Dosage and Administration
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Filgrastim is available in vials, single-use prefilled syringes, or in multipacks of vials or syringes. Pegfilgrastim is available in vials, prefilled syringes, or a new wearable delivery device the nurse places on the patient that administers the drug the next day.
Prophylactic use of G-CSF is recommended for patients whose risk for febrile neutropenia is greater than 20%. In cases of curative or life-extending treatment, filgrastim or biosimilar dose is 5 mcg/kg (rounding to the nearest vial or syringe defined by institution weight limits). Doses are usually started the next day (24 hours) or up to 4 days after completion of chemotherapy and continue until nadir ANC recovery is met or near to normal levels by laboratory standards.5
Recommendations call for pegfilgrastim administration 24 hours after completion of chemotherapy. Because pegfilgrastim is a longer acting form of filgrastim, a single 6-mg dose is sufficient for each chemotherapy cycle.5
Nursing Management
White and colleagues stress the importance of making sure the patient and family understand the chemotherapy regimen and the risk for neutropenia and infection.10 Education for the family members and/or the caregivers should include risk factors associated with neutropenia and signs and symptoms of infection. In addition, the importance of undergoing weekly laboratory tests for blood cell counts, strict adherence to hand washing practices, and avoidance of people who may be infectious or ill when the patient has reached nadir.
Adverse skin reactions are associated with G-CSFs, in particular filgrastim. The patient’s skin should be carefully examined prior to injection of G-CSF medications to ensure early recognition of skin reactions should they occur. Pegfilgrastim is a glycosylated form of filgrastim, which therefore has a prolonged effect, reduced renal clearance, and usually few side effects. However, immediate type hypersensitivity reaction with filgrastim and biosimilars have been reported.11
G-CSF therapy should continue until nadir ANC recovery is met. The need for continuing therapy is determined via weekly blood counts, depending on chemotherapy regimen.
Patients receiving G-CSFs should be assessed for pain. Patient education should include potential causes of pain and use of pain-relieving agents, such as antihistamines. Acetaminophen and NSAIDS are avoided due to their risk of masking fever, which may be one of the first signs of infection. However, if pain is severe, acetaminophen, NSAIDS, or opioid may be considered for pain management.12
Careful records regarding administration of G-CSFs are essential. These agents may influence diagnostic imaging results, leading to false positives.
In addition to patient education on G-CSF therapy, patients using the new wearable device also need information on how the device works and how to troubleshoot potential problems. Their family and/or caregivers also need to be trained about how to manage the device.
Conclusion
Oncology nurses are responsible for maintaining a familiarity with existing therapies, their potential adverse effects, and available formulation and alternate options. They are also charged with being able to advocate for the patient in discussions with primary healthcare clinicians about the available options regarding G-CSF therapy, including alternate formulations, offering a better adverse effect burden; biosimilars, which may be more affordable than the originator drug; and novel administration methods, which may reduce the need multiple clinic visits.
References
1. Actor JK. Introductory Immunology: Basic Concepts for Interdisciplinary Applications. San Diego, CA: Academic Press; 2014.
2. Panopoulos AD, Watowich WW. Granulocyte colony-stimulating factor: molecular mechanisms of action during steady state and ‘emergency’ hematopoiesis. Cytokine. 2008;42(3):277-288.
3. Hübel K, Dale DC, Liles WC. Therapeutic use of cytokines to modulate phagocyte function for the treatment of infectious diseases: current status of granulocyte colony-stimulating factor, granulocyte-macrophage colony-stimulating factor, macrophage colony-stimulating factor, and interferon-gamma. J Infect Dis. 2002;185(10):1490-1501.
4. Neupogen® (filgrastim). http://www.neupogenhcp.com. Accessed October 18, 2017.
5. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Myeloid growth factors. Version 2.2017 — October 13, 2017. https://www.nccn.org/professionals/physician_gls/pdf/myeloid_growth.pdf. Accessed October 18, 2017.
6. Mitchell S, Li X, Woods M, et al. Comparative effectiveness of granulocyte colony stimulating factors to prevent febrile neutropenia and related complications in cancer patients in clinical practice: a systematic review. J Oncol Pharm Pract. 2016;22(5):702-716.
7. Smith TJ, Khatcheressian J, Lyman GH, et al. 2006 update of recommendations for the use of white blood cell growth factors: an evidence-based clinical practice guideline. J Clin Oncol. 2006;24(19):3187-3205.
8. D’Souza A, Jaiyesimi I, Trainor L, Venuturumili P. Granulocyte colony-stimulating factor administration: adverse events. Tranfus Med Rev. 2008;22(4):280-290.
9. Lambertini M, Del Mastro L, Bellodi A, Pronzato P. The five “Ws” for bone pain due to the administration of granulocyte-colony stimulating factors (G-CSFs). Crit Rev Oncol Hematol. 2014;89(1):112-128.
10. White N, Maxwell C, Michelson J, Bedell C. Protocols for managing chemotherapy-induced neutropenia in clinical oncology practices. 2005;28(1):62-69.
11. Dadla A, Tannenbaum S, Yates B, Holle L. Delayed hypersensitivity reaction related to the use of pegfilgrastim. J Oncol Pharm Pract. 2015;21(6):474-477.
12. Moore K, Haroz R. When hydromorphone is not working, try loratadine: an emergency department case of loratadine as abortive therapy for severe Pegfilgrastim-induced bone pain. J Emerg Med. 2017;52(2):e29-e31.
