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Anemia is a common comorbidity in patients with acute and chronic heart failure (HF) with preserved and reduced systolic function. It is recognized as a new therapeutic goal in HF since the reduction in hemoglobin levels is considered a significant independent predictive factor of mortality and hospitalization. At present, it is difficult to determine the real magnitude of the problem in terms of actual incidence and prevalence as no consistent definition of anemia associated with HF does exist, and a variety of hemoglobin thresholds have been used in clinical trials and epidemiological studies. The etiology of anemia is multifactorial with the main causes including renal failure, gastrointestinal bleeding and nutritional deficiency. Nevertheless, such criteria are not present in some patients, who show a peculiar type of anemia that may be classified as anemia of chronic diseases, likely due to the chronic inflammatory process of HF. No guidelines for the treatment of anemia in HF patients are available. Most of the previous studies in the literature are limited by small sample sizes. The very few randomized multicenter studies that evaluated the effects of erythropoiesis-stimulating agents associated with intravenous iron therapy did not provide the expected results. Indeed, despite an increase in hemoglobin levels, they did not show any improvement of NYHA functional class, nor of left ventricular ejection fraction. In addition, reasonable hemoglobin levels as a goal of therapy have not been established yet, in particular in relation to the side effects and the cardiovascular risk observed after the administration of erythropoiesis-stimulating agents in oncologic patients. Further studies are warranted to define the magnitude of the problem and establish appropriate therapeutic strategies. It is likely that more reliable data will be derived from an ongoing randomized, double-blind, multicenter study, the RED-HF (Reduction Event with Darbepoetin alfa in Heart Failure), which aims at evaluating morbidity and mortality in a cohort of 2600 HF patients with anemia treated with darbepoetin alfa.

Due to the increased emphasis on cost-containment, drugs must be proven not only to be safe and effective, but also to reduce costs, prior to be used in clinical practice. In the context of this saving policy, 12 clinically stable patients on hemodialysis who were administered darbepoetin-alpha (Aranesp (DARB) for at least 16 months in single weekly doses, were converted to EPO-alpha, administered 2-3 times per week. The initial dose of EPO-alpha was calculated on the basis of a dose-conversion ratio (DCR) of 200 IU EPO-alpha = 1 mcg DARB. The mean Hb value in the six months preceding the conversion was between 11 and 12 g/dL, with a monthly dose of DARB unchanged/ reduced during the last three months. During the last month of treatment with DARB, the mean Hb value of the cohort was 11.4+/-0.5 g/dL and the mean weekly dose per patient was 24 +/- 12 mcg. After two months of EPO-alpha use, the mean Hb value dropped to 10.8+/-0.7 g/dL, with a mean monthly dose per patient of 5.667+/-2.229 IU, corresponding to a DCR of 234. In order to bring the Hb values back to above 11 g/dL, doses of EPO-alpha were progressively increased up to a maximum of 10.000+/-5.461 IU per patient, corresponding to a DCR of 414. The attempt to convert 12 hemodialysis patients treated with darbepoetin-alpha to an ESA with an apparent lower cost resulted in a worsening of the anemia of the patients after the conversion. Instead of leading to savings, the conversion actually increased expenditures.

Blood Doping has recently obtained a large diffusion between professional and nonprofessional athletes, in particular for endurance sports it has almost become a necessary way to warrant best performance. Seven years after the publication of our article "Blood Doping", this second installment was born to emphasize the way the biomedical research supplies (often unintentionally) new drugs and new technology to improve athletic performance and, on the other hand, to underline the antidoping strategies.

Background: Darbepoetin alpha is a novel erythropoiesis stimulating protein with unique properties as compared to recombinant human erythropoietin (rHuEPO), including a three-fold longer elimination half-life that allows for less frequent dosing. This study was aimed at testing the efficacy and safety of darbepoetin alpha in a large number of chronic dialysis patients switched from rHuEPO., Methods: Nine hundred and fifty dialysis patients in stable treatment with rHuEPO were switched to darbepoetin alpha. Patients receiving rHuEPO 2 or 3 times weekly were switched to once weekly darbepoetin alpha and those receiving rHuEPO once weekly were switched to once every other week darbepoetin alpha. Patients received darbepoetin alpha by the same route of administration (SC or IV) as the one used for rHuEPO. The unit doses of darbepoetin alpha (10-150 microg) were titrated to maintain haemoglobin concentration within -1.0 and +1.5 g/dL of the individual mean baseline haemoglobin levels and between 10 and 13 g/dL for 24 weeks., Results: The mean change in haemoglobin from baseline to the evaluation period (weeks 21-24) was statistically but not clinically significant [-0.10 g/dL (95% CI: -0.18, -0.02]. In general, the geometric mean weekly dose of study drug from screening/baseline to evaluation period remained substantially unmodified [(from 26.10 micro g/wk to 25.90 microg/wk; percentage change -0.40% (95% CI: -3.78, 3.10)]. Overall, darbepoetin alpha was well tolerated., Conclusions: The treatment of anaemia of a large dialysis patient population with unit dosing of darbepoetin alpha is effective and safe in maintaining target haemoglobin concentration at reduced dose frequency.