Route of EPO Administration

In the U.S., erythropoietin is typically delivered as 3x/week intravenous injections in the ESRD population. This turns out to be a fairly significant cost, as Medicare-related payments for EPO comprise about 25% of the ESRD budget, which itself is a significant chunk (about 6-7% as of 2002) of the overall Medicare budget.

This cost could probably be decreased by moving to subcutaneous dosing of erythropoietin. One study in France showed in a 1-year crossover study in which ESRD patients received subcutaneous dosing for 6 months, followed by intravenous dosing for 6 months, the EPO dose required to keep the Hgb within a usual target range was far less in the subcutaneous group (74 Units/kg/week) compared to the intravenous group (156 Units/kg/week).

I would imagine that the main barriers towards achieving this would be (a) financial--as it stands now, dialysis units make more money if they administer greater amounts of EPO, (b) legislative--the Social Security Act which has made the Medicare ESRD Program into what it is today specifies that self-administered medications are not covered by Medicare, (c) patient preference--most patients would prefer to avoid another needle stick each dialysis session, and (d) the status quo--that's just the way we're used to doing things.