This month, Sonali M. Smith, MD, advises on the use of pegfilgrastim with ABVD for treating Hodgkin lymphoma.
What is your opinion on the use of pegfilgrastim with ABVD for classical Hodgkin lymphoma? Is it necessary, or would you treat without regard to neutrophil count and include it only if the patient has a neutropenic fever event?
EXPERTS MAKE THE CALL
For unclear reasons, most patients with ABVD-associated neutropenia (especially younger patients) actually do quite well and do not develop neutropenic fevers or other related consequences.
In addition, there are retrospective data from several institutions demonstrating that the addition of pegfilgrastim to a bleomycin-containing regimen is associated with an increased risk of bleomycin-induced lung injury. We published our own citywide experience with elderly patients with Hodgkin lymphoma in Blood.1 In this population, the risk of lung injury with growth factors led to a very high percentage of pneumonitis, which was fatal in 30 percent of cases.
The American Society of Clinical Oncology and National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology recommend restricting pegfilgrastim use to regimens with at least 21 days between exposure to chemotherapy. An every-two-week regimen would not be appropriate for a long-lasting growth factor.
For these reasons, our practice has been to use prophylactic antimicrobials (usually aciclovir, sulfamethoxazole/trimethoprim, and a quinolone) if there is prolonged neutropenia and to give this prophylaxis for the duration of therapy. If a patient develops a neutropenic infection, then we add in support with filgrastim.
- 1. Evens AM, Helenowski I, Ramsdale E, et al. A retrospective multicenter analysis of elderly Hodgkin lymphoma: outcomes and prognostic factors in the modern era. Blood. 2012;119:692-5.
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