Optimizing Anemia Management in CKD: A Focus on Ferric Carboxymaltose

Anemia is commonly associated with chronic kidney disease (CKD) and associated with CKD progression, cardiovascular risk, mortality, poor quality of life and increased hospitalizations. Iron therapy and erythropoiesis stimulating agents (ESAs) are cornerstones in the management of anemia in CKD. There are various challenges associated with anemia management in CKD e.g. undertreatment, target hemoglobin level achievement, paradoxical outcomes with ESAs. Recent years, there has been shift in focus towards utilizing iron therapy compared to ESA in the management of anemia. Ferric carboxymaltose (FCM) is an intravenous iron preparation that has shown efficacy and safety for iron deficiency anemia management in CKD patients. Inj. FCM can be administered as high dose (1000 mg) in single administration and rapidly replenishes iron stores. It also avoids the need of ESA and in patients on ESA, it reduces up to 36% of ESA dose requirement. It also provides favorable adherence and overcomes limitations of oral iron (gastrointestinal side effects, reduced intestinal absorption of iron due to hepcidin). FIND-CKD trial has confirmed efficacy and safety of inj. FCM in CKD patients not on dialysis. However, REVOKE trial with iron sucrose in similar patient population was terminated early due to higher risk of serious adverse events observed in the iron sucrose group. Recent data indicating significantly less liver iron concentration with inj. FCM compared to iron sucrose may explain these apparent paradoxical results of FIND-CKD and REVOKE trials. Inj. FCM is also associated with less release of labile iron compared to iron sucrose and has not been associated with acute endothelial dysfunction unlike iron sucrose. Routine intravenous FCM treatment in an outpatient clinic of non-dialysis dependent (NDD)-CKD patients result in better correction of iron-deficiency anemia when compared to oral ferrous sulfate. Early treatment of anemia with inj. FCM has potential to improve outcomes. Inj. FCM will be beneficial to CKD patients with anemia across the spectrum, i.e. both CKD patients not on dialysis as well as patients on dialysis. Overall, the administration of intravenous ferric carboxymaltose appears to be the best answer available for addressing the challenges in the anemia management in CKD.