Iron is necessary for hemoglobin and red blood cell formation and function. It is advisable to administer iron at the start
of ESA therapy and with continued ESA usage to ensure adequate response.19 Iron can be supplemented orally or parentally. Oral iron, such as ferrous sulfate compounds, tends to be less effective,
is not well absorbed in the gastrointestinal system, and tastes bitter; hence, many animals reject oral iron. Recommended
dosages are 100 to 300 mg/day for dogs (providing 20 to 60 mg of elemental iron) and 50 to 100 mg/day for cats (10 to 20 mg
of elemental iron). Certain oral liquid multivitamins, such as Pet-Tinic (Pfizer Animal Health), contain about 14 mg of iron
per teaspoon. Iron tablets contain anywhere from 35 to 100 mg of iron.
Intramuscular iron dextran given every three or four weeks may be a better alternative. Dosages are typically 50 mg/cat and
10 to 20 mg/kg for dogs. Iron dextran administration may be painful, and iron dextran should not be given intravenously as
there is a risk of anaphylaxis. Although intramuscular administration is considered safe, a low risk of anaphylaxis exists
with this administration route, as well.33
Iron sucrose is used extensively in people and is given intravenously, but no reports exist of its use in animals.
Patient monitoring during iron therapy. Submit an iron panel (serum iron and ferritin concentrations, total iron-binding capacity, % transferrin saturation) before
and one month after starting iron therapy and every three months after that to estimate iron stores and prevent overdosing.
The lack of adequate iron stores is an important reason for ESA failure.34 However, aggressive administration of iron products may potentially cause oxidative stress.35 Thus, judicious use is recommended.
Transfusion of whole blood or packed red blood cell preparations is indicated when there is acute blood loss or when a patient
demonstrates clinical signs of anemia that require rapid correction. However, disadvantages of blood transfusions include
the possibility of immune reactions, incompatibility, the limited availability of blood products, the reduced lifespan of
infused blood products in a uremic patient, the associated costs, and the lack of long-term effectiveness of these products.3
Oxyglobin (OPK Biotech) is a hemoglobin-based oxygen carrier used in place of whole blood or packed red blood cells.36 Its main indication is for temporary oxygen-carrying capacity. Oxyglobin must be used with caution as fluid overload is
possible because of its high colloid oncotic pressure. The cost is a limiting factor, and the effects are short-lived. Oxyglobin
is unavailable at this time, and it is unclear if the product will return to the market.
B vitamins, such as vitamin B12, folic acid, niacin, and vitamin B6, are important for erythrogenesis. Supplementation is
recommended in polyuric patients; however, the contribution of vitamin supplementation to the overall correction of anemia
The administration of anabolic steroids such as nandrolone or stanozolol is not recommended because of the lack of efficacy
for correcting anemia and the high risk of liver toxicosis in cats.37,38