Background Erythropoiesis stimulating agents (ESAs) has been shown to be highly effective in anaemia in chronic kidney disease (CKD). Various biological ESAs are available such as epoetin alfa, beta, darbepoetin alfa and C.E.R.A, including three biosimilars, epoetin alfa, zeta and theta. National regulations are trying to promote the prescription of the biosimilars, especially in ESA-naive patients. Switching between products is not recommended and the pharmacist can’t replace one epoetin with another. However, changes do occur in clinical practise.

Purpose In the Pharmacy Department of the Palermo Local Health Unit (LHU) we observed that nephrologists frequently switch patients but not in order to reduce costs. Therefore, the aim of this study was to calculate the prevalence and patterns of switching and to evaluate the reasons for them and the results for these changes.

Materials and Methods Distributing all the epoetins, after a discharge or a DH (docetaxel/trastuzumab) regimen and ensuring appropriate continuity of care, the Department collected and retrospectively analysed an electronic database with all the prescriptions for both non-dialysis-dependent CKD or dialysis patients. Furthermore, haemoglobin levels (Hb) were collected, if available, from the paper prescriptions. The period of observations was January 2011–June 2012.

Results 2,711 patients received an epoetin for CKD (from a population of 750,550). 368 patients (13.6%) had been switched. Of this group, only 194 patients were evaluable (98 female, mean age 73.57+-SD:14.21). The inclusion criteria were: receiving ESAs for at least four months; less than 60 days between two prescriptions. Treatments were less commonly switched from biosimilars than originator formulations. Only in 7 cases did nephrologists cite the lack of efficacy of the ESA previously administered, with demonstrated worsening of the patient’s clinical status (Aranesp 4, Mircera 2 and NeoRecormon 1). In 9 cases we assumed lack of efficacy of the first ESA, based on measurement of the haemoglobin (Hb) values. In the following prescription the clinicians switched and reported an Hb level lower than the first (≤10 g/L). In 24 cases, the ESAs varied with the prescriber. There was no reason for the switch or it was made for trivial reasons. 5 changes from the biosimilar were the pharmacist’s wrong decision, due to not checking the patient’s last prescription on the database. 5 changes from Mircera occurred after the announcement of a worldwide shortage. Only in 9 cases had the clinicians decided to shift toward a biosimilar on cost grounds. In the remaining cases, Hb levels remained stable before and after the switch. We can also state that no spontaneous reports of adverse drug reactions regarding ESAs have been received.

Conclusions Our results demonstrates that all the switches were well tolerated. This may support the use of biosimilars in terms of safety and efficacy and switches towards less expensive epoetins. The decision to start ESA treatment with a biosimilar must be considered, and it will also be possible to change pretreated patients.

No conflict of interest.