Colony stimulating factors

Question 1

Granix generic name

Answer 1

Filgrastim

Question 2

udenyca is

Answer 2

pegfilgrastim biosimilar (cheaper, covered by more insurance)

Question 3

Neulasta

Answer 3

Pegfilgrastim

Question 4

Timing of colony stimulating factor

Answer 4

24-72 hours after chemo finishes (would counteract myeloablation)

Question 5

Colony stimulating factors also termed

Answer 5

Hematopoietic growth factors

Question 6

FDA approved granulocyte colony-stimulating factors

Answer 6

Filgrastim
pegfilgrastim
filgrastim-sndz (“biosimilars”
couple others

Question 7

What are the FDA approved HGF’s categories?

Answer 7

ESA's
G-CSF
GM-CSF
IL-11
Thrombomimetics

Question 8

FDA approved Granulocyte-macrophage CSF?

Answer 8

sargramostim

Question 9

What are the thrombomimetics?

Answer 9

Eltrombopag
Romiplostim
Avatrombopag

Question 10

Indications for EPO

Answer 10

• board question
  1) CKD
  2) chemo-associated anemia (w/ palliative intent)
  3) HIV pts receiving zidovudine
  4) reduction of RBC transfusions in elective non-cardiac, non-vascular surgery
  5) MDS (not FDA but okay per ASH)

Question 11

indications for epo in CKD

Answer 11

• Hgb<10
• lowest dose sufficient to reduce transfusions
• STOP when Hgb >11
• escalate dose over 12 week period

Question 12

most impt SE’s to be aware when using EPO with palliative intent

Answer 12

• prothrombotic
• potential for shorter survival (so has a black box warning in cancer patients)
• shortened time to tumor progression

Question 13

Why Epo may be used for palliative treament

Answer 13

Reduce transfusions

Question 14

Adverse effects of ESA’s

Answer 14

• common board question
  1) In CKD –> HTN + Seizures
  2) VTE
  3) allergic reactions
  4) neutralizing antibodies may lead to pure red cell aplasia

Question 15

FDA approved granix indications

Answer 15

1) myelosuppressive chemo
2) AML induction/consolidation
3) HSCT
4) Blood progenitor cell collection
5) severe chronic neutropenia

Question 16

Indication for GCSF for primary prophylaxis of febrile neutropenia

Answer 16

• greater than 20% risk of febrile neutropenia (high risk regimens – MVAC, CHOP-14)
• write this in your notes so it’ll be approved by insurance

Question 17

Management of patient with febrile neutropenia during previous cycle on GCSF

Answer 17

Dose reduction of chemo

Question 18

Management of patient with febrile neutropenia on GCSF

Answer 18

continue CSF, dose reduce

Question 19

management of patient with febrile neutropenia + not on CSF

Answer 19

• not used unless high risk features:
  prolonged/profound neutropenia, age over 65, uncontrolled malignancy, hypotension, invasive fungal infection, hospitalized when fever developed)

Question 20

Granix dosing

Answer 20

Weight based (5 mcg/kg) 
SC daily until post nadir recovery (ANC>2K)

Question 21

neulasta and biosimilar dosing

Answer 21

6 mg SC

Question 22

Why you can’t use G-CSF in general for aplastic anemia

Answer 22

insufficient stem and progenitor cells

Question 23

Adverse effects of G-CSF

Answer 23

**bone pain
hypersensitivity reactions
*ARDS (sequestration of granulocytes in the pulmonary circulation)
DAH
Splenic rupture (particularly in sickle cell patients)
Increased incidence of MDS/AML

Question 24

Indications for GM-CSF

Answer 24

• induction chemo in older adults with AML (Day 11 assuming Day 10 marrow aplastic)
• mobilization and following transplant for autologous peripheral blood progenitor cells
• HSCT failure or engraftment delay
• Acceleration of myeloid recovery in patients with NHL ALL and Hodgkin’s disease undergoing autologous BMT

Question 25

G-CSF and GM-CSF contraindications

Answer 25

Blasts > 10% | Concurrent with chemo or RT

Question 26

GM-CSF side effects

Answer 26

*Capillary leak syndrome SVT hypersensitivity

Question 27

Where is TPO produced

Answer 27

Liver AND kidney

Question 28

TPO mimetics (TPO receptor agonist)

Answer 28

Romiplostim | Eltrombopag

Question 29

Indications for romiplostim

Answer 29

- chronic ITP (where there is an insufficient response to first line therapy and severe thrombocytopenia with increased bleeding or an increased bleeding risk

Question 30

romiplostim adverse effects

Answer 30

- prothrombotic - increased blasts in MDS - transient rebound thrombocytopenia

Question 31

eltrombopag SE's

Answer 31

- nausea and vomiting (needs to be taken on empty stomach without antacid) - menorrhagia - myalgia - rare hepatotoxicity

Question 32

filgrastim dosing duration

Answer 32

depends on indication + formulation

Question 33

Role of G-CSF for treatment of febrile neutropenia

Answer 33

G-CSF is effective for prophylaxis and secondary prophylaxis of neutropenia but has little benefit in patients who are currently neutropenic

Question 34

threshold for risk of febrile neutropenia administering myeloid growth factors

Answer 34

greater than 20%

Question 35

High risk chemo regimens confering risk of febrile neutropenia greater than 20%

Answer 35

``` ESHAP HyperCVAD RICE ICE Adriamycin-cyclophosphosphamide folloewd by paclitaxel ```

Question 36

Why should you not give GCSF within 24 hours of chemo?

Answer 36

Administration of filgrastim or pegfilgrastim within 24 hours before or after chemotherapy is not currently recommended because of the theoretical potential for increasing chemotherapy toxicity to myeloid progenitor cells after growth factor stimulation.