Eprex Dosage/Direction for Use

General considerations for administration: Eprex may be administered by intravenous or subcutaneous injection.
As for any parenterally administered drug, the injection solution should be inspected for particles and discoloration prior to administration. Do not shake; shaking may denature the glycoprotein, rendering it inactive.
Each Eprex syringe is for single use only: only one dose of Eprex should be administered from each syringe.
Eprex in single use syringes contains no preservatives. Do not re-use syringe. Discard unused portion.
Intravenous Injection: Eprex should be administered over at least one to five minutes, depending on the total dose.
A slower injection may be preferable in patients who react to the treatment with flu-like symptoms.
In hemodialysis patients, a bolus injection may be given during dialysis via a suitable venous port in the dialysis line. Alternatively, at the completion of a hemodialysis session, the injection can be given via the fistula needle tubing, followed by 10 mL of isotonic saline to rinse the tubing and to ensure satisfactory injection of the product into the circulation.
Eprex should not be administered by intravenous infusion or mixed with other drugs.
Subcutaneous Injection: The maximum volume per injection site should be 1 mL. In case of larger volumes, more than one injection site should be used.
The injections should be given in the limbs or the anterior abdominal wall.
In situations where the physician determines that a patient or caregiver can safely and effectively administer Eprex subcutaneously, instruction as to the proper dosage and administration should be provided.
Dosage: Chronic Renal Failure Patients: In patients with chronic renal failure where intravenous access is routinely available (hemodialysis patients), administration by the intravenous route is preferable. Where intravenous access is not readily available (patients not yet undergoing dialysis and peritoneal dialysis patients), Eprex may be administered subcutaneously.
The hemoglobin concentration aimed for should be between 10 to 12 g/dL (6.2-7.5 mmol/L) in adults and 9.5 to 11 g/dL (5.9-6.8 mmol/L) in children.
In patients with chronic renal failure, maintenance hemoglobin concentration should not exceed the upper limit of the hemoglobin concentration range (see Precautions, Renal Failure Patients).
When changing the route of administration, the same dose should be used initially and then titrated to keep hemoglobin in the hemoglobin concentration range.
In the correction phase, the dose of Eprex should be increased if the hemoglobin does not increase at least 1 g/dL (0.62 mmol/L) per month.
A clinically significant increase in hemoglobin is usually not observed in less than 2 weeks and may require up to 6 - 10 weeks in some patients.
When the hemoglobin concentration is within range, the dose should be decreased by 25 IU/kg/dose in order to avoid exceeding the hemoglobin concentration range. Dose should be reduced when hemoglobin approaches 12 g/dL.
Dose reductions may be made by omitting one of the weekly doses or by decreasing the amount of each dose.
Adult Hemodialysis Patients: In patients on hemodialysis, where intravenous access is readily available, administration by the intravenous route is preferable.
The treatment is divided into two stages: Correction Phase: 50 IU/kg three times per week.
When necessary, dose adjustments should be made in increments of 25 IU/kg three times per week at intervals of at least 4 weeks until the hemoglobin concentration range (10 - 12 g/dL [6.2-7.5 mmol/L]) is achieved.
Maintenance Phase: Adjust dosage in order to maintain hemoglobin values at the desired level: Hb between 10 and 12 g/dL (6.2 - 7.5 mmol/L).
The maintenance dose should be individualized for each chronic renal failure patient. The recommended total weekly dose is between 75 and 300 IU/kg.
Available data suggest that patients with a baseline hemoglobin (< 6 g/dL or < 3.7 mmol/L) may require higher maintenance doses than patients with a baseline hemoglobin (> 8 g/dL or > 5 mmol/L).
Pediatric Hemodialysis Patients: The treatment is divided into two stages: Correction Phase: 50 IU/kg three times per week by the intravenous route.
When necessary, dose adjustments should be made in increments of 25 IU/kg three times per week at intervals of at least 4 weeks until the hemoglobin concentration range (9.5 - 11 g/dL [5.9-6.8 mmol/L]) is achieved.
Maintenance Phase: Appropriate adjustment of the dose should be made in order to maintain the hemoglobin concentration within the desired range between 9.5 g/dL to 11 g/dL (5.9 to 6.8 mmol/L).
Generally, children under 30 kg require higher maintenance doses than children over 30 kg and adults. For example, the following maintenance doses were observed in clinical trials after 6 months of treatment. (See Table 6.)

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Available data suggest that patients whose initial hemoglobin is very low (hemoglobin < 6.8 g/dL [4.2 mmol/L]) may require higher maintenance doses than patients whose initial hemoglobin is higher (hemoglobin > 6.8 g/dL [4.2 mmol/L]).
Adult Peritoneal Dialysis Patients: In peritoneal dialysis patients, where intravenous access is not readily available, Eprex may be administered subcutaneously.
The treatment is divided into two stages: Correction Phase: 50 IU/kg twice per week.
When necessary, dose adjustments should be made in increments of 25 IU/kg twice per week at intervals of at least 4 weeks until the hemoglobin concentration range (10 - 12 g/dL [6.2-7.5 mmol/L]) is achieved.
Maintenance Phase: The usual dose to maintain the hemoglobin concentration range (10 - 12 g/dL [6.2-7.5 mmol/L]) is between 25 and 50 IU/kg twice per week in two equal injections.
Adult Predialysis Patients (Adult Patients With End Stage Renal Insufficiency): In patients with renal insufficiency not yet undergoing dialysis, where intravenous access is not readily available, Eprex may be administered subcutaneously. The treatment is divided into two stages: Correction Phase: 50 IU/kg three times per week.
When necessary, dose adjustments should be made in increments of 25 IU/kg three times per week at intervals of at least 4 weeks until the hemoglobin concentration range (10-12 g/dL [6.2-7.5 mmol/L]) is achieved.
Maintenance Phase: The usual dose to maintain the hemoglobin concentration range is between 17 and 33 IU/kg three times per week.
The maximum dosage should not exceed 200 IU/kg 3 times per week.
Cancer Patients: Adult Cancer Patients: The subcutaneous route of administration should be used.
The hemoglobin concentration range should be 10 to 12 g/dL (7.5 mmol/L) in men and women and it should not be exceeded.
Eprex therapy should continue until one month after the end of chemotherapy. However, the need to continue Eprex therapy should be re-evaluated periodically.
The initial dose for the treatment of anemia should be 150 IU/kg 3 times per week.
Alternatively, Eprex can be administered at an initial dose of 40,000 IU subcutaneously once weekly.
If after 4 weeks of treatment at the initial dose, the hemoglobin has increased by at least 1 g/dL (0.6 mmol/L) or the reticulocyte count has increased ≥ 40,000 cells/mcL above baseline the dose should remain unchanged.
If after 4 weeks of treatment at the initial dose, the hemoglobin has not increased by ≥ 1 g/dL (0.6 mmol/L) and the reticulocyte count has not increased by ≥ 40,000 cells/mcL above baseline, in the absence of red blood cell transfusion, the dose should be increased to 300 IU/kg 3 times per week or 60,000 IU weekly.
If after 4 weeks of additional therapy with 300 IU/kg 3 times per week or 60,000 IU weekly, the hemoglobin has increased ≥ 1 g/dL (≥ 0.6 mmol/L), or the reticulocyte count has increased ≥ 40,000 cells/mcL the dose should remain unchanged.
If after 4 weeks of additional therapy with 300 IU/kg three times per week or 60,000 IU per week, the hemoglobin has increased < 1 g/dL (0.6 mmol/L) and the reticulocyte count has increased < 40,000 cells/mcL above baseline, response is unlikely and treatment should be discontinued.
The recommended dosing regimen is described in the following diagram: (See Figure 1.)

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A rate of rise in hemoglobin of greater than 1 g/dL (0.6 mmol/L) per 2 week or 2 g/dL (1.25 mmol/L) per month or hemoglobin levels of > 12 g/dL (> 8.1 mmol/L) should be avoided. If the hemoglobin is rising by more than 1 g/dL (0.6 mmol/L) per two week or 2 g/dL (1.25 mmol/L) per month or hemoglobin is approaching 12 g/dL (7.5 mmol/L), reduce the Eprex dose by about 25 - 50% depending upon the rate of rise of hemoglobin. If the hemoglobin exceeds 12 g/dL (7.5 mmol/L), withhold therapy until it falls below 12 g/dL (7.5 mmol/L) and then reinitiate Eprex therapy at a dose 25% below the previous dose.
Zidovudine Treated, HIV-Infected Patients: Adult Zidovudine Treated HIV-Infected Patients: Prior to beginning Eprex, it is recommended that the endogenous serum erythropoietin level be determined prior to transfusion. Available data suggest that patients with endogenous serum erythropoietin levels > 500 mU/mL are unlikely to respond to therapy with Eprex.
The treatment is divided into two stages: Correction Phase: 100 IU/kg three times per week by subcutaneous or intravenous route for 8 weeks.
If the response is not satisfactory (i.e., reduced transfusion requirements or increased hemoglobin) after 8 weeks of therapy, the dose of Eprex can be increased. Dose increases should be made in increments of 50 to 100 IU/kg three times per week at intervals of at least 4 weeks. If patients have not responded satisfactorily to a Eprex dose of 300 IU/kg three times per week, it is unlikely that they will respond to higher doses.
Maintenance Phase: After the desired response is attained, the dose should be titrated to maintain the hematocrit between 30 - 35%, based on factors such as variations in zidovudine dose and the presence of intercurrent infections or inflammatory episodes. If the hematocrit exceeds 40%, the dose should be discontinued until the hematocrit decreases to 36%. When treatment is resumed, the dose should be reduced by 25% and then titrated to maintain the desired hematocrit.
In zidovudine-treated HIV-infected patients the hemoglobin concentration should not exceed 12 g/dL (7.5 mmol/L).
Adult Surgery Patients in an Autologous Pre-Donation Program: The intravenous route of administration should be used. Eprex should be administered after the completion of each blood donation procedure.
Mildly anemic patients (hematocrit of 33 to 39% and/or hemoglobin 10 to 13 g/dL (6.2-8.1 mmol/L) requiring predeposit of ≥ 4 units of blood, should be treated with Eprex at 600 IU/kg 2 times weekly for 3 weeks prior to surgery.
For those patients who require a lesser degree of erythropoietic stimulation, a dose regimen of 150 - 300 IU/kg administered twice weekly has been shown to augment autologous pre-donation and to decrease the subsequent decline in hematocrit.
Adult Perisurgery Patients (Without Autologous Blood Donation): The subcutaneous route of administration should be used.
The recommended dose regimen is 600 IU/kg of Eprex given weekly for three weeks (days -21, -14, and -7) prior to surgery and on the day of surgery.
In cases where there is a medical need to reduce the time before surgery to less than three weeks, the recommended dose regimen is 300 IU/kg for 10 consecutive days before surgery, on the day of surgery and up to 4 days after surgery. 300 IU/kg/day is recommended for hemoglobin levels ≤ 13 g/dL (8.1 mmol/L). If the hemoglobin level reaches 15 g/dL, or higher, administration of Eprex should be stopped and further doses should not be given.
Adult Patients with low- or intermediate-1-risk MDS: The subcutaneous route of administration should be used.
Eprex should be administered to low- or intermediate-1- risk MDS patients with anemia (e.g. hemoglobin concentration ≤ 10 g/dL (6.2 mmol/L)).
The recommended starting dose is Eprex 450 IU/kg (maximum total dose is 40000 IU) administered subcutaneously once every week.
It is recommended that response be assessed at week 8. If no erythroid response is achieved after 8 weeks according to IWG 2006 criteria (see Pharmacology: Pharmacodynamics under Actions), and the hemoglobin concentration is below 11 g/dL (6.8 mmol/L), the dose should be increased from 450 IU/kg once every week to 1050 IU/kg once every week (maximum dose is 80000 IU per week). If the patient loses response or haemoglobin concentration drops by ≥1 g/dL upon dose reduction the dose should be increased by one dosing step. A minimum of 4 weeks should elapse between dose increases.
Appropriate dose adjustments should be made to maintain hemoglobin concentrations within the target range of 10 g/dL to 12 g/dL (6.2 to 7.5 mmol/L). See diagram as follows for guidelines for stepwise dose adjustment. Eprex should be withheld or the dose reduced when the hemoglobin concentration exceeds 12 g/dL (7.5 mmol/L). Upon dose reduction, if hemoglobin concentration drops ≥1 g/dL the dose should be increased. Once the haemoglobin level is <11 g/dL the dose can be restarted on the same dosing step or one dosing step down based on physician judgement. Decreasing the dose by one dosing step should be considered if there is a rapid increase in haemoglobin (> 2 g/dL over 4 weeks). (See Figure 2.)

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A sustained hemoglobin concentration of greater than 12 g/dL (7.5 mmol/L) should be avoided.
Special populations: Pediatrics (17 years of age and younger): Treatment of pediatric patients with chemotherapy-induced anemia: The safety and efficacy of Eprex in pediatric patients receiving chemotherapy have not been established.
Treatment of pediatric Zidovudine treated HIV-infected patients: The safety and efficacy of Eprex in pediatric Zidovudine treated HIV-infected patients have not been established.
Treatment of pediatric surgery patients in an autologous predonation program: The safety and efficacy of Eprex in pediatric surgery patients in an autologous predonation program have not been established.
Treatment of pediatric patients scheduled for major elective orthopedic surgery: The safety and efficacy of Eprex in pediatric patients scheduled for major elective orthopedic surgery have not been established.
Elderly (65 years of age and older): Dose selection and adjustment for an elderly patient should be individualized to achieve and maintain the hemoglobin concentration range.