G-CSF 與 pegfilgrastim

Buzzwords → Dx

Workup before initiation

• Cancer + chemo regimen FN risk assessment.
• Risk factors: age >65, prior chemo / RT, baseline cytopenia, mucositis, CHF, CKD, infection.
• Schedule: start 24–72 h post-chemo; pegfilgrastim ≥24 h before next chemo cycle.

Indications

1. Primary prophylaxis for chemo with FN risk ≥20 %.
2. Secondary prophylaxis for previously febrile cycle.
3. Stem cell mobilization (autologous / allogeneic).
4. Severe neutropenia in MDS / AA / cyclic neutropenia / chronic idiopathic neutropenia.
5. Adjunct in serious FN with infection-related complications (high-risk pts; per ASCO 2015).
6. Marrow transplant to accelerate engraftment.

Treatment Algorithm

flowchart TD
  A[Chemotherapy planned] --> B[Calculate FN risk per regimen]
  B --> C{FN risk?}
  C -- ≥20% --> D[Primary G-CSF prophylaxis<br>filgrastim daily or pegfilgrastim per cycle]
  C -- 10-20% with risk factors --> D
  C -- <10% --> E[No primary ppx<br>monitor; secondary if FN occurs]
  E -- FN occurs --> F[Add secondary G-CSF prophylaxis next cycle]
  D --> G{Concurrent radiation to mediastinum / chest?}
  G -- yes --> H[Avoid G-CSF during RT; reactive pneumonitis risk<br>esp. with bleomycin]
  G -- no --> I[Standard G-CSF dosing]
  D --> J{Stem cell mobilization}
  J -- autologous --> K[G-CSF 10 µg/kg/d × 5 d<br>± plerixafor for hard-to-mobilize]
  J -- allogeneic donor --> L[G-CSF 10 µg/kg/d × 5 d]

Pearls / Pitfalls

• G-CSF + bleomycin → synergistic pulmonary toxicity — avoid concurrent. Modern HL regimens often omit bleomycin if PET-2 negative (RATHL).
• Pegfilgrastim must be given ≥24 h post-chemo AND ≥14 d before next chemo — premature dosing risks myelosuppression accumulation.
• Bone pain is most common AE — treat with loratadine or NSAIDs (often more effective than opioids; ASCO recommends).
• G-CSF for AML / MDS in remission: avoided in active disease (theoretical leukemia stimulation); used post-induction once recovery starts.
• Avoid in CML / aggressive MDS (theoretical risk of myeloid clone stimulation).
• Spleen rupture is rare but reported with mobilization — counsel about LUQ pain.
• Mobilization failure (<2 × 10⁶ CD34+/kg) — plerixafor (CXCR4 antagonist) added to G-CSF rescues most.
• Severe chronic neutropenia (Kostmann syndrome, cyclic, CIN) — chronic low-dose G-CSF effective; monitor for MDS/AML evolution.
• G-CSF in FN sepsis — adjunctive role per ASCO 2015 in high-risk FN with serious complications; not routine.
• Pegfilgrastim on-body injector (Onpro) — automated 27 h post-chemo delivery; alternative to clinic visits.

Cross-references

• Febrile Neutropenia — primary use
• Hematopoiesis + mobilization
• Auto-HCT — G-CSF mobilization
• HL — bleomycin avoidance
• Drug Regimens — filgrastim, pegfilgrastim, plerixafor

相關題目

• Q-196 — G-CSF — primary prophylaxis indication
• Q-197 — G-CSF + bleomycin combination
• Q-198 — G-CSF — bone pain management

Sources