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Erythropoietin (EPO) is a glycoprotein hormone that primarily controls red blood cell production. Interest in utilizing this pharmaceutical agent to treat acute SCI stems from one of its most commonly studied secondary functions, the prevention of neuronal apoptosis in the presence of ischemia (Siren et al. 2001). Even less well understood, EPO has been shown to elicit anti-inflammatory properties, minimize lipid peroxidation, scavenge free radicals, regenerate axons, and reduce calcium ions and influx of glutamate in in vitro and in vivo animal studies (Matis & Birbilis, 2009). Experimental SCI studies in animal models to date have shown that EPO elicits a neuroprotective benefit that contributes to neurological recovery (Hong et al. 2011; Okutan et al. 2007).

Table 6. Erythropoietin for Neuroprotection in Acute SCI

Author Year

Country

Research Design

PEDro

Sample Size

MethodsOutcomes
Alibai et al. 2015

Iran

RCT

PEDro= 8

Ninitial= 27, Nfinal= 20

Population: Mean age= 40.1±9.5yr; Gender: male= 90%, female= 10%; Level of injury: cervical; Severity of injury: complete= 60%, incomplete= 40%

Treatment: Patients were first administered methylprednisolone per standard protocol. Patients were then randomly assigned to receive erythropoietin or placebo. The EPO dosage was 500 IU/mL immediately and 24 hours later.

Outcome Measures: Assessed baseline, 1, 6, and 12 months post-injury: ASIA sensory and motor scores.

Chronicity: Individuals were studied within 8 hr of sustaining injury.

1.     No significant differences between EPO and placebo groups on ASIA motor scores at any time point (p>0.05).

1.     No significant differences between EPO and placebo groups on ASIA sensory scores at any time point (p>0.05).

Costa et al. 2015

Italy

RCT

PEDro= 7

Ninitial= 19, Nfinal= 19

Population: Mean age= 27.67y Gender: male= 94.7%, female= 5.3%; Level of injury: cervical, thoracic; Severity of injury: AIS A or B

Treatment: Participants were randomized to receive either methylprednisolone or erythropoietin treatment groups for 48 hours.

Outcome Measures: ASIA motor and sensory, MAS, Penn Score, VAS, SCIM. Evaluated at baseline, day 3, 7, 14, 30, 60, and 90.

Chronicity: Screened and enrolled within 8 hours of sustaining injury.

1.     No between-groups difference on ASIA motor and sensory, MAS, Penn score, VAS or SCIM (p>0.05) at day 90.
Alibai et al. 2014

Iran

RCT

PEDro=6

N=30

Population: Age range=18-65 yr; Gender: male=77%, female=23%; Level of injury: cervical-thoracic; Severity of injury: complete=47%, incomplete=53%.

Treatment: Patients were randomly assigned to receive either recombinant human erythropoietin (rhEPO) + methylprednisolone sodium succinate (MPSS; 500 unit/kg of rhEPO) or placebo + MPSS. MPSS was administered according to National Acute Spinal Cord Injury Study (NASCIS) III guidelines.

Outcome Measures: The following after 1 week, 1 month, and 6 months: neurological recovery using the AIS.

The following after 6 months: sexual dysfunction.

Chronicity: Individuals studied were admitted to hospital within less than 6 hr after trauma.

1.     Patients who received rhEPO + MPSS recovered significantly more neurological function according to the AIS compared to patients who received placebo + MPSS after 1 week (p=0.046), 1 month (p=0.021) and after 6 months (p=0.018).

2.     There were no significant differences in sexual dysfunction between patients who received rhEPO + MPSS and patients who received placebo + MPSS (p>0.05).

Xiong et al. 2011

China

Prospective Control Trial

N=63

Population: Mean age=53 yr; Gender: male=62%, female=38%; Level of injury: cervical-thoracic; Severity of injury: complete=14%, incomplete=86%.

Treatment: Patients who developed ischemia-reperfusion injuries during spinal decompression surgery received either erythropoietin (EPO) + methylprednisolone (MP) or MP alone. MP was delivered intravenously according to National Acute Spinal Cord Injury Study (NASCIS) II guidelines. EPO was injected intramuscularly three times a week (3000U/vial) for 8 weeks.

Outcome Measures: The following after 1 week, 1 year, and 2 years: neurological recovery using ASIA score (motor function and sensory function), activities of daily living (ADLs), and adverse event outcomes.

Chronicity: Individuals were studied at 1 week, 1 year and 2 years post spinal surgery.

1.     Patients who received EPO + MP experienced significantly higher neurological recovery based on the ASIA scale compared to those receiving MP alone after 1 week, 1 year, and 2 years (p<0.05).

2.     Patients who received EPO + MP achieved significantly higher ADL scores than patients who received MP alone 1 week and 1 year after treatment (p<0.05).

3.     Three patients who received EPO + MP and two patients who received MP alone experienced adverse event outcomes that resolved after treatment. No statistical tests were performed to determine significant differences between the two groups.

Discussion

Two studies to date have shown promising results for EPO in treating acute SCI (Alibai et al. 2014; Xiong et al. 2011). It is important to note that these studies have very small sample sizes (n<70); further, study participants were neither blinded nor randomized. Large-scale RCTs are warranted to determine the effectiveness of EPO in treating acute SCI.

Conclusion

There is level 1b evidence (from one RCT and one prospective controlled trial; Alibai et al. 2014; Xiong et al. 2011) that erythropoietin is effective in promoting neurological recovery in acute SCI individuals.

Erythropoietin may be effective for neurological recovery during the acute phase post SCI.