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Comparison of Pegfilgrastim and Filgrastim for the Primary

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Comparison of Pegfilgrastim and Filgrastim for the Primary Vol. 139, No. 4 YAKUGAKU ZASSHI 139,629633 (2019) 629 ―Regular Article― Comparison of Pegˆlgrastim and Filgrastim for the Primary Prophylactic EŠect for Preventing Febrile Neutropenia in Patients Undergoing Rituximab with Dose-adjusted EPOCH Chemotherapy Tatsuo Kataoka,Hiroshi Sakurashita, Takanori Taogoshi, Ryo Nishigakiuchi, Tetsuya Murase, Satoru Izumitani, Yasuyuki Saeki, and Hiroaki Matsuo Department of Pharmacy, Hiroshima University Hospital; 123 Kasumi, Minami-ku, Hiroshima 7348551, Japan. (Received May 14, 2018; Accepted December 12, 2018) The combination of dose-adjusted etoposide, prednisone, vincristine, cyclophosphamide and doxorubicin with rituximab (DA-EPOCH-R) is used for non-Hodgkin lymphoma patients. Febrile neutropenia (FN) is a common com- plication of treatment with myelo-suppressive chemotherapy, so preventing FN is important for maintaining chemother- apy dosage. Recently, pegˆlgrastim has been used as the primary prophylaxis of FN in Japan, but there have been few cases reported using pegˆlgrastim for the primary prophylaxis in DA-EPOCH-R. In this study, we retrospectively com- pared the e‹cacy of pegˆlgrastim with that of ˆlgrastim in patients receiving DA-EPOCH-R in Hiroshima University Hospital. E‹cacy assessment was based on incidence of FN and serious neutropenia (neutrophil count ＜500/mL), hospitalization days and chemotherapy dosage level. Ten patients met the inclusion criteria: pegˆlgrastim (n＝5, 30 cy- cles) or ˆlgrastim (n＝5, 16 cycles). No diŠerence in e‹cacy existed between pegˆlgrastim and ˆlgrastim in the ˆrst cy- cle; however, 2 of 5 patients in ˆlgrastim group reduced dose level in the total cycles of chemotherapy, no patients in peg- ˆlgrastim group reduced. In conclusion, pegˆlgrastim seemed better than ˆlgrastim for the primary prophylaxis in DA- EPOCH-R. Key words―pegˆlgrastim; ˆlgrastim; primary prophylaxis; dose-adjusted etoposide, prednisolone, vincristine, cy- clophosphamide and doxorubicin with rituximab chemotherapy regimen has been used for NHL patients. In the DA- INTRODUCTION EPOCH-R regimen, granulocyte colony-stimulating Febrile neutropenia (FN) was deˆned as an axillary factor (G-CSF) is recommended to use for individual temperature above 37.5°C or oral temperature above patient dose adjustment.3) In Hiroshima University 38.0°C and an absolute neutrophil count (ANC) Hospital, patients receiving DA-EPOCH-R were ＜500/mLorANC＜1000/mL and expected to fall often given G-CSF for individual patient dose adjust- below 500/mL within 48 h, according to the deˆnition ment and the primary prophylaxis of FN. Recently, of FN in the Clinical Practice guideline for FN in pegˆlgrastim was approved in Japan for the primary Japan.1) When FN occurs, we decrease chemotherapy prophylaxis of FN. Pegˆlgrastim seems to better dose and/or delay chemotherapy treatment schedule; eŠect than ˆlgrastim in reducing FN in some these approaches lead to an eŠect on relative dose in- reports,46) however in these studies pegˆlgrastim tensity (RDI). This is the reason prevention of FN is mainly used higher dose than Japan (6mgvs.3.6 a very important matter. Pettengell et al.reported mg). In Japanese study showed non-inferiority of a about patients with non-Hodgkin lymphoma (NHL) single subcutaneous dose of pegˆlgrastim compared who received prednisone, vincristine, cyclophospha- with daily subcutaneous doses of ˆlgrastim,7) mide and doxorubicin (CHOP) chemotherapy. The however these eŠect was not clear in clinical practice. group receiving reduced chemotherapy (RDI 90％) Pegˆlgrastim was used instead of daily G-CSF in the had reduce overall survival compared with the RDI ＞ DA-EPOCH-R regimen; however, few cases have 90％ group.2) From this report, preventing FN or been reported about using pegˆlgrastim for the pri- neutropenia seems to have a potential impact for mary prophylaxis of FN and dose adjustment in DA- chemotherapy outcome. Recently, dose-adjusted EPOCH-R and its e‹cacy has been poorly under- etoposide, prednisone, vincristine, cyclophosphamide stood. In this study, we retrospectively compared the and doxorubicin with rituximab (DA-EPOCH-R) e‹cacy of pegˆlgrastim with ˆlgrastim used for this purpose in patients receiving DA-EPOCH-R. e-mail: ta-kataoka0208＠hiroshima-u.ac.jp 2019 The Pharmaceutical Society of Japan 630 YAKUGAKU ZASSHI Vol. 139, No. 4 (2019) Table 1. Dose-adjusted Etoposide, Prednisolone, Vin- PATIENTS AND METHODS cristine, Cyclophosphamide, Doxorubicin, Rituximab Regi- meninHiroshimaUniversityHospital(Level 1 dose) Study Design and Patient Selection This study was approved by the Hiroshima University Institu- Drug Dose Route Treatment days tional Ethical Committee (approval No. E-401). Etoposide 50 mg/m2/d civ 1, 2, 3, 4 Consecutive patients with aggressive NHL who Doxorubicin 10 mg/m2/d civ 1, 2, 3, 4 2 received the DA-EPOCH-R regimen were screened Vincristine 0.4 mg/m /d civ 1, 2, 3, 4 Cyclophosphamide 750 mg/m2/ddiv 5 from April 2013 to February 2017. The patients en- Prednisolone 60 mg/m2/d div or po 1, 2, 3, 4, 5 ( ) rolled in this study fulˆlled the following criteria: 1 Rituximab 375 mg/m2/ddiv received ˆlgrastim or pegˆlgrastim for the primary G-CSF sc 6～ prophylaxis in the ˆrst cycle; (2) received DA- Next cycle Day 21 EPOCH-R regimen Level 1 dose in the ˆrst cycle; (3) G-CSF: granulocyte colony-stimulating factor. civ: continuous in- no ˆxed dosage with renal or hepatic function. We ex- travenous drip infusion. div: intravenous drip infusion. po: per os.sc:sub- cutaneously. cluded patients who received ˆlgrastim or pegˆl- grastim with ANC ＜1000/mL in the ˆrst cycle. Patients were divided into two group according to the cycle was administered similarly. drug received, daily subcutaneous injection of Gran Evaluation of E‹cacy and Adverse Event In or biosimilars of ˆlgrastim (ˆlgrastim)(FG group) theˆrstcycle,wecheckedthewhitebloodcell or single subcutaneous injection of G-Lasta(pegˆl- (WBC) count, ANC, incidence of FN, duration of grastim)(PEG group). ˆlgrastim use, hospital duration from start of Data Collection Data were collected and chemotherapy, and dose level at second cycle. managed using Data Warehouse database system. The duration of ˆlgrastim was deˆned as days ˆl- Age, sex, performance status, chemotherapy history, grastim used for preventing FN, so days ˆlgrastim bone marrow inˆltration, date of chemotherapy initi- used after incidence of FN were not included in the ation and completion, the number of chemotherapy duration. cycles, date of ˆlgrastim initiation and completion, In total cycles, we checked incidence of leukopenia complete blood counts (CBCs), date of FN onset and (Grade 4),neutropenia(Grade 4) and FN, duration hospital duration from start of chemotherapy were of ˆlgrastim use, hospital duration from start extracted from medical records. Hospital duration chemotherapy; average of hospital duration in each was decided by the physician considering patient con- cycle, and dose level change. We checked bone pain dition and myelosuppression; at ˆrst cycle, patient for adverse event. Each adverse event was graded ac- could leave hospital after recovery of myelosuppres- cording to the National Cancer Institute Common sion with physician's decision. Toxicity Criteria (version 4.0). We deˆned the CBCs measured within 7 d before Statistical Analysis Analysis of the patient's administration of the DA-EPOCH-R regimen as ini- background and other normal distributions was per- tial blood test value. formed using the Student's t-test; for non-normal dis- Chemotherapy and Dose Adjustment DA- tributions we used the Mann-Whitney U test. Analy- EPOCH regimen was administered as previously sis of incidence of FN, leukopenia or neutropenia and described3) with slight modiˆcation. Prednisone was dose level of chemotherapy was performed using the changed to prednisolone and vincristine capped at 2 Fisher's exact test. p＜0.05 was considered statistical- mg (Table 1 shows Level 1 dose DA-EPOCH-R regi- ly signiˆcant. men). Rituximab was administered at a ˆxed dose of RESULTS 375 mg/m2 per day of body surface area and adminis- tration date was decided by the physician in charge. Patient Characteristics Twenty patients with Cycles were administered at intervals of at least 21 d NHL received the DA-EPOCH-R regimen from April and the pharmacodynamics dose adjustment was 2013 to February 2017 and 10 of them were excluded based on CBCs at the nadir of each cycle. Filgrastim from analysis. Five of them were given G-CSF after 75 mg per day was administered at least 24 h after ANC fell to less than 1000/mL, 3 received ˆxed chemotherapy until post nadir or pegˆlgrastim 3.6 mg/ chemotherapy dosage with renal function, and the Vol. 139, No. 4 (2019) YAKUGAKU ZASSHI 631 Table 2. Summary of Patient Characteristics Table 3. Summary of Results in First Cycle Patient FG (n＝5) PEG (n＝5) p-value FG PEG p-value (n＝5) (n＝5) AEFJ Sex (male/female) 4/14/11.0 Leukopenia (Grade 4), n (％) 3(60.0) 0(0.0) 0.17 Age (year) 59.4(3578) 47.6(3370) 0.29 Neutropenia (Grade 4), n (％) 3(60.0) 1(20.0) 0.52 Febrile neutropenia, n (％) 1(20.0) 1(20.0) 1.00 2 1.70 1.69 Body surface area (m ) (1.511.83) (1.531.84) 0.89 6.4 Filgrastim use duration (d) (410) Bone marrow inˆltration 1/40/51.0 (Yes/No) ＜10 d 4 Previous chemotherapy 10 d 1 2/31/41.0 treatment (Yes/No) Hospital duration from start of 19.0 16.2 0.55 Performance status chemotherapy (d) (1423) (1033) 4/1/03/2/0 (0/1/2) Reduced dose level to ＜11(20.0) 0(0.0) 1.00 Age and body surface area are shown mean (minmax). Performance Leukopenia (Grade 4): white blood cell count ＜ 1000/mL. Filgrastim status was corrected by physician records. FG: ˆlgrastim group, PEG: peg- use duration and hospital duration from start of chemotherapy, days are ˆlgrastim group. shown mean (minmax).
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