost?

Each Eprex needle costs about $ 500.00. At this time the health care system does not routinely provide Eprex for patients having an operation. Private insurance plans may cover some or all of the expense. (Eprex Drug Information Number (DIN): 02240722)

For some patients, a letter asking for coverage of the cost of Eprex can be sent to the Ontario Ministry of Health (some or all of the cost might be covered). If this applies to you, the patient blood management team will organize sending the letter and arrange for the Eprex treatment. Assistance to find out about possible coverage for the cost of Eprex is available.