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Retrospective Comparison of Day +1 Versus Day +7 Initiation of G-CSF in Patients Undergoing Autologous Hematopoietic Stem Cell Transplantation
Background: Giving Filgrastim (G-CSF) following high dose chemotherapy and autologous stem cell reinfusion (HSCT) is routinely used to shorten duration of neutropenia and decrease risk of infection. The optimal post-transplant day of initiation of G-CSF is not standardized. We recently studied a change from initiation of G-CSF from day +1 to day +7 in light of recent data showing equivocal results.
Methods: Beginning November 1st, 2012 a control group consisting of 83 patients with multiple myeloma or lymphoma undergoing autologous HSCT received G-CSF subcutaneously daily from Day+1 until absolute neutrophil count (ANC) of 1500 for two consecutive days. Beginning February 1st, 2013 we evaluated 56 patients who received G-CSF starting day +7 and compared time to ANC engraftment between the groups. Both groups received G-CSF to the same ANC endpoint. Patients were matched for diagnosis, comorbidity index, number of prior therapies, and performance status. Additional endpoints included incidence of infection, transfusion support, and length of stay.
Results: 83 patients in the control group received G-CSF beginning day +1, and 56 study group patients received G-CSF beginning day +7. There was a significant difference in ANC recovery both to >500 and >1500 between the groups. On average, patients who received G-CSF starting Day +7 required 1.53 more days for ANC recovery >500 and 1.89 more days for ANC recovery >1500. However, there was no statistical difference in platelet reconstitution or length of stay.
Conclusion: Day +1 administration of G-CSF was associated with earlier neutrophil recovery but there was no improvement in incidence of infection or length of stay when compared to administration beginning day +7.
Table 1. Patient Characteristics
| Day +1 | Day +7 |
# Patients | 83 | 56 |
Age | 56 | 50.9 |
Sex | 36 F, 47 M | 24 F, 23 M |
Race | White:74 Black: 9 | White: 49 Black:6 Hispanic:1 |
Wt | 85.06 | 86.64 |
KPS | 84.08 | 84.46 |
CMI | 3.108 | 2.929 |
# of Prior Treatments | 2.1 | 2.7 |
Multiple Myeloma | 50 | 30 |
Lymphoma | 30 | 22 |
Other* | 3* | 4 |
Patients Undergoing a Second Transplant | 4 | 4 |
*BuVP 2; VPCARB 1.# BCNUTHIO:2 BPCARB:1 TBICY:1
Table 2. Transplantation Data Following Engraftment
| Day+1 | Day+7 | P Value |
Transplanted CD 34+ cells | 5.024 | 4.018 | 0.0617 (95% C.I. -2.062 to 0.04946) |
Leukocyte Reconstitution ANC >500 | 9.9 | 11.43 | <0.0001 (95% C.I. 1.136 to 1.914) |
Leukocyte Reconstitution ANC >1500 | 10.86 | 12.75 | 0.0001 (95% C.I. 0.06929 to 2.096) |
Platelet Reconstitution >20 | 19.48 | 20.61 | 0.3577 (95% C.I. -1.298 to 3.569) |
Platelet Reconstitution >50 | 21.12 | 21.84 | 0.6821 (95% C.I. –2.749 to 4.118) |
Length of Stay | 18.16 | 18.91 | 0.3982 (95% C.I. -1.006 to 2.514) |
Table 3. Infection rates
| Day +1 | Day +7 | P Value ( Fisher's Exact Test) |
Total Blood Stream Infections (BSI) | 23 | 14 | 0.8453 |
Peripheral BSI | 11 | 10 |
|
Line Associated BSI | 12 | 6 |
|
UTI | 19 | 7 | 0.1827 |
Other | 2* | 2 |
|
*1 sputum with proteus mirabilis, 1 lesion with candida glabrata, 1 sputum with Candida, 1 throat culture with beta hemolytic strep