According to guidelines, ESAs, with or without G-CSF, are considered a first-line treatment for patients with lower-risk non-del(5q) MDS and a low transfusion burden (<2 RBC units/month) or with serum EPO ≤500 mU/mL.2,17 Epoetin alfa is approved in the EU for treatment of symptomatic anemia (Hb level ≤10 g/dL) in adults with Low- or Int-1 risk primary MDS who have low serum EPO (<200 mU/mL). This evidence concerns the gene GSTM1 and anemia (phenotype).