Case # 4: 2011, OSHU:
Gyne cancer….
• 47 yo JW admitted with vaginal bleeding and uterine
pain; an abnormal pap in 2006 had been ignored/
treated homeopathically
• Hb 12.6 (4 mos pta)  3.7 gm/dl on admission;
MCV 70.8; reticulocyte count rel/abs: 3.3 (0.5-1.5)/
52.9 (10-90); INR 1.43; ferritin 19 (6-132); Cr 6.7
• Found to have stage IV cervical cancer with ureteric
obstruction  unable to stent  dialysis ~ 1 wk later
 Initially treated for anemia and coagulopathy with:
• IV Fe++: Venofer 200 qd x 5 days
• Folic acid, B12, IV Vit K
 Hb continued to decrease  3.0 gm/dl:
• Persistent reticulocytopenia despite Fe++
and hematinics
 High dose darbepoietin (200 mcgm q o d)
begun
 over next 2 weeks Hb 3.0  5.4 with
increase in reticulocyte count :
rel/abs: 3.3 (0.5-1.5) / 52.9 (10-90)
 12.3
/ 243.3
• Opted for palliative care; survived for 3 mos;
visited by many out of town relatives and
friends
• ESA use in adults with critical illness and with
malignancy is associated with increased
thrombogenicity (blood clots, heart failure,
myocardial infarction, stroke).
 consideration should be given to prophylactic
doses of antithrombotics when using ESAs in such
patients.
• In the case of cancer in adult populations, use of
ESAs is also associated with increases in mortality
independent of thrombogenicity and possibly
mediated by tumor receptors for ESAs and
promotion of angiogenesis.
• The U.S. Food and Drug Administration (FDA) issued a
block box warning for ESAs in 2007 (Mitka 2007) prompting
a series of revised clinical guidelines (see Rizzo et al 2010)
• As of 2010, the FDA is requiring that all ESAs given to
patients with malignancy be prescribed under a Risk
Evaluation and Mitigation Strategy (REMS) which includes
a medication guide to explain risks to patients and
caregivers, and the ESA APPRISE (Assisting Providers and
cancer Patients with Risk Information for the Safe use of
ESAs) Oncology Program
(http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafety
InformationforPatientsandProviders/ucm200297.htm).
Mitka M (2007) FDA sounds alert on anemia drugs. JAMA 297(17):1868-69.
Rizzo, JD, Brouwers M, Hurley Pet al. (2010) American Society of Hematology/
American Society of Clinical Oncology clinical practice guideline update on the
use of epoetin and darbepoetin in adult patients with cancer. Prepublished online as
Blood First Edition paper, October 25, 2010 DOI 10.1182/blood-2010- 08-300541
Summary: Jehovah’s Witness Patients:
• Transfusion alternatives and “fractions”
can be life-saving in Witness patients
• An integrated approach is best
• Work in partnership with the patient & JW
community; act as patient’s advocate.
• Know & explore the acceptability of the full
range of non-blood therapeutic options with
the patient--and use them!!
• Act pre-emptively if possible
• Realize physiological tolerance of anemia is
generally greater than you may think
• Don’t be afraid to get treatment advice
elsewhere and ask for help
• In pediatric patients use the same general guiding
principles as in other JWs; try to involve a JW
Hospital Liaison elder; communicate your legal
obligation to transfuse to preserve life/ prevent serious
harm to parents; try to avoid Court Orders
or get them limited to blood products alone
• Don’t be afraid of intraoperative salvage in
obstetrics
• Remember ESA’s work slowly, need Fe++ repletion,
and work better pre-op and in the absence of
inflammation; higher doses necessary post-op and in
inflammation; risk of thrombogenicity and cancer
progression and special consent (APPRISE) may be
needed in cancer (esp being treated curatively)
• Treatment of Witnesses poses many
challenges BUT can provide unique
opportunities both for learning and
for the exercise of compassion