Is there a role for adjuvant therapy in patients being treated with epoetin?

Adjuvant therapy may allow patients being treated with epoetin to derive gr eater clinical benefits. Iron supplementation is currently the most widely used form of adjuvant therapy; intravenous (i.v.) iron is required by the m ajority of haemodialysis patients receiving epoetin. Measurement of hypochr omic red blood cells is the most direct way of assessing iron supply to the bone marrow. During the correction phase, a dose of i.v. iron equivalent t o 50 mg/day if recommended, with the total dose not exceeding 3 g. When sub clinical vitamin C deficiency is suspected. ascorbic acid may be given oral ly (1-1.5 g/week) or i.v. (300 mg three times weekly at the end of dialysis ). The active vitamin D metabolites alfacalcidol and calcitriol may, under some circumstances, improve anaemia and reduce epoetin dosage requirements. Vitamin B-6 requirements are increased during epoetin therapy, and supplem entation at a dose of 100-150 mg/week is recommended. Supplementation of vi tamin B-12 is optional. Folic acid is supplemented routinely in haemodialys is patients, though evidence that it increases the efficacy of epoetin is l imited. Low doses (2-3 mg/week) should normally be sufficient to maintain o ptimal folic acid stores in epoetin-treated patients, although higher doses are necessary for patients with hyperhomocysteinaemia. L-Carnitine supplem entation may be appropriate in some patients with anaemia of chronic renal failure (CRF) unresponsive to, or requiring large doses of, epoetin. Androg ens potentially could reduce epoetin costs in countries with limited resour ces, but should only be used in men older than 50 years with a remnant kidn ey. Recent animal studies indicate that the combination of epoetin and insu lin-like growth factor 1 might be beneficial in CRF patients. High doses of angiotensin-converting enzyme (ACE) inhibitors should be reserved for dial ysis patients who have hypertension that cannot be controlled by other agen ts, or who require an ACE inhibitor for treatment of heart failure.