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Guideline update on prevention of febrile neutropenia with G-CSF Posted 29/03/2013

Patients undergoing chemotherapy for cancer are at risk of developing the sometimes fatal condition of febrile neutropenia (FN), involving infection, fever and sepsis due to a loss of neutrophils. Prophylaxis with recombinant granulocyte colony-stimulating factor (G-CSF) has been shown to reduce hospital admissions, antibiotic use and the need for chemotherapy dose reduction. Several forms of recombinant G-CSF are available, including filgrastim and its biosimilars, or the pegylated version of filgrastim. All three are considered to be equivalent in terms of clinical efficacy and safety.

In 2010, the European Organisation for Research and Treatment of Cancer (EORTC) updated its 2006 guideline on the use of G-CSF for the prevention of FN. The update follows a systematic review of literature published between 2006 and 2009, and expert presentations, which have provided a greater understanding of the factors predisposing patients to FN [1].

The 2010 guideline considers the assessment of individual patient risk, including factors such as their tumour type, chemotherapy regime and patient-related factors such as a prior episode of FN.

Key recommendations of the 2010 EORTC updated guideline:

  1. The updated guideline confirms that the patients most at risk of FN are those over the age of 65, at an advanced stage of disease, and have had previous experience of FN, or prior chemotherapy.
  2. Care should be taken on selection of drug combinations for chemotherapy, as some combinations may intensify myelosuppression and hence increase the risk of FN.
  3. G-CSF treatment can prevent FN in patients with a wide range of malignancies, including breast cancer and lymphoma. Patients must be assessed individually according to patient-related risk factors, the chemotherapy regime, and treatment intent. The 2010 guideline confirms that G-CSF is of benefit to patients whose FN risk is equal to, or above, 20 per cent.
  4. For patients with an ongoing episode of FN, the 2010 EORTC guideline recommends G-CSF treatment only in ‘patients who are not responding to appropriate antibiotic management and who are developing life-threatening infectious complications (such as severe sepsis or septic shock).’
  5. The updated guidelines recommend the use of filgrastim and lenograstim (daily injections) and pegfilgrastim (once per cycle administration) to prevent FN and FN-related complications, where indicated. Filgrastim biosimilars are also included in this recommendation.

Overall, the 2010 EORTC updated guideline is intended to be of use in optimising local protocols and patient management strategies, so as to improve patient care and treatment outcomes [2].

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1.  Aapro MS, Bohlius J, Cameron DA, et al. 2010 update of EORTC guidelines for the use of granulocyte-colony stimulating factor to reduce the incidence of chemotherapy-induced febrile neutropenia in adult patients with lymphoproliferative disorders and solid tumours. Eur J Cancer. 2011;47(1):8-32.

2.  Clayton J. EORTC continues to support the appropriate treatment of adult patients with G-CSF to prevent febrile neutropenia: guideline updates. Generics and Biosimilars Initiative Journal (GaBI Journal). 2013;2(1):47-8. doi:10.5639/gabij.2013.0201.016

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