Use of subcutaneous injections of Epogen for dialysis patients could save Medicare $537 million annually

Administering the anti-anemia drug Epogen to kidney dialysis patients by subcutaneous injections rather than intravenously could save the federal government hundreds of millions of dollars annually, the Boston Globe reports.

Epogen, which is manufactured by California-based Amgen, is administered to kidney disease patients on dialysis to replenish red blood cells. About 95% of the 325,000 U.S. residents on dialysis receive Epogen intravenously, although studies have found that about 30% less Epogen is required if the drug is injected under the skin, the Globe reports. Medicare spends close to $2 billion per year on Epogen, more than on any other drug. According to a study conducted by researchers at Detroit-based Henry Ford Hospital and published in the American Journal of Kidney Disease, administering Epogen subcutaneously rather than intravenously would save the federal government as much as $537 million annually. The study found that the annual Epogen cost per dialysis patient in 2002 was $6,000. Researchers determined that switching to subcutaneous injections would save up to 30%, or $1,761, per patient. A separate study of dialysis clinics in 2004 found that patients received 21% less Epogen when given subcutaneous injections, the Globe reports. Last year, FDA allowed Amgen to change the label on Epogen to state that intravenous delivery is preferred because of a rare disorder called pure red cell aplasia that developed in 175 patients from 1998 through 2003. Those patients received Eprex, a drug similar to Epogen that is manufactured by a Johnson & Johnson subsidiary. J&J said the cases likely were linked to rubber stoppers in some of its syringes and that the outbreak ended after the stoppers were replaced.

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California-based DaVita and Germany-based Fresenius Medical Care, the two leading dialysis clinic chains in the U.S., have said they prefer to administer Epogen intravenously because patients already have IVs inserted while they undergo dialysis, according to the Globe. DaVita chief medical officer Charles McAllister said, "We don't have any opinion on subcutaneous or intravenous" methods, adding that doctors at the company's clinics determine the best way to give Epogen. Fresenius did not comment. Robert Brenner, an Amgen medical director, said, "It is important for patients and physicians to make their own decisions," adding, "Where patients are hooked up to a blood line to a dialysis machine, there would be some logic to have that administration occur intravenously, as opposed to having that patient exposed to an additional injection." Some kidney specialists and patient advocates say DaVita and Fresenius use the intravenous method to boost profits. Noshi Ishak, a kidney specialist who owns an independent dialysis clinic in New Hampshire, said DaVita and Fresenius "give it intravenously" to "milk the system." Ishak, who uses the subcutaneous method, said Amgen sales representatives have told him that he could increase his profits by administering the drug intravenously. Peter Crooks, who oversees dialysis of 3,000 patients for Kaiser Permanente in Southern California, said, "The industry is incentivized to use intravenous because they make a profit margin on every unit they administer," adding, " Many dialysis facilities feel that if it wasn't for the profit margin they make on [Epogen], they would go out of business" (Rowland, Boston Globe, 10/24).