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Bone marrow stimulation with G-CSF for lymphoma


Medical editor Harald Holte MD
Oncologist
Oslo University Hospital

Dag Torfoss MD
Infection Specialist
Oslo University Hospital

General

G-CSF (granulocyte colony-stimulating factor) is a hematopoetic growth factor. Human G-CSF is a glycoprotein which regulates production and liberation of neutrophile granulocytes from bone marrow.  

For bone marrow stimulation with G-CSF, the drugs Neupogen® and Neulasta® are injected subcutaneously. Neulasta® and Neupogen® are available in prefilled syringes. Neupogen® is given once daily during aplasia. Neulasta® has a protracted effect and is given only one day after chemotherapy (i.e. day 2-4).

The patients may administer the injection themselves at home if they are instructed and comfortable doing so.  

 

Indications

  • Mobilization of stem cells to peripheral blood for autologous stem cell harvesting, usually a dosage of 10 µg/kg/day.
  • For high-dose chemotherapy with autologous stem cell support (HMAS), where bone marrow is used as the stem cell source. 
  • Primary prophylaxis to maintain dose intensity for curative chemotherapy with documentation that this is not possible without G-CSF (for example CHO(E)P-14, dose-escalated BEACOPP).
  • Secondary prophylaxis for curative chemotherapy where the patient after previous chemotherapy developed neutropenic fever. 
  • Secondary prophylaxis to maintain dose intensity for curative chemotherapy where experience has shown that the patient developed neutropenia that would have led to neutropenia leading to dose reduction or postponement of therapy (for example CHOP-21, ABVD, standard BEACOPP)
  • Lasting neutropenic fever in a critically ill patient, for example serious pneumonia, hypotension, serious sepsis, or fungal infection. 

Preparation

  • Adequate information to the patient
  • Instruction in subcutaneous injection for patients giving self-injections.

  • Implementation

    • The Neupogen® dose is 5 µg/kg/day. For patients over 80 kg, 480 µg x 1 s.c. Otherwise, 300 µg x 1 s.c. (in protocol studies, dosage may be different). Neulasta® has a standard dosage of 6 mg s.c. (used only one day after chemotherapy).

    • G-CSF is used from 2–5 days after neutrophile > 5 x 109/l or > 1 x 109/l for three days.
    • Use of G-CSF for mobilization of stem cells to peripheral blood before autologous stem cell harvesting is usually given as 10 µg/kg/day distributed as two doses per day (morning and evening).
    • Before stem cell harvesting the entire dose is given in the morning.

    Follow-up

    • It is very important that the patient is informed of the risk for infections associated with low neutrophil counts.
    • Patients at risk for low leukocyte values must be given information about precautions for rising temperature. The patient should immediately contact a doctor if the temperature rises above 38.5 °C, or 38.0 °C measured over two hours.  
    • G-CSF may cause influenza-like symptoms as well as pain in large bone marrow-producing bones. The need for pain medication must be weighed against the fever-reducing effect. 
    • Some patients have required opiates for pain during treatment with growth factor. 

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