[Importance of the different i.v. iron generations for everyday medical practice]. / Bedeutung der verschiedenen i.v.-Eisengenerationen für den medizinischen Alltag.

BACKGROUND: Iron deficiency and anaemia occur in particular in women or as comorbid conditions to a varietyof chronic diseases. Besides oral preparations, parenteral iron therapies are also available for the treatment of iron deficiency or anaemia. In the light of the growing importance and increasing number of parenteral iron preparations, theirpharmacology and application as well as the chronology of their approvals and thecharacteristicsof the various preparations are presented herefor comparison. METHOD: Review. RESULTS: To date, there are three different generations of parenteral iron preparations, which differ in terms of stability, safety and dosage. In particular, the active substances of the third generation, ferric carboxymaltose, iron isomaltoside and ferumoxytol are characterised by high complex stability and comparable safety, also allowing rapid application of high doses of iron. CONCLUSIONS: High molecular weight iron dextran, as a representative of 1st generation iron preparations, should no longer be used if possible, as more recent i.v. iron preparations are available with considerably lower risk of serious anaphylactic reactions. Ferrous gluconate and iron sucrose, as representatives of the 2nd generation, are very efficient preparations, but they require frequent visits to the clinic or the doctor, as they may only be administered in low doses because of labile iron complexes. The three 3rd generation parenteral iron formulations have advantages in handling in everyday practice, since they offer comparably good safety profiles, high complex stability and thus the possibility of rapid application of high doses of iron up to the total cumulative dose. Furthermore, test doses are not required with these preparations, which also simplifies their use.

Cinacalcet treatment of primary hyperparathyroidism.

Although parathyroidectomy remains the only curative approach to most primary hyperparathyroidism cases, medical treatment with cinacalcet HCl has been proven to be a reasonable alternative for several patient subgroups. Cinacalcet almost always controls hypercalcemia and hypophosphatemia sufficiently. PTH levels are lowered, and cognitive parameters improve. While an increase in bone mineral density DEXA scan scores was not demonstrated in cinacalcet trials, the same applies to more than half of patients after parathyroidectomy. Medical therapy should be first choice in patients with hyperplasia in all glands rather than an isolated adenoma (10-15%), patients with persisting HPT following unsuccessful surgery or inoperable cases due to comorbidities, and patients detected in lab screens for hypercalcemia before developing symptoms who should be treated early but are usually reluctant to undergo surgery. Nephrolithiasis was not found to occur more frequently in cinacalcet trial groups, but urine calcium excretion as one major risk factor of this complication of primary HPT may increase on cinacalcet. Patients carrying the rs1042636 polymorphism of the calcium-sensing receptor gene respond more sensitively to cinacalcet and have a higher risk of calcium stone formation. Cinacalcet is usually administered twice daily but three or four doses per day should be discussed to mimic the beneficial pulsatile PTH-pattern.

Clinical outcome and quality of life after interventional treatment of left main disease with drug-eluting-stents in comparison to CABG in elderly and younger patients.

INTRODUCTION: The aim of this study was to prospectively assess the clinical outcome and quality of life of elderly patients who underwent either coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) with drug-eluting stents (DES) for treatment of significant left main disease (LMD) compared to a younger patient population. METHODS: Consecutive patients, admitted into our institution between 04/2004 and 12/2007 with LMD and a life expectancy of >1 year were prospectively included and stratified in two groups (either CABG or left main stenting [LMS] with DES) based on the patients' age at inclusion (> or ≤75 years). Rates of death, myocardial infarction (MI), stroke, and target lesion revascularization (TLR) were evaluated over a 12 month follow-up. Six months after the initial procedure, additionally, quality of life was assessed using the SF-36 questionnaire. RESULTS: A total of 300 patients was included; 56 of the 95 PCI patients (59%) were ≤75 years and 39 (44%) >75 years, whereas 155 of 205 patients in the CABG group were ≤75 years (76%), and 50 patients (24%) were >75 years. Mean follow-up was 312 ± 226 days in the PCI and 377 ± 286 in the CABG group. Rates of death and MI were not significantly different between the four groups at the end of follow-up. There was no difference in quality of life after 6 months. CONCLUSION: In this prospective trial, PCI of LM with DES in elderly patients was feasible with a short- and intermediate term outcome comparable to CABG procedure and to a younger patient cohort.

Switch of ESA therapy from darbepoetin-alpha to epoetin-beta in hemodialysis patients: a single-center experience.

AIMS: No study has previously investigated a switch from darbepoetin-alpha to epoetin-beta in unselected dialysis patients. Our study determined the intravenous epoetin-beta dose necessary to maintain or to achieve hemoglobin targets after switching from darbepoetin-alpha. METHODS: In our dialysis center, all eligible dialysis patients (n = 90) were switched from darbepoetin-alpha i.v. to epoetin-beta i.v. in 2005. The epoetin-beta dose was calculated according to the recommended European equimolar conversion factor (1 : 200 microg darbepoetin-alpha corresponds to 200 IU epoetin-beta. The intraindividual evaluation compared 12 weeks before with 16 weeks after the switch. The dose of the erythropoiesis-stimulating agents (ESA) and the hemoglobin levels were analyzed for the whole period and for the last 4 weeks of both treatment periods. RESULTS: During treatment with darbepoetin-alpha, 71% of a total of 90 patients achieved a hemoglobin level > or = 11.0 g/dl. After switching to epoetin-beta, the mean hemoglobin level decreased significantly from 11.4 A+/- 1.0 g/dl to 11.1 A+/- 0.9 g/dl (p = 0.0016) and the percentage of patients with hemoglobin levels > or = 11.0 g/dl fell to 50% (p = 0.00138). Furthermore, the mean required ESA dose increased by 13% from 4,335 A+/- 3,217 IU/week darbepoetin-alpha to 4,885 A+/- 3,077 IU/week epoetin-beta (p = 0.0001). Comparing the last 4 weeks, the ESA dose increased by 17% from 4,583 A+/- 3,391 IU/week darbepoetin-alpha to 5,372 A+/- 3,672 IU/week epoetin-beta (p = 0.0003). CONCLUSIONS: After switching from darbepoetin-alpha i.v. to epoetin-beta i.v., the equimolar epoetin-beta dose was not sufficient to maintain hemoglobin levels with the same efficacy above 11.0 g/dl. Significantly less patients achieved hemoglobin target values as suggested by the EBPG guidelines.