Use of granulocyte colony stimulating factors in adult patients with chemotherapy-induced neutropenia and conditions other than acute leukemia, myelodysplastic syndrome, and hematopoietic cell transplantation
- Richard A Larson, MD
Richard A Larson, MD
- Editor-in-Chief — Hematology
- Section Editor — Leukemia
- Professor of Medicine
- University of Chicago Pritzker School of Medicine
Cytotoxic chemotherapy can cause profound and sometimes prolonged neutropenia, which may result in hospitalization for treatment of fever or cause potentially fatal infection [1,2]. Although profound prolonged neutropenia is most likely in the pre-engraftment phase of hematopoietic cell transplantation (HCT, particularly allogeneic) and in patients undergoing induction therapy for acute leukemia, chemotherapy-related neutropenia can also occur in patients receiving standard-dose chemotherapy for other neoplasms. In an attempt to decrease infectious complications, recombinant human granulocyte colony-stimulating factor (G-CSF, filgrastim and pegylated filgrastim) and granulocyte-macrophage colony-stimulating factor (GM-CSF, sargramostim) have been used to reduce the duration and degree of neutropenia.
The role of the G-CSFs in patients receiving standard dose myelosuppressive chemotherapy for conditions other than acute leukemia or myelodysplastic syndrome or in patients undergoing HCT will be reviewed here. The role of granulocyte CSFs in patients with myelodysplastic syndrome, in those undergoing induction chemotherapy for acute leukemia, and in the setting of HCT is addressed elsewhere, as are the potential side effects of CSFs (eg, bone pain, risk of therapy-related myeloid neoplasms). (See "Induction therapy for acute myeloid leukemia in younger adults", section on 'Prophylaxis' and "Treatment of acute myeloid leukemia in older adults", section on 'Use of growth factors' and "Management of the complications of the myelodysplastic syndromes", section on 'Myeloid growth factors' and "Prevention of infections in hematopoietic cell transplant recipients", section on 'Immunomodulation' and "Introduction to recombinant hematopoietic growth factors", section on 'Toxicity of colony-stimulating factors' and "Hematopoietic support after hematopoietic cell transplantation", section on 'Growth factor support'.)
An overview of neutropenic fever syndromes; antibacterial, antifungal, and antiviral prophylaxis for patients undergoing myelosuppressive chemotherapy or induction therapy for acute leukemia or HCT; and the management of patients with neutropenic fever are discussed elsewhere. (See "Overview of neutropenic fever syndromes" and "Prophylaxis of infection during chemotherapy-induced neutropenia in high-risk adults" and "Induction therapy for acute myeloid leukemia in younger adults", section on 'Prophylaxis' and "Prophylaxis of invasive fungal infections in adults with hematologic malignancies" and "Prophylaxis of invasive fungal infections in adult hematopoietic cell transplant recipients" and "Prevention of infections in hematopoietic cell transplant recipients" and "Treatment and prevention of neutropenic fever syndromes in adult cancer patients at low risk for complications" and "Treatment of neutropenic fever syndromes in adults with hematologic malignancies and hematopoietic cell transplant recipients (high-risk patients)".)
Neutropenia — Although definitions are variable from institution to institution, neutropenia is defined as an absolute neutrophil count (ANC) of <500/microL, or an ANC that is expected to decrease to <500/microL within the next 48 hours . Profound neutropenia is defined as an ANC <100/microL. The ANC is equal to the product of the white blood cell count (WBC) and the fraction of polymorphonuclear cells (PMNs) and band forms:
ANC = WBC (cells/microL) x percent (PMNs + bands) ÷ 100
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- GRANULOCYTE COLONY STIMULATING FACTORS
- Primary prophylaxis
- - Indications, benefits, and guidelines
- - Use with concomitant chemoradiotherapy
- Secondary prophylaxis
- Therapeutic use in patients with neutropenia
- - Neutropenia without fever
- - Neutropenic fever
- GM-CSF versus G-CSF
- Dose and timing of G-CSF and GM-CSF
- - Pegfilgrastim and other long-acting agents
- Possible stimulation of malignancy
- SUMMARY AND RECOMMENDATIONS
- Primary prophylaxis
- Secondary prophylaxis
- Patients with neutropenia