Pegfilgrastim


Article Author:
Savannah Parker


Article Editor:
Tibb Jacobs


Editors In Chief:
Lauren Camaione


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Kavin Sugumar


Updated:
1/6/2019 7:11:12 PM

Indications

Pegfilgrastim is a pegylated granulocyte colony-stimulating factor that is FDA-approved to decrease the risk of patients developing febrile neutropenia when receiving myelosuppressive chemotherapy regimens. For primary prophylaxis, the risk of developing febrile neutropenia should be 20% or higher, and there should be no other safer regimen that is equally effective available to the patient. A patient's chance for developing febrile neutropenia is determined by definable risk factors, listed here:

  • 65-years-old or older
  • Advanced disease
  • Previous chemotherapy or radiation therapy
  • Preexisting neutropenia or bone marrow involvement with a tumor
  • Infection
  • Open wounds or undergoing recent surgery
  • Poor performance or nutritional status
  • Impaired renal function
  • Inadequate liver function, mainly indicated by elevated bilirubin
  • Cardiovascular disease
  • Multiple comorbid conditions
  • HIV

It is important to note that the risk for developing febrile neutropenia is less than 20% in many readily used chemotherapy regimens. Therefore, it is essential to make individualized, patient-based decisions when deciding if the use of a granulocyte-colony-stimulating factor is required.[1]

Pegfilgrastim is also FDA-approved to help increase the survival of patients exposed to myelosuppressive doses of radiation. Receiving acute myelosuppressive doses of radiation is a syndrome known as Acute Radiation Syndrome, and pegfilgrastim's indication is for the hematopoietic sub-syndrome.[2]

Mechanism of Action

Pegfilgrastim is the long-acting form of filgrastim, both of which are granulocyte colony-stimulating factors. Pegfilgrastim has a polyethylene glycol molecule covalently bound to it, which results in its prolonged duration of action. It helps prevent febrile neutropenia by increasing the body's neutrophil level by inducing neutrophil proliferation, differentiation, and maturation. It also enhances the survival of mature neutrophils.[3]

Administration

Pegfilgrastim has specific administration instructions for both the prevention of febrile neutropenia and the prevention of the hematopoietic sub-syndrome of acute radiation syndrome.

For the prevention of febrile neutropenia, a 6 mg dose of pegfilgrastim is given to the patient at least 24 hours after receiving chemotherapy.[1] It has two administration options; one is a pre-filled syringe and the other an on-body injector. Both the pegfilgrastim pre-filled syringe and on-body injector are typically given either on the back of the upper arm or the abdomen, at least 2 inches from the navel. When receiving pegfilgrastim in the pre-filled syringe, the patient must make an extra trip to a healthcare facility for subcutaneous administration by a healthcare professional. With the on-body injector, the patient can have it administered the day of their chemotherapy regimen before leaving the clinic which improves both patient satisfaction and compliance.  The healthcare professional fills the on-body injector with the pegfilgrastim dose immediately prior to applying it to the patient's skin. Once filled with the medication, the unit activates automatically. Three minutes after activation, the on-body injector deploys a needle which is then inserted into the patient subcutaneously by the healthcare provider. The device is then attached to the patient via its adhesive backing. The pegfilgrastim dose is not injected into the patient until 27 hours after activation. Once the drug dose has been administered, the patient may appropriately discard the on-body injector.[4] The patient should receive pegfilgrastim with the first dose of chemotherapy, and administrations should continue throughout the patient's subsequent chemotherapy cycles. It is also important to note that pegfilgrastim should not be given to patients weighing under 45 kg because these patients require weight-based dosing. Since the pre-filled syringe and on-body injector both administer precisely 6 mg of pegfilgrastim and have no marks for measuring, they should not be used for patients who require weight-based dosing.[1]

For the prevention of the hematopoietic sub-syndrome of acute radiation syndrome, the recommended dose of pegfilgrastim is two doses of 6 mg each, and they should be administered one week apart after the patient has been exposed to the radiation.[2]

Adverse Effects

The most common adverse effect experienced with pegfilgrastim is bone pain. However, the pain appears to be manageable with non-steroidal anti-inflammatory drugs (NSAIDs).[5] It is important to note that NSAIDs may not be an appropriate option for pain relief in some patient populations, such as the elderly or those with kidney disease. Recently, antihistamines have been studied as a potentially acceptable option to help ease the bone pain associated with receiving pegfilgrastim. When comparing loratadine to both naproxen and placebo, both the naproxen and loratadine groups had consistently reduced levels of bone pain. There was no statistically significant difference between naproxen and loratadine, but the loratadine group had fewer adverse effects, such as gastrointestinal issues. Therefore, loratadine could be a potentially inexpensive and helpful option for patients experiencing bone pain while on pegfilgrastim.[6]

Contraindications

Pegfilgrastim can cause hypersensitivity reactions.[7] Therefore, it is contraindicated in patients who have experienced hypersensitivity to pegfilgrastim, filgrastim, or any component of the formulation.

Monitoring

Since pegfilgrastim works on neutrophils to prevent febrile neutropenia, it is imperative to monitor the patient's complete blood count throughout the treatment regimen, with special attention given to the white blood cell count.[5] Pegfilgrastim has been shown to cause leukocytosis, so it is essential to monitor for elevated white blood cell counts [8] exceeding 11,000 per cubic millimeter.[9] Pegfilgrastim, along with all other granulocyte colony-stimulating factors, can also cause capillary leak syndrome. Therefore, it is vital to monitor for signs of capillary leak syndrome, which include hypotension, edema, and hypoalbuminemia.[10] It is also critical to monitor the patient's temperature to detect the potential onset of febrile neutropenia.[5]

Toxicity

The maximum safe dose of pegfilgrastim has not been established. The highest dose studied in clinical trials has been 300 mcg/kg. There have been instances of accidental overdoses occurring in patients. In one such case, the patient was a 79-year-old male who self-administered pegfilgrastim for eight days in a row. He experienced no symptoms during this time but was monitored closely by his doctor three times a week, during which he only complained of bone pain. In another overdose case, the patient was a 69-year-old male who self-administered a 36 mg overdose of pegfilgrastim. He was admitted to the hospital where leukocytosis, bone pain, and rhinorrhea were observed. Due to the current lack of appropriate treatment for pegfilgrastim overdose, the best course of action for overdose is prevention, by vigilant monitoring for signs and symptoms of toxicity.[11]

Enhancing Healthcare Team Outcomes

Cancer is a very complex disease state that requires the interprofessional communication between a multitude of healthcare workers. The administration of pegfilgrastim in cancer patients receiving myelosuppressive chemotherapy is only a small part of the patient's entire treatment regimen; however, it still requires exceptional patient-centered care when being given to the patient. Some examples of the roles of each health care member are:

  • Physicians must monitor the patient carefully for any signs of adverse events, especially in the case of accidental overdose.[11] [Level V]
  • Nurses must appropriately administer pegfilgrastim if given in the pre-filled syringe. They must also attach the on-body injector properly when using this option.[4] [Level V]
  • Pharmacists must help ensure that the patient is receiving the right dose of pegfilgrastim to prevent an accidental overdose as well as the side effects that associated with an overdose. Pharmacists must also help educate patients why they are receiving pegfilgrastim.[11] [Level V]

Each member of the healthcare team plays a vital role in the patient's overall well-being while being treated for cancer. It is imperative that the entire team work together each step of the way throughout the patient's treatment to ensure that the patient is receiving the best care possible.


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Pegfilgrastim - Questions

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Pegfilgrastim administration during chemotherapy is useful for which of the following?



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What is the advantage of pegfilgrastim over filgrastim?



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Pegfilgrastim is used to prevent which of the following disease states in cancer patients receiving myelosuppressive chemotherapy?



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A 54-year-old female with breast cancer lives very far away and does not want to drive back to the cancer center to receive her dose of pegfilgrastim. What would be the best option for this patient while ensuring that she receives the appropriate pegfilgrastim dose?



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A 5-year-old male with neuroblastoma weighing 23 kg, is at risk for developing febrile neutropenia. What is the appropriate recommendation for this patient regarding the administration of pegfilgrastim?



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Pegfilgrastim - References

References

Smith TJ,Bohlke K,Lyman GH,Carson KR,Crawford J,Cross SJ,Goldberg JM,Khatcheressian JL,Leighl NB,Perkins CL,Somlo G,Wade JL,Wozniak AJ,Armitage JO, Recommendations for the Use of WBC Growth Factors: American Society of Clinical Oncology Clinical Practice Guideline Update. Journal of clinical oncology : official journal of the American Society of Clinical Oncology. 2015 Oct 1     [PubMed]
Hankey KG,Farese AM,Blaauw EC,Gibbs AM,Smith CP,Katz BP,Tong Y,Prado KL,MacVittie TJ, Pegfilgrastim Improves Survival of Lethally Irradiated Nonhuman Primates. Radiation research. 2015 Jun     [PubMed]
Yang BB,Kido A, Pharmacokinetics and pharmacodynamics of pegfilgrastim. Clinical pharmacokinetics. 2011 May     [PubMed]
Yang BB,Morrow PK,Wu X,Moxness M,Padhi D, Comparison of pharmacokinetics and safety of pegfilgrastim administered by two delivery methods: on-body injector and manual injection with a prefilled syringe. Cancer chemotherapy and pharmacology. 2015 Jun     [PubMed]
Kosaka Y,Rai Y,Masuda N,Takano T,Saeki T,Nakamura S,Shimazaki R,Ito Y,Tokuda Y,Tamura K, Phase III placebo-controlled, double-blind, randomized trial of pegfilgrastim to reduce the risk of febrile neutropenia in breast cancer patients receiving docetaxel/cyclophosphamide chemotherapy. Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer. 2015 Apr     [PubMed]
Kirshner JJ,McDonald MC 3rd,Kruter F,Guinigundo AS,Vanni L,Maxwell CL,Reiner M,Upchurch TE,Garcia J,Morrow PK, NOLAN: a randomized, phase 2 study to estimate the effect of prophylactic naproxen or loratadine vs no prophylactic treatment on bone pain in patients with early-stage breast cancer receiving chemotherapy and pegfilgrastim. Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer. 2018 Apr     [PubMed]
Wolff AC,Jones RJ,Davidson NE,Jeter SC,Stearns V, Myeloid toxicity in breast cancer patients receiving adjuvant chemotherapy with pegfilgrastim support. Journal of clinical oncology : official journal of the American Society of Clinical Oncology. 2006 May 20     [PubMed]
Riley LK,Rupert J, Evaluation of Patients with Leukocytosis. American family physician. 2015 Dec 1     [PubMed]
Rechner I,Brito-Babapulle F,Fielden J, Systemic capillary leak syndrome after granulocyte colony-stimulating factor (G-CSF). The hematology journal : the official journal of the European Haematology Association. 2003     [PubMed]
Riu G,Estefanell A,Nomdedeu M,Creus N, Overdose of pegfilgrastim: case report. International journal of clinical pharmacy. 2012 Oct     [PubMed]
Dadla A,Tannenbaum S,Yates B,Holle L, Delayed hypersensitivity reaction related to the use of pegfilgrastim. Journal of oncology pharmacy practice : official publication of the International Society of Oncology Pharmacy Practitioners. 2015 Dec     [PubMed]

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