Which EPO dose per week?

Sir, Weiss et al. [1] have reported that once weekly erythropoietin b is as effective as more frequent dosing intervals in haemodialysis (HD) patients receiving treatment for the anaemia of end-stage renal failure. In view of their findings we switched all of our stable HD patients to once a week erythropoietin (EPO) providing that they were receiving less than 10 000 U subcutaneouslyuweek. A total of 36 otherwise unselected patients were then followed monthly by routine monitoring as part of our on going audit process. Patients were using both EPO a and b. Mean haemoglobin (Hb) decreased from 12.1"1.1 to a nadir of 11.0"1.6 gudl at 16 weeks (paired t-test, Ps0.002). The Hb achieved by )85% of patients fell from 11 to 9.5 gudl, a value below the standard set by the UK Renal Association. Mean weekly EPO dose increased from 97"39 to 107"46 Uukguweek (Ps0.04) equating to an increase in weekly EPO cost from £46 to 51. As a result of these audit results, patients were converted back to two or three times per week regimes. At a further 16 weeks Hb had increased to 12.1"1.3 gudl and the Hb achieved by 85% of patients was 10.5 gudl. The EPO dose reached a plateau and had started to decrease but remained higher than baseline at 102"60 Uukguweek. Serum ferritin and C-reactive protein remained stable during the audit period. We conclude that converting the evidence base from a carefully conducted study to an unselected patient population must be approached with caution. A rigorous audit process is necessary to ensure that there is no detriment to achieved outcomes. In our experience, EPO once a week is less efficient and less cost effective than more frequent dosing schedules. We suggest that this approach cannot be recommended in everyday practice.