Erythropoiesis-stimulating agent

From WikiProjectMed
Jump to navigation Jump to search
Erythropoiesis-stimulating agent
Drug class
Structure of erythropoietin
Other namesErythropoiesis-stimulating drugs,[1] erythropoietin-type blood factors[2]
Clinical data
UsesAnemia due to end stage kidney disease, chemotherapy, major surgery, or certain treatments in HIV/AIDS[3][2]
Side effectsJoint pain, rash, vomiting, headache, heart attacks, stroke, increased cancer growth, pure red cell aplasia[2][4]

Erythropoiesis-stimulating agents (ESA) are medications which stimulate the bone marrow to make red blood cells.[3] They are used to treat anemia due to end stage kidney disease, chemotherapy, major surgery, or certain treatments in HIV/AIDS.[3][2] In these situations they decrease the need for blood transfusions.[2] The different agents are more or less equivalent.[2] They are given by injection.[2]

Common side effects may include joint pain, rash, vomiting, and headache.[4] Serious side effects may include heart attacks, stroke, increased cancer growth, or pure red cell aplasia.[2] It is unclear if use is safe during pregnancy.[5][6] They work similar to naturally occurring erythropoietin.[3]

They were first approved for medical use in the United States in 1989.[5] It is on the World Health Organization's List of Essential Medicines.[7] Commercially available agents include epoetin alfa and darbepoetin alfa, as well as biosimilars.[3][2] The wholesale cost of one version in the developing world, as of 2015, is about 3.80 USD per 2000 unit vial.[8] In the United Kingdom this amount costs about 10 pounds as of 2015.[6] Use among athletes is prohibited by the World Anti-Doping Agency.[5]

Medical uses

ESAs are used to maintain hemoglobin at the lowest level that both minimizes transfusions and best meets a person's needs.[9] Medical speciality professional organizations do not recommend the use of ESAs in people with chronic kidney disease (CKD) who have hemoglobin levels greater than 10 g/dL and do not have anemia symptoms.[9][10] In preterm babies ESAs may help reduce the need for red blood cell transfusions.[11]

There is no evidence that one agent is better than another in the setting of CKD.[12]


ESAs may fail to achieve an adequate therapeutic response when one or more of the following is present:[13]

  • Occult blood loss and/or iron deficiency
  • Vitamin B12 or folate deficiency
  • Infection and inflammation
  • Inadequate dialysis
  • Hyperparathyroidism
  • Aluminum toxicity
  • Patient adherence
  • Hypothyroidism
  • Primary disease activity
  • Transplant rejection
  • Malignancy
  • Pure red cell aplasia


The defined daily dose is not established.[14]



The following types of ESAs are available:

Available forms

Recombinant erythropoietin has a variety of glycosylation patterns giving rise to alpha, beta, delta, and omega forms:

  • epoetin zeta (biosimilar forms for epoetin alpha):
  • Miscellaneous:
    • Epocept, made by Lupin Pharmaceuticals
    • EPOTrust, made by Panacea Biotec Ltd
    • Erypro Safe, made by Biocon Ltd.
    • Repoitin, made by Serum Institute of India Limited
    • Vintor, made by Emcure Pharmaceuticals
    • Epofit, made by Intas pharma
    • Erykine, made by Intas Biopharmaceutica
    • Wepox, made by Wockhardt Biotech
    • Espogen, made by LG life sciences.
    • ReliPoietin, made by Reliance Life Sciences
    • Shanpoietin, made by Shantha Biotechnics Ltd
    • Zyrop, made by Cadila Healthcare Ltd.
    • EPIAO (rHuEPO), made by Shenyang Sunshine Pharmaceutical Co.. LTD. China
    • Cinnapoietin, made by CinnaGen biopharmaceutical Iran.

Darbepoetin alfa, which early literature during its development often termed as novel erythropoiesis-stimulating protein (NESP), is a form created by five substitutions (Asn-30, Thr-32, Val-87, Asn-88 and Thr-90) that create two new N-glycosylation sites.[25] This glycoprotein has a longer terminal half-life, meaning it is possible to administer it less frequently.


Erythropoiesis-stimulating agents have a history of use as blood doping agents in endurance sports, such as horseracing, boxing,[26] cycling, rowing, distance running, race walking, snowshoeing, cross country skiing, biathlon, Mixed Martial Arts and triathlon. The overall oxygen delivery system (blood oxygen levels, as well as heart stroke volume, vascularization, and lung function) is one of the major limiting factors to muscles' ability to perform endurance exercise. Therefore, the primary reason athletes may use ESAs is to improve oxygen delivery to muscles, which directly improves their endurance capacity. With the advent of recombinant erythropoietin in the 1990s, the practice of autologous and homologous blood transfusion has been partially replaced by injecting erythropoietin such that the body naturally produces its own red cells. ESAs increase hematocrit (% of blood volume that is red cell mass) and total red cell mass in the body, providing a good advantage in sports where such practice is banned.[27] In addition to ethical considerations in sports, providing an increased red cell mass beyond the natural levels reduces blood flow due to increased viscosity, and increases the likelihood of thrombosis and stroke. Due to dangers associated with using ESAs, their use should be limited to the clinic where anemic patients are boosted back to normal hemoglobin levels (as opposed to going above the normal levels for performance advantage, leading to an increased risk of death).

Though EPO was believed to be widely used in the 1990s in certain sports, there was no way at the time to directly test for it, until in 2000, when a test developed by scientists at the French national antidoping laboratory (LNDD) and endorsed by the World Anti-Doping Agency (WADA) was introduced to detect pharmaceutical EPO by distinguishing it from the nearly identical natural hormone normally present in an athlete's urine. The first EPO-doping cases were found by the Swiss Laboratory for Doping Analyses.[28]

In 2002, at the Winter Olympic Games in Salt Lake City, Dr. Don Catlin, the founder and then-director of the UCLA Olympic Analytical Lab, reported finding darbepoetin alfa, a form of erythropoietin, in a test sample for the first time in sports.[29] At the 2012 Summer Olympics in London, Alex Schwazer, the gold medalist in the 50-kilometer race walk in the 2008 Summer Olympics in Beijing, tested positive for EPO and was disqualified.[30]

Since 2002, EPO tests performed by US sports authorities have consisted of only a urine or "direct" test. From 2000–2006, EPO tests at the Olympics were conducted on both blood and urine.[31][32] However, several compounds have been identified that can be taken orally to stimulate endogenous EPO production. Most of the compounds stabilize the hypoxia-inducible transcription factors which activate the EPO gene. The compounds include oxo-glutarate competitors, but also simple ions such as cobalt(II) chloride.[33]

Inhalation of a xenon/oxygen mixture activates production of the transcription factor HIF-1-alpha, which leads to increased production of erythropoietin and improved performance. It has been used for this purpose in Russia since at least 2004.[34]


Recombinant EPO is believed to have come into use in cycling about 1990.[35] In theory, EPO use can increase VO2max by a significant amount,[36] making it useful for endurance sports like cycling. Italian antidoping advocate Sandro Donati has claimed that the history of doping in cycling can be traced to the Italian Dr Francesco Conconi at the University of Ferrara. Conconi had worked on the idea of giving athletes transfusions of their own blood in the 1980s. Donati felt this work "opened the road to EPO . . . because blood doping was a trial to understand the role of EPO".[37]

Dr. Michele Ferrari, a former student and protege of Conconi,[38] had a controversial interview mentioning the drug in 1994, just after his Gewiss-Ballan team had a remarkable performance in the La Flèche Wallonne race. Ferrari told l'Equipe journalist Jean-Michel Rouet that EPO had no "fundamental" effect on performance and that if his riders used it, it would not "scandalize" himself. After the journalist pointed out several riders were suspected of dying from EPO, Ferrari said EPO was not dangerous, and only abuse of it was dangerous, saying, "It's also dangerous to drink 10 liters of orange juice." The 'orange juice' comment has been widely misquoted.[39][40] Ferrari was fired shortly after, but continued to work in the industry with top riders, allegedly including Lance Armstrong.[38][41] That same year, Sandro Donati, working for the Italian National Olympic Committee, presented a report accusing Conconi of being linked to the use of EPO in the sport.[37]

In 1997, the Union Cycliste Internationale (UCI) instituted a new rule that riders testing above 50% haematocrit were not only immediately disqualified, but banned from racing for two weeks.[42][43] Robert Millar, former racer, later wrote for Cycling News that the 50% limit was "an open invitation to dope to that level", pointing out that normally haematocrit levels would start "around 40-42%" and drop during the course of a "grand tour", but after EPO, they were staying at 50% for "weeks at a time".[44] By 1998, EPO use had become widespread, and the Festina affair tarnished the 1998 Tour de France.[35] One manager offered a 270,000-franc-per-month raise to Christophe Bassons if he would use EPO, but Bassons refused.[45]

In the 1998 Tour de France Stuart O'Grady won one stage, held the Tour de France yellow jersey for three days, and came second in the points classification with the assistance of EPO.[46] In 2010, Floyd Landis admitted to using performance-enhancing drugs, including EPO, throughout his career as a professional cyclist.[47] In 2012, the USADA released a report on its investigation into massive doping by the US Postal Service cycling team under the leadership of Lance Armstrong. The report contained affidavits from numerous riders on the team, including Frankie Andreu, Tyler Hamilton, George Hincapie, Floyd Landis, Levi Leipheimer, and others, outlining that they and Armstrong used a cocktail of performance-enhancing substances for the Tour de France, most notably EPO, during Armstrong's seven consecutive Tour wins. It detailed how Armstrong and the Postal manager, Johan Bruyneel, forced other team members to dope as well. It also went to the root of their doping network, targeting the shadowy doctors and back room enablers who helped cyclists procure and administer drugs as well as highly placed executives who helped to avoid doping controls and hide positive test results. Armstrong was subsequently stripped of all of his victories from 1998 onward—including his Tour wins and his performance in the 2000 Summer Olympics. The UCI concurred with the decision. While several of the doping offenses took place outside the normal eight-year statute of limitations for doping offenses, USADA contended the statute of limitations did not apply due to Armstrong's "fraudulent concealment" of his doping. Longstanding precedent in U.S. law holds that the statute of limitations does not apply in cases of fraudulent conduct by a defendant.[48] In accordance with this decision, Tour organizers removed Armstrong's name and results from the race's history.[49]

Witnesses testified that code words used for EPO included "Edgar", "Poe",[50] "Edgar Allan Poe", and "Zumo" (Spanish for 'juice').[51]


Dynepo is the brand name for a form of EPO developed by Shire Pharmaceuticals. The first development steps were performed by HMR and Aventis. Aventis obtained the license in Europe in 2002. The company expected to launch the product in Europe in 2006, although patents held by the American biotechnology company Amgen, Inc. may have precluded its sale in the United States.

Dynepo was made in cultured human cells. It was therefore expected to have an authentic human form of sialic acid and other oligosaccharide residues. It was hoped that this would make a longer-acting product than existing brands. There were concerns that such production would also make Dynepo undetectable in the urine tests for EPO used, at that time, to detect doping by athletes. Dynepo was withdrawn from European markets on 17 February 2009, for commercial reasons.[52][22] On July 1, 2009, professional cycling team Silence–Lotto announced that Thomas Dekker was tested positive for Dynepo on a test taken on December 24, 2007, while Dekker was riding for Rabobank.[53]


  1. Tanne, Janice Hopkins (2010). "FDA restricts use of erythropoiesis stimulating drugs". BMJ. 340: c1050. doi:10.1136/bmj.c1050.
  2. 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 "WHO EML 2016-2017 - Application for erythropoietin-stimulating agents (erythropoietin type blood factors)" (PDF). WHO. 23 December 2016. Archived (PDF) from the original on 31 August 2020. Retrieved 13 December 2017.
  3. 3.0 3.1 3.2 3.3 3.4 Research, Center for Drug Evaluation and. "Drug Safety and Availability - Information on Erythropoiesis-Stimulating Agents (ESA) Epoetin alfa (marketed as Procrit, Epogen), Darbepoetin alfa (marketed as Aranesp)". Archived from the original on 31 August 2020. Retrieved 14 October 2017.
  4. 4.0 4.1 "Highlights of Prescribing Information" (PDF). FDA. Archived (PDF) from the original on 10 December 2019. Retrieved 13 December 2017.
  5. 5.0 5.1 5.2 "Epoetin alfa Use During Pregnancy |". Archived from the original on 14 December 2017. Retrieved 13 December 2017.
  6. 6.0 6.1 British national formulary : BNF 69 (69 ed.). British Medical Association. 2015. pp. 666–671. ISBN 9780857111562.
  7. World Health Organization (2019). World Health Organization model list of essential medicines: 21st list 2019. Geneva: World Health Organization. hdl:10665/325771. WHO/MVP/EMP/IAU/2019.06. License: CC BY-NC-SA 3.0 IGO.
  8. "Single Drug Information". International Medical Products Price Guide. Archived from the original on 11 December 2017. Retrieved 10 December 2017.
  9. 9.0 9.1 Aapro, M. S.; Link, H. (2008). "September 2007 Update on EORTC Guidelines and Anemia Management with Erythropoiesis-Stimulating Agents". The Oncologist. 13: 33–36. doi:10.1634/theoncologist.13-S3-33. PMID 18458123.
  10. American Society of Nephrology, "Five Things Physicians and Patients Should Question" (PDF), Choosing Wisely: an initiative of the ABIM Foundation, American Society of Nephrology, archived from the original (PDF) on April 16, 2012, retrieved August 17, 2012
  11. Aher, SM; Ohlsson, A (28 January 2020). "Late erythropoiesis-stimulating agents to prevent red blood cell transfusion in preterm or low birth weight infants". The Cochrane Database of Systematic Reviews. 1: CD004868. doi:10.1002/14651858.CD004868.pub6. PMC 6986694. PMID 31990982.
  12. Palmer, SC; Saglimbene, V; Mavridis, D; Salanti, G; Craig, JC; Tonelli, M; Wiebe, N; Strippoli, GF (8 December 2014). "Erythropoiesis-stimulating agents for anaemia in adults with chronic kidney disease: a network meta-analysis". The Cochrane Database of Systematic Reviews. 12 (12): CD010590. doi:10.1002/14651858.CD010590.pub2. PMC 6885065. PMID 25486075.
  13. Burtis, C.A.; Ashwood, E.R. and Bruns, D.E. Tietz Textbook of Clinical Chemistry and Molecular Diagnostics. 5th Edition. Elsevier. pp 1554
  14. "WHOCC - ATC/DDD Index". Archived from the original on 1 July 2021. Retrieved 11 September 2020.
  15. "Aranesp(darbepoetin alfa)". Archived from the original on 2006-10-18. Retrieved 2009-04-29.
  16. "Aranesp EPAR". European Medicines Agency (EMA). 13 January 2020. Archived from the original on 12 November 2020. Retrieved 10 March 2020.
  17. "Binocrit EPAR". European Medicines Agency (EMA). 31 October 2019. Archived from the original on 30 December 2019. Retrieved 10 March 2020.
  18. "Procrit (Epoetin alfa)". Ortho Biotech Products. Archived from the original on 2009-10-26. Retrieved 2009-04-29.
  19. "Probiomed". Archived from the original on 2018-03-26. Retrieved 2018-03-21.
  20. "Abseamed EPAR". European Medicines Agency (EMA). 8 October 2019. Archived from the original on 23 March 2020. Retrieved 10 March 2020.
  21. "Mircera EPAR". European Medicines Agency (EMA). 20 December 2019. Archived from the original on 29 December 2019. Retrieved 10 March 2020.
  22. 22.0 22.1 "Dynepo EPAR". European Medicines Agency (EMA). 23 April 2009. Archived from the original on 11 August 2020. Retrieved 10 March 2020.
  23. "Silapo EPAR". European Medicines Agency (EMA). 10 March 2020. Archived from the original on 22 October 2020. Retrieved 10 March 2020.
  24. "Retacrit EPAR". European Medicines Agency (EMA). 14 January 2020. Archived from the original on 30 December 2019. Retrieved 10 March 2020.
  25. Macdougall IC (Jul 2000). "Novel erythropoiesis stimulating protein". Seminars in Nephrology. 20 (4): 375–81. PMID 10928340.
  26. "Boxing Scandals". Bleacher Report. December 2011. Archived from the original on 2011-12-08. Retrieved 2011-12-22.
  27. Jelkmann W, Lundby C (Sep 2011). "Blood doping and its detection" (PDF). Blood. 118 (9): 2395–404. doi:10.1182/blood-2011-02-303271. PMID 21652677. Archived (PDF) from the original on 2021-08-28. Retrieved 2018-10-24.
  28. History of the Swiss Laboratory for Doping Analyses Archived 2016-03-29 at the Wayback Machine, (page visited on 11 June 2014).
  29. Steeg JL (2007-02-28). "Catlin has made a career out of busting juicers -". USA TODAY. Archived from the original on 2009-02-26. Retrieved 2009-03-31.
  30. "FDA Reports New Risks Posed by Anemia Drugs" Associated Press story in the Washington Post (August 8, 2012)
  31. Lasne F, Martin L, Crepin N, de Ceaurriz J (Dec 2002). "Detection of isoelectric profiles of erythropoietin in urine: differentiation of natural and administered recombinant hormones". Analytical Biochemistry. 311 (2): 119–26. doi:10.1016/S0003-2697(02)00407-4. PMID 12470670.
  32. Kohler M, Ayotte C, Desharnais P, Flenker U, Lüdke S, Thevis M, Völker-Schänzer E, Schänzer W (Jan 2008). "Discrimination of recombinant and endogenous urinary erythropoietin by calculating relative mobility values from SDS gels". International Journal of Sports Medicine. 29 (1): 1–6. doi:10.1055/s-2007-989369. PMID 18050057.
  33. Jelkmann W (2012). "The disparate roles of cobalt in erythropoiesis, and doping relevance". Open Journal of Hematology. 3: 3–6. doi:10.13055/ojhmt_3_1_6.121211.
  34. "Breathe it in". The Economist. 8 February 2014. Archived from the original on 16 August 2017. Retrieved 27 August 2017.
  35. 35.0 35.1 Lodewijkx HF, Brouwer B (Dec 2011). "Some empirical notes on the epo epidemic in professional cycling". Research Quarterly for Exercise and Sport. 82 (4): 740–54. doi:10.5641/027013611X13275192112069. PMID 22276416.
  36. Lundby C, Robach P, Boushel R, Thomsen JJ, Rasmussen P, Koskolou M, Calbet JA (Aug 2008). "Does recombinant human Epo increase exercise capacity by means other than augmenting oxygen transport?". Journal of Applied Physiology. 105 (2): 581–7. doi:10.1152/japplphysiol.90484.2008. hdl:10553/6534. PMID 18535134.
  37. 37.0 37.1 Harrison C (2003-03-01). "The Man Who Knows Too Much". Sport Monthly. chrisharrisonwriting. Archived from the original on 2014-02-26.
  38. 38.0 38.1 Gifford B (Jan–Feb 2006). "Paging Doctor Ferrari". Bicycling: 50–59.
  39. Maloney T (2003). "An Interview With Dr. Michele Ferrari, part two: That l'Equipe Interview". by Jean-Michel Rouet, from l'Equipe, 1994, reprinted excerpt. Cycling News. Archived from the original on 2009-07-28. Retrieved 2016-02-17.
  40. 10 liters of orange juice: see the article on Water intoxication, for example.
  41. Juliet Macur: Cycle of Lies: The Fall of Lance Armstrong
  42. Martin DT, Ashenden M, Parisotto R, Pyne D, Hahn AG (March–April 1997). "Blood testing for professional cyclists: What's a fair hematocrit limit?". Sports Science. Archived from the original on 2019-08-29. Retrieved 2016-02-17.
  43. "Pantani: Future 'in doubt'". BBC. 5 June 1999. Archived from the original on 29 October 2013. Retrieved 30 June 2011.
  44. Millar R (2003-10-23). "The Bare Minimum". Cycling News. Archived from the original on 2014-11-04. Retrieved 2016-02-17.
  45. Startt J (2012-10-15). "Christophe Bassons Interview: 'People Now See I Wasn't Lying'". This Just In. Archived from the original on 2013-11-04.
  46. "Stuart O'Grady admits to doping at 1998 Tour de France". 2013-07-25. Archived from the original on 2013-07-24. Retrieved 2013-07-25.
  47. "Landis admits to illegal drug use". BBC News. 2010-05-20. Archived from the original on 2016-01-05. Retrieved 2016-02-17.
  48. United States Anti Doping Agency. "Report on proceedings under the world anti-doping code and the usada protocol united states anti-doping agency, claimant, v. lance armstrong, respondent. reasoned decision of the united states anti-doping agency" (PDF). USADA. Archived (PDF) from the original on 2012-10-29. Retrieved 2012-10-28.
  49. "A lifetime ban: Does the time fit the crime?" Velo News, 12/16/13
  50. "U.S. Postal Service Pro Cycling Team Investigation". Statement From USADA CEO Travis T. Tygart Regarding The U.S. Postal Service Pro Cycling Team Doping Conspiracy. USADA. 2012-10-10.[permanent dead link]
  51. Chapman M (2012-10-15). "Cycling's Dirty Truth". Sport, Peddlers. BBC Radio 5. Archived from the original on October 16, 2012.
  52. Wathion, Noël. "Public statement on Dynepo (epoetin delta)" (PDF). European Medicines Agency. Archived (PDF) from the original on 24 September 2015. Retrieved 31 August 2015.
  53. Bauer, Kristian (2011). Ride a Stage of the Tour De France The Legendary Climbs and How to Ride Them. London: A & C Black. p. 35. ISBN 978-1-4081-3333-0.

External links

  • "Erythropoietin". Drug Information Portal. U.S. National Library of Medicine. Archived from the original on 2020-04-07. Retrieved 2020-04-07.
  • "Epoetin alfa". Drug Information Portal. U.S. National Library of Medicine. Archived from the original on 2020-04-07. Retrieved 2020-04-07.
  • "Epoetin beta". Drug Information Portal. U.S. National Library of Medicine. Archived from the original on 2020-04-07. Retrieved 2020-04-07.
  • "Darbepoetin Alfa". Drug Information Portal. U.S. National Library of Medicine. Archived from the original on 2020-04-07. Retrieved 2020-04-07.
  • "Methoxy polyethylene glycol-epoetin beta". Drug Information Portal. U.S. National Library of Medicine. Archived from the original on 2020-04-07. Retrieved 2020-04-07.