# Anaemia during chemotherapy: investigation, iron and erythropoiesis-stimulating agents

Source: https://onco.cc/protocols/chemotherapy-induced-anaemia-esa-and-iron/  
OnCo record `chemotherapy-induced-anaemia-esa-and-iron` (Protocol). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Chemotherapy often lowers the red blood cells, causing tiredness and breathlessness. Your team should first look for other causes such as low iron or blood loss. If the treatment is not aimed at cure, injections that stimulate red cell production (ESAs) or a blood transfusion are options; if the aim is cure, ESAs are not used because of their risks.

## Summary

ASCO/ASH (2019) ask clinicians first to look for and treat other causes of anaemia (drug history, blood film, iron studies including ferritin and transferrin saturation, folate, vitamin B12, reticulocytes, occult blood loss, renal function, erythropoietin level, thyroid where indicated). ESAs may be offered for chemotherapy-associated anaemia when treatment is not curative in intent and haemoglobin has fallen below 10 g/dL, with red cell transfusion as an alternative (evidence based, high quality, strong); they should not be offered when treatment is curative (strong), nor to most people whose anaemia is not chemotherapy-associated (strong), except lower-risk myelodysplastic syndromes with erythropoietin 500 IU/L or below.

ESAs raise the risk of venous thromboembolism (high quality, strong), so the risk is weighed for each person. Doses follow the product's licence; haemoglobin is raised only to the lowest level that avoids transfusion; ESAs stop if there is no response in 6 to 8 weeks, prompting a search for progression or iron deficiency (strong). Iron replacement may be used with an ESA, with baseline and periodic iron studies (weak). In myeloma, non-Hodgkin lymphoma and CLL the response to cancer treatment is observed before an ESA is considered. NICE TA323 recommends ESAs within their licences for anaemia in people having chemotherapy, choosing the cheapest suitable product. Epoetin alfa and beta, darbepoetin and biosimilar epoetin alfa are considered equivalent.

## Fields

- Kind: Protocol
- Last checked: 2026-11-11
- Also known as: chemotherapy-induced anaemia; ESA in cancer; epoetin for anaemia in cancer; darbepoetin; iron for anaemia during chemotherapy; cancer-associated anaemia
- Tags: protocol; anaemia; supportive-care

## Connected records

- cancers: [Myelodysplastic syndromes / neoplasms (MDS)](https://onco.cc/cancers/mds/)
- protocols: [Red cell and platelet transfusion thresholds in cancer care](https://onco.cc/protocols/red-cell-and-platelet-transfusion-thresholds/)
- fronts: [Supportive Care & Survivorship](https://onco.cc/fronts/supportive-care/)
- technologies: [Transfusion support and anaemia management](https://onco.cc/technologies/transfusion-support/)
- drugs: [Darbepoetin alfa](https://onco.cc/drugs/darbepoetin-alfa/), [Epoetin alfa](https://onco.cc/drugs/epoetin-alfa/), [Epoetin theta](https://onco.cc/drugs/epoetin-theta/)
- institutions: [American Society of Clinical Oncology (ASCO)](https://onco.cc/institutions/asco/), [National Institute for Health and Care Excellence](https://onco.cc/institutions/nice/)
- terms: [Anaemia](https://onco.cc/terms/anaemia/)

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