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Cytokines

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Indications

These indications are all guidelines and the individual patient's situation needs to be considered when a decision to use G-CSF is made. The decision and type of G-CSF to use outside a clinical trial should be made by the treating oncologist.

Primary Prophylaxis
Clinical trials where G-CSF is mandatory. 
Dose-intense treatments e.g., osteosarcoma, neuroblastoma. 
Patient deemed to be at high risk of sepsis due to pre-existing wound or condition. 
Secondary Prophylaxis - consider if:
prolonged neutropenia < 0.2 x 109/l for > 7 days 
proven prior fungal or bacterial infection 
previous episode of neutropenia leading to reduced dose intensity of therapy. 
Interventional Use - consider if:
Febrile neutropenia on antibiotics with:
-invasive fungal infection
-severe gram negative infection
-pneumonia
-multi-organ failure. 
Severe neutropenia with fever for 4 or more days. 
Severe localised sepsis . e.g., necrotising fasciitis, cellulitis, abscesses, sinusitis. 
Clinical deterioration e.g., hypotension ascribed to sepsis whilst neutropenic at any stage. 
Infants < 1 year of age with febrile neutropenia. 
Prolonged neutropenia (not necessarily with fever) > 28 days (e.g., AML, post-transplant). 
Stem Cell Harvesting
Allogeneic peripheral blood stem cell harvesting (this is uncommon as bone marrow is preferred as a stem cell source). 
Autologous bone marrow harvesting. 
Autologous Stem Cell Rescue
G-CSF can improve count recovery. Use if recommended on stem cell treatment protocol 
Allogeneic Stem Cell Transplantation
Not used routinely. Use as dictated by patient protocol or treating oncologist. 
Other Possible Indications
Myelodysplastic syndrome - recommended for use for severe life-threatening infection. 
Acquired agranulocytosis - with severe infection. 
Severe congenital neutropenia (Kostmann syndrome) 
Cyclical neutropenia - use when patient symptomatic. 
Severe and very severe aplastic anaemia. May be used as part of immunosuppressive therapy. The risks and benefits need to be determined by the treating haematologist/oncologist. 
Glycogen storage disease type 1b - for patients with recurrent infection. 
Shwachman Syndrome - for patients with recurrent infection. 
AIDS - for patients severely neutropenic from aggressive anti-retroviral therapy. 
Neonates - not routinely indicated but may be used in neonates with neutropenia and sepsis. 

Granulocyte colony stimulating factor

For prophylaxis (primary, secondary, autologous bone marrow stem cell rescue procedure), see recommended dose below or as recommended in treatment protocols.

Do 1st FBC at day 10 from start of chemotherapy, then daily until neutrophils > 0.5 x 109/l for two consecutive days, at which stage the GCSF is stopped.

Filgrastim

Give subcutaneously via Insuflon catheter. This can remain in for 7 days.
Dose - round dose to nearest vial size or multiple thereof:

Weight range GCSF dose 
5 - 12 kg  50 microg 
12 - 18 kg  75 microg 
18 - 25 kg   100 microg 
25 - 37 kg  150 microg 
37 - 50 kg  225 microg 
50 - 75 kg  300 microg 
> 75 mg  480 microg 

Lenograstim

150 mcg/m2 once daily.

Pegfilgrastim (Neulasta™)

This is a pegulated form of GCSF. GCSF is only lost via usage (by leucocytes) or renally. The attachment to Polyethalene glycol makes the molecule too large for renal excretion and so it remains in the body until there are granulocyte precursors for it to act on. It is more expensive but has the advantage of being a single dose that can be given prior to discharging children to remote areas.

Weight range Dose 
< 10 kg  Not eligible 
10 - 20 kg   2 mg 
20 - 30 kg   3 mg 
30 - 40 kg   4 mg 
> 40 kg  6 mg 

Granulocyte-Macrophage colony stimulating factor

Sargramostim (GM-CSF)

250 mcg/m2 once daily.

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  • Date last published: 04 August 2015
  • Document type: Clinical Guideline
  • Services responsible: National Child Cancer Network