Panel Discussion



Andrea Easom, Deborah Bowe
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This satellite symposium is sponsored by an unrestricted educational grant from Watson Pharma, Inc. This activity has been planned and produced in accordance with CE guidelines and policies. From a CE symposium held on April 5, 2006 at the American Nephrology Nurses' Association (ANNA) Annual Meeting in Nashville, TN. This symposium was approved by ANNA. It was not part of the official ANNA Annual Meeting.
This activity provides 1.8 contact hours. The American Nephrology Nurses’ Association (ANNA) is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. ANNA is a Provider approved by the California Board of Registered Nursing, provider number CEP 00910.
Posting Date: September 15, 2006
CE Credit Eligible Through: September 15, 2008
CE Credit Hours/Completion Time: 1.8
Target Audiences: Nurses, nurse practitioners, and other healthcare professionals who treat and manage patients with CKD.
Method of participation: Listen to the talk, read the PubMed abstracts linked to data slides and talk references, take the post-test, read the linked abstracts in the post-test answer feedback material.
 
LEARNING OBJECTIVES:
The educational objectives for this talk are presented on the conference page. To view the objectives, click here.
SPEAKER DISCLOSURE STATEMENT:
Andrea Easom, MA, MNSc, APN, BC, CNN, is a member of the Speakers Bureau for Watson Pharma, Inc., Abbott, Amgen, and Pfizer.
Deborah Bowe, RN, CNN, has received grant/research support from Watson Pharma, Inc, and is a member of the Speakers Bureau for Watson Pharma, Inc.
No disclosed off-label use.


SPONSORSHIP / SUPPORT :
This ANNA Satellite symposium was developed in conjunction with Fallon Medica and ANNA, and sponsored by a restricted educational grant from Watson Pharma, Inc.

ANNA AND HDCN CE POLICY STATEMENTS:
The CE policy and disclosure statements of ANNA are given in detail on the Symposium Home Page. The CE policy statements of HDCN are listed on this page.

DISCUSSION

I thought as we start assessing our patients, because this is really where we are going - better assessment by the nurse at the bedside - and just like I have my story with my patient, and I have other stories, it would be so nice if we could accumulate data from the things that you find as you go and you look for serum ferritins. So my e-mail address is Ms. Easomandreak@uams.edu. You have my name, so you know how spell it and all, and then just add @uams.edu. So, if you all start finding some things that you think are unique, we seldom think anything we do is unique; if you start finding some good stories about what you have discovered with high ferritins, it would make a great journal article and I would be happy to put that through and put all of you as co-authors on that. This would be a good journal article for the ANNA journal: just a good nursing assessment. I see that there are lots of questions.

Q1: What is the best way to manage patients in an acute setting who come in with hematocrits greater than 40 or hemoglobin too high and are on epogen? We currently hold them but holding is not good. What is the answer?

Ms. Easom:
My experience in the acute arena is, that when our patients go into hospital, it is like kind of putting leeches on them. They may have come in high but they do not go out high. My best advice to you would be to kind of cut the EPO dose by 50% or discuss it with your physician or your nurse practitioner, but that would be my goal. We used to have a problem and I cannot say it is 100% fixed; our acute nurses manage, and the DaVita Unit owns, the acute program at the hospital. I never understood why we could not get a process going back and forth so that our patients could continue to get their usual medications while they were in the hospital. Finally, going through a system CQI approach, we found that the nurses in the hospital were not allowed to give medications from the hospital but they did have access to put in orders, and so we empowered our acute nurses to put in the EPO orders; so the chronic unit communicates with the acute unit and back. It is a two-way street, and they put in the usual dose. We actually do not let them put in the iron dose, because if patients are in the hospital, they well could have infection, etc., and I ask them to remind the doctors that the patients are on iron and to let them continue it, but we do continue the same dose. An acute nurse who recognizes that it is too high, you really need a protocol to cover yourself while you are there, but if the patients go in with a high Hb, then at least cut the EPO dose by 25%; that would make the government happy and they really do not look at what is going on (in terms of Hb levels) in the hospital. Depending on how high the Hb is, you may make a decision on changing the EPO dose, but you know you are going to get lot more blood draws. Also, it is likely that in-hospital there will be some kind of process going in that is going to affect their erythropoiesis, probably, while they are there. What you do depends on what the Hb was and how quickly it got there. Remember how many g/dL Hb points should you go up in a month? 2. If you are trending up and if they were 11 and now they are 14, I would cut the EPO dose by 50% but if they have been running in the 12s and they were up to 13.5, I probably would cut the EPO dose by 25% or I may not even cut it at all, knowing that we are going to draw blood everyday and lots of it.

Q2: Can you ask the audience as to how many are still using the dextran molecule products?

Ms. Easom:
To make this person happy, if you are using iron dextran, and I know there is some still being used… anybody in this room using IV iron dextran? Okay. There is somebody in the back. I quit using the iron dextran simply because there is a black box warning on it and simply because I have had some anaphylaxis. I have never had any anaphylaxis with and I do not have any experience with, Venofer, so I am sorry I cannot say much about Venofer. I have had some reactions with Ferrlecit but the reactions usually occur when the iron is given too fast. Sometimes they are given IV irion too fast accidentally, and then other times, they are given IV iron too fast for that particular patient. One of the first patients in my CKD Clinic, and fortunately she was very sweet, dropped her blood pressure, etc., and on those patients, when I am going to treat them again, I usually will drip the IV iron in, but she was getting 125 or may be 250 mg. Once you get to bigger doses, you need to drip it, you need to drip it slower; normally, we push 62.5 mg over 4 minutes, 125 mg over 10 minutes, and for doses bigger than 125 mg, we drip it or, if they have acted ugly the last time we gave 125, we drip it. That is kind of how I handle it and I have never had an anaphylaxis but I do get that drop in blood pressure, that feeling bad, if the IV iron is given too fast. The reason we went to the 31.25 mg doses given weekly is because when you really get down and dig, no telling what you are going to find out; and what I found out was, that I thought I was being nice giving 62.5 mg every other week to patients who just needed a little bit of iron, or 125 every other week, but 125 over 10 minutes. If your nurse has not gotten back to continually push that through, 10 minutes at shift change is an eternity and if your tech says, “Hey! You haven’t given all the iron!”, I found more often than not in our unit, that the iron then just gets given to the garbage can. Because you have one of three things happen: (1) they can either stand there for that length of time, whenever they need to push in the dose, (2) or they push it in too quick, or (3) they just throw it away. That little dose, 31.25, if you do not have a problem with drawing up the IV iron twice, or even the 62.5 mg, which is to be given over 4 minutes, and you know, 4 minutes does not sound like a long time, but it is a long time in a dialysis unit - but 31.25 mg, if they can just push it in right there when they hook the patient up and then it is done. With 62.5 mg doses, they usually push half of it in, and then come back and push the other half.

Q3: What ill effect on patients would occur if you gave IV iron to the infected patient?

Ms. Easom:
That is one of those theoretical questions. The thought would be that you give them iron-rich blood and you could make the infection a little bit worse. Do not know whether that plays into it hugely or not because not all bacteria like iron-rich blood so it would depend upon what the infection is. But if you cannot find the infection, if you do not know what is going on and you get that correlated by whoever you want to, it will either show itself or it will still stay occult. I have real problems with these long-term infections - we have grafts that have been infected, non-used grafts, the old ones that have these occult infections - that make the ferritins high; you just have underlying poor outcomes all across the board in such patients, but that is what you worry about. You worry about worsening that infection, but I cannot stand here and tell you that that happens all the time.

Q4: Would one IV iron dose show ill effects?

Ms. Easom:
No. I do not think so at all. There is a study from Taiwan. We think we have it bad - they have it really bad, at least they did when this study was done where they thought if they got to hemoglobin above... they did it on hematocrits above 30, they had to hold the iron and so, they had no limits on how much IV iron they can give and their baseline ferritins were up around 800 and what they did, they gave all of their patients iron, significance amounts of iron every week, and they got their hemoglobins or their hematocrits up and after a year, they only had a small increase in their serum ferritins. I do not think 1 iron dose will have an effect but 1 iron dose also is not going to tell you if it works. You are going to give it for a month to 6 weeks. If you are worried about it, I would talk to your prescriber and then if you do it and you are still worried about it, I would keep checking with that patient but I have really not had that problem.

Q5: If the patient has positive cultures, how long do you wait before restarting your IV iron?

Ms. Easom:
I will be honest. We are not organized enough to hold IV iron in the first place, except if I am giving a dose of vancomycin to somebody who has bacteremia and who really is sick. Our first line drug is a cephalosporin. We give cephalosporins if we just think, hey something funky is going on with you, it could be infectious, and we have done a lot of the research on cephalosporins. If I starting antibiotic drug treatment like that, then I do not give IV iron, but once you have a few doses of drug onboard, you are okay and you are only giving the iron generally once a week unless you are in some type of repletion-type schedule and your patient is depleted. If you were really organized, I would hold IV iron at least a week and then start back, but that is just a shoot-from-the-hip opinion!

Q6: Ms. Easom:
I have a new patient not on EPO with iron studies toward the end of the low target range. Should they be receiving iron doses if not receiving EPO?


Ms. Easom:
That is a really good question. We have, in the past, given a little bit of iron just to bring their TSATs up to a comfortable range. There have been some studies of patients just receiving iron and not being on EPO and their hemoglobin continues to climb. So, I think there is a need for iron.

Q7: How often do you consider use of IV L-carnitine and how long do you use it to see if it is being effective?

Ms. Bowe:
We have probably about 10 patients on Carnitor™ (IV L-carnitine) and in 8 of them, we have seen an improvement in hemoglobin, and we wait at least 3 to 4 months to see if their hemoglobin does improve. One big thing with that is do not ever recheck the serum carnitine level again because if it comes back normal, then Medicare will not pay for the drug in the future.

Q8: What do you do if your patient is allergic to Ferrlecit and Venofer?

Ms. Easom:
This depends on what you call an allergy. I have some patients who just kind of feel yucky or itch or something. If I really need to, I may premedicate them with steroids or Benadryl, but if I had somebody who really had a close to an anaphylactic reaction, and I am talking about iron dextran, I would put them on p.o. iron; and I will tell you that, you can laugh, but I have seen it work. I have followed 90 patients who are in my CKD Clinic that I have on IV iron and/or usually subcutaneous Aranesp and my medical director actually taught me that you can bring a TSAT from single digits up to 20 with p.o. iron in patients who are troublesome. I have seen it happen, although those CKD patients are not really losing much iron. But if you do not want to give IV iron, if your patient is truly allergic, then you cannot give IV iron.

For po irion I use Feosol. I use it for 2 reasons. I am one of those people who get all those samples those drug companies will send me and because my patients love to get samples, and Feosol does, but also, it works. It is available over the counter, it is easily tolerated, better tolerated than the ferrous sulfate. So if I really could not give IV iron, I would do that (give po iron) and I do the same thing with my PD patients. I have more of my PD patients on p.o. iron, which is another question, and we give them IV iron when they come in for their clinic visit. Usually we give 125 mg if they are real low, some of them get 62.5 mg. If they have had a bleed or some kind other problem is going on with them and they live close enough, we will bring them back in and give them 125 mg (of Ferrlecit) twice a month. Again, that iron is bioavailable, readily available, and giving IV iron only episodically tends to work for us because these (PD) patients are not having large losses or iron.

Q9: I have a question on reimbursement. How much EPO is too much EPO?

Ms. Easom:
The Federal Government in their wisdom has stepped in to tell us and they say that if you are giving over 500,000 units of EPO a month and you bill them for that, they will think, “Oh! You have made a mistake.” You have put your decimal in the wrong place, whatever and they will not pay that claim. Depending on how many treatments, you are talking about 35,000 to 38,000 units 3 times a week, and I will tell you that I have had patients in my unit who are getting more than that because they were following a company protocol and the doctors and I talked about it and we said, “well crud!” and it just was not worth it to fight about it. Those patients really need to be looked at. I would encourage you to go back and look at your patients who are requiring that much EPO. Either they have got dead bone marrow, they are bleeding, or you are missing functional iron deficiency because you have been holding at a ferritin of whatever because usually it is 500 to 800. It probably was never meant for us to hold iron at any certain level of ferriting, but you have to have a protocol, and if you have a protocol in your unit, you have to follow it. You are bound by law to follow it, but we as patient advocates should be doing that assessment all along, not just now, and going back to that patient, seeing what is going on and going to the prescriber and saying, “Can I give a trial of IV iron?”

One of the tricks will be how do you communicate with your doctors and I know I have had a number of medical directors and, to my first one, I had a big need to tell and he did not have a big need to hear. We have a great working relationship but I knew that my need was, because I was novice in the role, and he was comfortable with me and comfortable with patients, and he did not have a big need to know. On the other hand, one of my fellows was my medical director for the last few years, after she finished her fellowship and went into private practice. She is also one of my best friends. She had a huge need to know, because when she got to a patient, if she did not know what was going on, she felt like there was something wrong with her. She could have been a great nurse! She called me every time she got into her car. I talked to her multiple times a day, and frequently she and her kids are at my house on the weekend. We talked patients all the time. You have to find out how do you talk to the people who are your prescribers. Frequently, just fragmented sentences in an e-mail. If the doctor knows you are going to be assessing ferritins, then you give them a list. "Ferritin this, stays in this range, have talked to the patient, cannot find anything, can I continue iron?" I find doctors respond really well to e-mails. Do whatever you need to take care of your patients.

Q10: What do I do with HIV-positive patients who do not respond to iron and elevated ESA doses?

Ms. Easom:
I treat them just like everybody else. I am probably going to ignore the ferritin a little bit and give low doses of iron unless I see that they have some type of opportunistic problem. I have a few HIV patients and I do not find that I have huge problems with them but if they really are, if you get a jump in their ferritin - usually, let us say, it is high, let us say it is 600 - and all of a sudden, the ferritin is 1000, and you did not do anything with your iron, then, hey - maybe something is going on and they are developing a secondary infection. You are going to expect them to have a little bit higher ferritins than the rest of the patient population

Q11: Can we get copies of the slides?

Ms. Easom:
I cannot give them to you from me but the people from Fallon Medical will help you and they will be on the web page that you can download, at least the printout. But if you want slides, the Fallon people outside the door will help you with that. I agree with you, I love the physiology slides.

Q12: If the iron indices indicate a need for iron but the hemoglobin is high, do you give iron?

Ms. Easom:
If I were going to do that, I would give iron but I would back off on the EPO. Again, it is a balance. If the Hb is much over 13, I might wait until it trends down a little bit because you have probably lowered your EPO dose, but again it is that balance. You hope to find it and fix it as it is going up but it certainly gets your attention when it is too high. It will take a while for you to get that balance in line but yes, I would go ahead and treat but I would treat at a low dose and I would back off on the EPO.

Q13: If you do not change your EPO more than once a month, why do you check the hemoglobin so frequently?

Ms. Easom:
Just because we can but also because it helps. If you have it in one snapshot, period of time, you really do not know what happened in between. Again, that is a trending issue and for me, it helps to see if the Hb is going up. For instance, one of the reasons I might change a dose quicker than not is because, remember: one should target an increase of 2 hemoglobin points (g/dL) per month. If I am going up quicker than that, I am going to adjust the EPO dose down.

Q14: If you are giving a weekly iron replacement, when do you recommend a lab test for your TSAT?

Ms. Easom:
What we do is we give our irons on Monday and we draw labs on Monday or Tuesday if they are Tuesday, Thursday, Saturday, so you have a whole week since your last dose and as Debbie mentioned, with the newer irons, sometimes it is not as big an issue since you are drawing your lab predialysis and you are giving your iron during dialysis, so you have a full week in between and that should be fine.

Q15: At what point do you hold iron if the serum ferritin is elevated above 800?

Ms. Easom:
It depends. It depends on the patient. Always go back to your patient because I have lots of patients as do Dr. Fishbane and Dr. Foley from looking at the transcript. It is not that you stop but that you look and see what is going on with the patients because some patients certainly need IV iron even above a ferritin of 800.

Q16: What tests would you order for a patient with no identifiable source of infection or inflammation?

Ms. Easom:
If I had a baseline CRP, I will get it. If the patient has a catheter, sometimes I will just draw a blood culture because even though you would think somebody who was septic would show it, I find sometimes that that is not always the case, that I can catch it quicker. You could look at your white blood cell count and see, are the white cells elevated? Look at that albumin and the TIBC and see if those are down. You look at the whole picture and then you are making a guess.

Thank you very much.