Neupogen question

[iwillbeatthis]

My GI and hemotologist seem to be confused about an issue early in my tx that is causing me trouble.
My WBC and ANC is low, 2.1 and 700. My hemo gave me Neupogen 480 shot tonight, and I'm going back in the morning to get another one. It seems as though my nice GI and not nice hemo don't have much experience with Neupogen and Interferon. So I am faced with convincing my GI tomorrow that I can take my 3rd shot tomorrow night. I did read that Neupogen and Interferon shots should be 2 days apart? Is that right? Both of them are already talking skipping a dose, which I don't want to do. Neither one is giving me black and white answers, my job for my GI tomorrow is go 'find a Hemotologist' that agrees that I can take my third shot (I can delay it by 2 days I heard?) with my CBC this week WBC 2.1, ANC 700, and with 2 shots of Neup 480. I'm hoping I can take my shot 2 days early on Sunday ? Please help anyone who has experience or that can refer me to published medical journals so I can do the work for my doctor and get him to agree to my 3rd shot. Please help.

[spectda]

Yes of course as you mentioned I had a different objective, and thanks for the advice you gave me.

[GoofyDad]

I think your WBC crashes after INF and so 1 day following INF is the best day to test - so you see the trough. Then you can inject Neup right away and enjoy reasonable WBC counts until the next INF. The schedule you laid out looks like only 1-2 days of decent WBC.. levels

Dave, I think I recall you having a pressing need for a decent CBC to keep the doc happy - that might have played into the schedule that was suggested in your case.

[iwillbeatthis]

Thanks Dave, my first hurdle, and it was big enough, for just coming up on shot 3, I was worried and knew I had to kick into gear, and just go after this like a torpedo.
Your ANC did what mine did, I went from .7 to 12000. That's good advice about CBC being away from both. I take my INF on Friday, and CBC is on Monday, you think that is OK if I then do Neup on Weds? Yea I am relieved, for now. I was in the middle of this mess last night, and asked this on the board so I could see responses this morning, this is what made me realize NOT to do the second 480 Neup shot this morning. I was really grateful. This board can provide vital information, and fast. Off to do shot #3.
See ya, Bree

[spectda]

Great news! You really put that together quickly! i am impressed!

I have had several cbc's since I started the neupogen. My anc really spikes a day or two after the injection. Of course when I take the Interferon it comes crashing down. Just a few weeks ago I did a cbc and MY anc was .3 I took the neupogen and two days later it's 6500. You should figure out with your new doc what day is the best to do the cbc on so it's not immediately after either the interferon or the neupogen. That's the advice I got from one of the forum members when I was trying to sort this out.

I am sure you are really relieved to have this resolved. It's really important to advocate for ourselves and being well educated about the disease and the tx is the only way to do that. The people on the forum make it a lot easier to get the information.

Take care.
- Dave

[iwillbeatthis]

Yea I was just going to say the same thing, we crossed :)
I was so stressed, to go from a mean fool that is telling me that he can't treat me because I thought 3 mega shots of Neup was too much, and that lots of people go through this when tx for HCV, and that I was going to take me INF shot tonight, he didn't like someone having something to say about this tx that he apparently knows nothing about, he was just horrible, and then to end up with such a magnificent women Dr.... I'm really happy.....it was pretty dicey because my GI gave me the ultimatum (nicely) that I had to get a second opinion by today so that I could continue with INF shot tonight, I told my GI I was doing my shot tonight so to get used to the idea. He's nice, not super up on HCV tx problems, but he's workable.  I spent 24 hours putting this together, and God was with me.

[Trish77]

My post crossed over with yours.  She sounds fabulous and the careful monitoring sounds great.  Nice to have this in place for the duration of your treatment.  Well done!

Trish

[Trish77]

Personally, I don't know that you have enough history built up with your neupogen to forgo it.   While an ANC of 700 is not too low for someone on treatment, you're only 3 weeks into treatment as well and you have a ways to go.  It won't hurt your ANC to go UP a bit more either, even though it's not at a danger point....*for someone on treatment*.      Getting your ANC at a decent level is not a bad thing so that you have some room for it to drop some when you either reduce or withdraw the neupogen.  The last thing you want is to get your ANC up just enough, withdraw the neupogen and have your ANC drop again and end up back in the same rollercoaster.  Alot of us went on maintenance doses of procrit or neupogen to avoid that kind of thing once our levels stabilized rather than withdraw it completely - as long as it's not above that level where it's recommended to stop neupogen entirely, of course. Your new hemo will hopefully be able to address this.  

Frijole's recommendation to do weekly CBC's is also worth considering.  I had weeklys for a very long time and a short reprieve to every two weeks for awhile .. and then back to weeklys for the duration, just to keep tabs on my hgb, ANC and other white counts that were being monitored, simply because they were always so close to the cutoff point.

Perhaps when you're shopping for hematologists you can ask if they have any experience treating patients with Hep C.  During my treatment I required an endocrinologist for onset of treatment-induced thyroid issues.  My first one had NO understanding, knowledge or experience with Hep C treatment-related thyroid issues and it was my treatment team that found me a new endo out of alarm at his approach to my care.  The next one was well-versed in the impact of interferon on thyroid and he is still my endocrinologist to this day even though he's a 1-2 hour drive one way depending on traffic.

Good luck with this.

[iwillbeatthis]

Okay, saw the new woman hemo, she was extraordinary, she agreed the 3 shots of neupogen 480 was outrageous and way too much.
She sent me over to the hospital, we got immediate CBC....
WBC had gone from 2.1 to 12.7! ANC went from .7 to 12.06!
She said that I am apparently very sensitive to Neupogen, and that she would not have kept blasting me with shots of course not knowing what my CBC's were.
So if I had taken even a second shot today, I think I might have been in trouble.
She's a super doctor, will be checking my blood again tomorrow and Monday, and gave me a standing order for CBC every Monday for the duration of my tx. She said we will simply balance the CBC so that I can maintain tx. By the way, she knew a lot more about HCV than my GI, so together, I'm covered.
It's shot #3 tonight. You really have to be on top of all of this or you are screwed.
Thanks everyone,
Bree

[spectda]

I guess the problem is that more often then not the neupogen is handled by the doctor doing the treating, hopefully a hepatologist or gastro  that has a lot of expereince.

[FlGuy]

You might consider showing a little restraint when you talk to hemo #2 about hemo #1.  They share the same secret handshake.  You are in a situation that requires history and facts not emotion and blame.

[frijole]

To give the hemotologist a break, you must realize that all of them are used to treating patients on chemotherapy where the risk of infection is very great.  I pissed my hemotologist off but she did let me regulate the timing of the neupogen within bounds and I only got sick once my whole 56 weeks of treatment - but it was a doosy.  

Once you are on these rescue drugs, you should probably get a weekly CBC.  I got them in the hospital in the oncology department (where the hemotologist worked) and waited for the result then conferred with the nurse to determine when to do the procrit and the neupogen.  I also kept my own spread sheet  to keep record of my hgb, anc, and the dates of the procrit and neupogen shots.  That way both the hemo nurse and I could look at what was happening (since this is a long-term fix).

I would do the interferon tonight (full dose) and do the neupogen next Monday.  Are they making you get the shots at the hospital/doctor's office?  That was another learning thing for the hemotologist.  They are used to patients needing the quick neupogen shot and giving them there.  We normally get our monthly prescription and do them according to what the hemotologist says. You should ask about that.

frijole

[iwillbeatthis]

Just got back from firing my hemo, am seeing another one in one 2 hours, I got all my records and notes from the idiot who was treating me like cancer patient, in black and white, he stated that he recommended that I stop my INF until my ANC is up to 1500, but that I refused to do so. And he got that right. In his earlier note he said that if ANC dips below 1000 he will prescribe Neupogen 480 mcg 3 days a week.
I have his notes in front of me. He is a dangerous man.
I wonder what a real hepatologist would say about this, I'm curious what the new hemo is going to say about this.

[spectda]

Strange that a hemo doesn't know about neupogen. Don't they usually treat people with cancer who take neupogen from chemo all the time? I can't imagine that one injection of neupogen 480 will harm you, although I think there are a small proportion of people that have reactions as with any drug.

The only problem i see about getting your cbc immediately is how your doctor may respond if by chance your anc is lower. ANC will bounce around even without the meds.

[iwillbeatthis]

Yes, that is what I am going to do. And yes, apparently he was blasting me like a cancer patient. I am not taking another neup shot, I am taking my INF tonight, and will get my blood checked on Monday as usual. And I'm obviously getting another hemo today.
Thank you guys, and thank you was it Carol? for that Georgia med report, I am printing it out and taking it to my GI. He has deficiencies too, but as least he is not an a$$.

[nygirl7]

Most docs won't even be concerned at 700.  Mine dropped but went right back up on it's own as happens quite often. I agree do NOT take your IFN shot later - if anything move that to earlier (but then you would have to do it that day every week or slowly spread it out to get it back to the correct day).  I wouldn't take the neupogen it works quickly and effectively - you need that IFN that is the priority.  Your anc won't be any issue if you have breakthrough and are foced to stop treatment........and 700 is not that low to begin with.

Of course none of us are doctors but we do have experience with this sort of stuff.  Some GIs unfortunately just don't and a hemo doc might not necessarily have experience with HCV treatment.

[FlGuy]

When I was on Neup it was almost always 3 shot in a row (ie Tues, Wed Thurs).  Then, when they dropped again, another 3-day series.  And...repeat.

[Trinity4]

Does the hemo guy realize he's not dealing with a cancer patient here?  Geez, no need to blast you with Neup.  The stuff works well and fast.  I wouldn't take another 480 mcg today.  I'd take my peg shot and and deal with the ANC on Monday.

[spectda]

I hate to give you advice like I am an expert or a doctor. This has been my limited experience which included a lot of advice from all the other people that responded to your thread and a lot of reading about the drug when my anc dropped.

I only know that my doctor prescribed 300 mcg once per week and didn't have an urgent need to test my blood until I saw him 1.5 weeks later. Most people seem to get a good response to the neupogen regarding increased anc. It has crappy side effects for me, although many people get no sides from it.

- Dave

[iwillbeatthis]

OK, so no way take that second shot of 480 I take it? And do you think it would be OK to get my GI to send me to the hospital to get a quick CBC? This way he can confirm I am still 700 or so?
Do you think it was 'safe' that I took the 480? This hemo was going to give me THREE! 480 shots in a row, the only reason he was only going to give me two was because they are closed tomorrow.

[spectda]

It may take more then one day for the neupogen to be effective, I am not sure. I think most docs would start you at 300 mcg once per week and not test you immediately after the first injection. It needs a little time to work, although it does work quickly.

Neupogen stimulates your bone marrow to produce more white blood cells. There are issues with taking too much or too little neupogen. You want to use the least amount possible to get you to a safe anc level (you are already safe), you are not looking to be in the normal anc zone. If you stayed where you are or between 700-1000 you would be just right.

- Dave

[iwillbeatthis]

thank you all. do you guys think that another neupogen 480 shot today is too much? should I have my blood checked before I take another strong shot? this hemo is really as a$$. he could check my blood today then I see.
And if I don't take the second shot, I can take my INF tonight.
So what I should really do is somehow have my blood checked today? Besides that hemo, can I get a fast CBC today somewhere?

[spectda]

I think that information I posted is good but a little dated. The dosing information for neup seems appropriate, but I believe that as treatment has evolved an aggressively treating hepatologist would not dose reduce unless you were below 500 and I have heard some will go as low as 300 anc.

I am in a trial that required dose reduction under 750 per the agreement with the fda so unfortunately I was dose reduced early in treatment also. The next viral load test after INF reduction showed a slight increase, I was undetectable after my interferon was increased again because of increased anc from neupogen. The neup works very well and quickly.

Good luck,
Dave

[frijole]

I almost wish I hadn't copied the above because it does say that protocol is to first reduce the interferon dose and I like so many members here don't want to do that.  

Still, if your GI insits that you do NO SHOT - print this out and let him read it and suggest that you do the 80% dose -- that is, the 135mg for Pegasys or the 1.0mcg for PegIntron.  

AS far as the 24 or 48 hours go, yes, they do counteract one another, but the most improtant thing is to NOT MISS YOUR INTERFERON TONIGHT.

I know this is a long stretch but if you could get your doctors to check clinical care options website, they could learn about current advances in hepatitis C treatment including "helper drugs" and even qualify for continuing education credts.  As a patient I have listened to many of these presentations and just wish my doctors would.

http://www.clinicaloptions.com/Hepatitis/Topics/HCV.aspx

Good luck, Iwillbeathis.

frijole

[frijole]

This was posted by specta just about a month ago:

Granulocyte Stimulating Colony Factor Criteria for Use for Hepatitis C Treatment-Related Neutropenia VHA Pharmacy Benefits Management Strategic Healthcare Group and Medical Advisory Panel Prepared by: K. Tortorice, PharmD BCPS , H. Yee Pharm D BCPS, E. Bi
by spectda    08/06/2010
This shows the dosing information for neupogen while on hcv tx. According to this information the neupogen should be stopped or taken less often if the anc is over 1000. Mine was at 6500 after five injections, and my doc tells me to keep taking the neupogen.

Granulocyte Stimulating Colony Factor Criteria for Use
for Hepatitis C Treatment-Related Neutropenia
VHA Pharmacy Benefits Management Strategic Healthcare Group and Medical Advisory Panel
Prepared by: K. Tortorice, PharmD BCPS , H. Yee Pharm D BCPS, E. Bini MD, M. Chapko PhD, T.
Chiao Pharm D, M. Goetz MD, E. Hansen NP, S Ho MD, G. Ioannou MD; R. Miller MD, E. Morrison
MD; H. Mun Pharm D, R. Reddy MD, S. Wongcharatrawee MD, T. Wright MD, J. Dominitz MD

Stimulating Colony Factor Criteria for Use
for Hepatitis C Treatment-Related Anemia
March 2006 1
Updated versions may be found at http://www.vapbm.org or http://vaww.pbm.med.va.gov
Granulocyte Stimulating Colony Factor Criteria for Use
for Hepatitis C Treatment-Related Neutropenia
VHA Pharmacy Benefits Management Strategic Healthcare Group and Medical Advisory Panel
Prepared by: K. Tortorice, PharmD BCPS , H. Yee Pharm D BCPS, E. Bini MD, M. Chapko PhD, T.
Chiao Pharm D, M. Goetz MD, E. Hansen NP, S Ho MD, G. Ioannou MD; R. Miller MD, E. Morrison
MD; H. Mun Pharm D, R. Reddy MD, S. Wongcharatrawee MD, T. Wright MD, J. Dominitz MD
The following recommendations are based on current medical evidence and expert opinion from
clinicians. The content of the document is dynamic and will be revised as new clinical data becomes available. The purpose of this document is to assist practitioners in clinical decision-making, to standardize and improve the quality of patient care, and to promote costeffective
drug prescribing. The clinician should utilize this guidance and interpret it in the clinical context of the individual patient. Additional information can be found at www.pbm.va.gov and http://vaww.pbm.va.gov
.
Introduction
Hepatitis C virus (HCV) infection is estimated to affect several million Americans and over 170 million people worldwide. Standard treatment for chronic HCV involves an interferon-based preparation and ribavirin for 24 to 48 weeks. Sustained virologic response (SVR), defined as having undetectable virus at 6 months post-treatment, occurs in 54% to 56% of overall patients treated with peginterferon alfa and ribavirin. Moderate neutropenia is a common adverse effect of hepatitis C antiviral therapy with peginterferon alfa causing bone marrow suppression, resulting in absolute neutrophil counts (ANC) of <750/mm3 in approximately 20% of those treated. Peginterferon alfa doses of <60% of target dose appears to reduce SVR. Conceptually, granulocyte colony stimulating factor use may overcome treatment-related neutropenia, maintain higher interferon doses and potentially reduce infection in high-risk patients, though clinical studies to recommend its use are lacking.

Patient Selection
Before using a granulocyte colony stimulating factor:
Peginterferon dose has been reduced•
o Peginterferon alfa 2a reduction from 180mcg/week to 135mcg/week
o Peginterferon alfa 2b reduction from 1.5mcg/kg/week to 1.0mcg/kg/week
AND
Persistent severe neutropenia• despite at least 2 weeks of reduced dose peginterferon along with:
o ANC 1000/mm3, stop filgrastim.


Safety Issues
The most common adverse effects associated with filgrastim include bone pain and generalized
musculoskeletal pain. Other adverse effects infrequently observed and possibly related to filgrastim use include injection site reaction, rash, hepatomegaly, and arthralgia.
Allergic reactions occurring on initial or subsequent treatment have been rarely reported (<1 in 4,000 patients), generally occurring within the first 30 minutes of administration. These have been generally characterized by systemic symptoms involving at least 2 body systems, most often skin (rash, urticaria, facial edema), respiratory (wheezing, dyspnea), and cardiovascular (hypotension, tachycardia). Symptom resolution occurred in most cases after administration of antihistamines, steroids, bronchodilators, and/or epinephrine. Rare fatal cases of splenic rupture have been reported following administration of filgrastim in both healthy volunteers and patients. Patients reporting left upper abdominal and/or shoulder tip pain should be evaluated for an enlarged spleen or splenic rupture. Cytopenias resulting from an antibody response to exogenous growth factors have been reported on rare occasions in patients treated with recombinant growth factors. Patients receiving filgrastim should be closely monitored for a paradoxical decrease in ANC and treatment should be discontinued in patients with evidence of neutralizing antibodies to filgrastim.
Severe sickle cell crisis resulting in death has been associated with filgrastim in patients with sickle cell disease. Risks and benefits of filgrastim use in patients with sickle cell disease must be carefully considered. Since filgrastim single-dose vials and prefilled syringes do not contain preservatives, the vial or prefilled syringe should only be used once and any unused portion should be discarded.
References
1. Alter MJ, Kruszon-Moran D, Nainan OV, McQuillan GM, Gao F, Moyer LA et al. The
prevalence of hepatitis C virus infection in the United States, 1988 through 1994. N Engl J
Med. 1999; 341:556-62.
2. Manns MP, McHutchison JG, Gordon SC, et al. Peginterferon alfa-2b plus ribavirin compared
with interferon alfa-2b plus ribavirin for initial treatment of chronic hepatitis C: a randomized
trial. Lancet 2001; 358:958-65.
3. Fried MW, Shiffman ML, Reddy R, et al. Peginterferon alfa-2a plus ribavirin for chronic
hepatitis C virus infection. N Engl J Med 2002; 347:975-82.
4. Hadziyannis SJ, Sette H Jr, Morgan TR, et al. Peginterferon alpha-2a and ribavirin
combination therapy in chronic hepatitis C: a randomized study of treatment duration and
ribavirin dose. Ann Intern Med 2004; 140:346-55.
5. Sulkowski M, Wasserman R, Hassanein T, et al. Changes in hemoglobin during interferon alpha-
2b plus ribavirin combination therapy for chronic hepatitis C infection. J Viral Hepat
2004;11:243-50.
6. McHutchison JG, Manns M, Patel K, et al. Adherence to combination therapy enhances sustained