Based on revised guidelines from the FDA, nonprofit health groups such as the National Comprehensive Cancer Network and the National Kidney Foundation, and the latest available evidence, our medical consultants offer the following recommendations for patients considering the use of ESAs for the conditions listed below. Recognize that these are general guidelines, not rigid rules; the actual decision must be made with your doctor based on your particular situation.

Cancer chemotherapy
Don't take ESAs if there's a reasonable chance that chemotherapy will cure the cancer or significantly extend your life; you could lose years if the anemia drug causes accelerated growth of the tumor or triggers some other deadly complication. Unless chemotherapy treatments are intended to primarily ease your symptoms, don't take these drugs at all except to avoid a transfusion, which may be indicated if your hemoglobin level is less than 10 g/dl. In fact, Medicare no longer pays for ESA treatment above that level for patients with cancer. Even then, take them at the lowest effective dose.

Kidney disease
ESAs are used for patients with chronic kidney disease primarily in order to avoid transfusions, which over the long-term are harmful. The restrictions here are fewer than those for cancer-chemotherapy patients, since the risk of accelerating the growth of a tumor is not applicable, and, the risks of mortality and cardiovascular problems are less with lower doses and lower hemoglobin levels.

Treatment should aim for a hemoglobin level between 10 and 12 g/dL. Your doctor should reduce the ESA dosage if your hemoglobin rises more than 1 g/dL in any two-week period, since that can increase your blood pressure. Conversely, Consumer Reports medical advisors suggest treatment should generally stop if your hemoglobin fails to rise (though it could take up to 12 weeks before a difference in levels is seen), since kidney patients who don't respond to the drug seem to face higher ESA risks. Your doctor may then want to reevaluate the cause of your anemia.

People with kidney problems should also have their blood pressure monitored frequently; whether ESAs raise blood pressure in other patients is not clear.

Surgery
You and your physician should carefully weigh ESAs' ability to reduce the need for transfusions against the drugs' ability to cause blood clots. If you opt for an ESA, ask about taking a blood thinner to counteract that risk. An alternative solution, if your surgeon agrees, could be to bank your own blood a week or two before surgery for possible use during your operation.

Uncontrolled hypertension
Avoid ESAs entirely if you have high blood pressure not adequately controlled with medication.

Off-label uses
Be even more cautious if your doctor recommends using an ESA for a purpose not approved by the FDA. While physicians can legally prescribe virtually any medication for such "off-label" use, there's usually little supporting evidence to back up such use. The National Comprehensive Cancer Network supports use of ESAs to treat anemia in myelodysplastic syndrome, which can be a precursor of leukemia, although many effective therapies for this disease have recently been approved by the FDA. In most other cases, take ESAs for unapproved uses only if there's a compelling need, you've discussed the research with your doctor, you're willing to face known and unknown risks, and you can pay for it. One dose of 10,000 units of Procrit (considered a minimal amount) can cost you up to $175 out of pocket.

In addition, all patients taking an ESA should be monitored frequently for neurological warning signs, since ESAs may increase the chance of stroke and seizures, and for unusual blood count changes.

Making the decision

Whether you have cancer, chronic kidney disease or are undergoing surgery, you should have the final say on whether or not to take an ESA, based on the likely benefits and risks, and how important they are to you. In addition to reading any patient medication information your doctor gives you, also be sure to ask your doctor these questions:

• Why do you think I should take the drug?
• Is it being prescribed for an off-label use or an approved indication?
• Am I especially susceptible to its side effects because of my blood pressure or heart disease?
• What's the chance I'll need a blood transfusions if I don't take an ESA? If I had to have a transfusion, what are the risks?
• How might the drug affect my cancer treatment?
• Will my insurance cover the cost?