TATM
PAUL STROSS
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Chronic iron deficiency is a common cause of symptomatic anemia, but despite this it is often overlooked or not optimally managed. Frequently, this is because the diagnosis is not confirmed and the response to treatment may be inadequate because of poor compliance, malabsorbtion or recurrent blood loss. Oral iron is blamed for many treatment-limiting gastrointestinal symptoms, and if patients are admitted to hospital with symptoms they are frequently transfused. Intravenous iron can be used to deliver a predictable dose of iron over a short time with many safety, time and economic advantages compared with blood transfusion. Unlike blood transfusion, it is easy to replace physiological storage iron or even to anticipate future blood loss. Preparations of intravenous iron are available which enable even severely anemic patients to be fully treated in two hospital visits. The speed of response to intravenous iron is fast, with rises in hemoglobin levels exceeding 2 g/dL per week in severely
iron-deficient subjects. In patients with recurrent blood loss and a satisfactory response, multiple ongoing treatments with intravenous iron are feasible.

TATM
MICHAEL AUERBACH
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Recently there has been an enormous tumult over the use of the erythropoiesis-stimulating agents (ESAs) epoetin alfa and beta and darbepoetin alfa. Recommendations ranging from stopping their use in certain tumor types to withholding therapy until hemoglobin levels reach 9 g/dL or less have been proposed. These recommendations result from inconclusive and imbalanced trials favoring the placebo groups but which nonetheless raise significant concerns about the potential of ESAs to upregulate erythropoietin receptors on tumor cells. Therefore, there has never been a greater need to ensure that appropriate administration of intravenous iron is given with ESAs. In several published and soon-to-be-published trials comparing adjuvant therapy with intravenous and oral iron, without exception intravenous iron improved hemoglobin and hematopoietic responses, shortened times to maximal response, decreased exposure to ESAs and provided huge cost savings. Furthermore, these benefits were independent of patients’ pretreatment iron parameters, such as serum ferritin, transferrin saturation and the presence or absence of bone marrow hemosiderin. Nonetheless, resistance to intravenous iron usage in oncology abounds. This resistance is due to misinformation and misinterpretation of the incidence and clinical nature of serious adverse events. Now that there are three safe intravenous iron preparations, a new paradigm incorporating intravenous iron to ESA therapy in oncology needs to be examined