@stragale Stagale, I hope that you have success in resolving your blood count issues.

I too have low hemoglobin, not as severe as you have, but troublesome to me. Your problem appears to be loss of red blood cells after they have been created. My problem is that the production of red blood cell is not sufficient to maintain hemoglobin above anemia levels.

In the first 2 years of ADT my hemoglobin dropped from 13.5 to an average of 12.6, which I find from research is the normal effect of ADT. It then proceeded on down to 11.2. I brought this to the attention of my oncologist and he referred ma to a hematologist on the staff of the provider group. A test indicated that the kidneys were not producing sufficient Erythropoietin to stimulate the bone marrow to make an adequate number of red blood cells. I attribute the damage to the kidneys to the ADT treatment, although I found there is little information on this in the literature.

The plan of the hematologist is to monitor the hemoglobin levels and when if falls below 10, and I am symptomatic for anemia, to use erythropoiesis-stimulating agents (ESAs) to raise the hemoglobin level modestly. The hematologist warned the ESAs can cause blood clots and other cardiac events. The FDA black box for an EAS drug has this at the beginning;

WARNING: ESAs INCREASE THE RISK OF DEATH,
MYOCARDIAL INFARCTION, STROKE, VENOUS
THROMBOEMBOLISM, THROMBOSIS OF VASCULAR ACCESS
AND TUMOR PROGRESSION OR RECURRENCE

Not a very good indication.

Recently I saw some articles that mentioned that patients with chronic kidney disease and or diabetics have modest increases in hemoglobin from the use of Sodium-Glucose Transport 2 (SGLT2) Inhibitors. The increase is about 0.7 g/dL, admittedly small but any gain in my book is good. I showed the articles to the oncologist, he asked if I was willing to take the medication, and when I said yes he refereed me to the endocrinologist on the staff of the group. The endocrinologist said he never prescribed the medication for the purpose of raising the hemoglobin, but if I was willing to try it, he would prescribe it.. Now I am in my first week of taking Dapagliflozin (Farxiga®) 5 mg tablets. I won't know the results for at least a month and perhaps 4 months.

Since the SGLT2 Inhibitors require prior approval by my insurance plan I may not be reimbursed for the cost of this medication. Since I am outside of the United States the cost per month is about $30, whereas in the United States the cost would be several hundred dollars per month.