Cancer Chemotherapy and Pharmacology (2018) 82:165–170
Reduced dose pegﬁlgrastim is associated with less bone pain
without increased neutropenia: a retrospective study
Elyse E. Lower
· Mahmoud Charif
· Meg Bartelt
Received: 29 December 2017 / Accepted: 22 May 2018 / Published online: 5 June 2018
© Springer-Verlag GmbH Germany, part of Springer Nature 2018
Background Chemotherapy for breast cancer is associated with a high risk of neutropenia. Pegﬁlgrastim reduces the risk of
neutropenic fever but commonly causes bone pain.
Objective Evaluate whether a reduced dose of pegﬁlgrastim (3 mg) reduced the frequency of bone pain without compromis-
Methods Records reviewed from breast cancer patients who received at least one 3 mg dose of pegﬁlgrastim, white blood
count (WBC), and absolute granulocyte counts (AGC) were collected. Musculoskeletal pain scale was collected at each visit.
Results 265 treatments from 36 women were analyzed. There was no diﬀerence in post-treatment AGC between 3 versus
6 mg. Leukocytosis (WBC > 20,000 cells/cu mm) was more likely for those treated with 6 mg (chi-square 5.265, p = 0.0215).
There was higher change in bone pain in patients who received 6 mg doses compared to none or 3 mg.
Limitations In this retrospective, non-randomized study, we found the majority of patients received the reduced 3 mg dose
after intolerance to the 6 mg dose. It is unknown if smaller or larger doses than 3 mg would achieve similar results or whether
3 mg dose would be eﬀective as an initial therapy or for patients receiving diﬀerent chemotherapy regimens. Pain is observed
despite premedication with naproxen and/or loratidine.
Conclusion Reduced dose of pegﬁlgrastim 3 mg was less likely to cause bone pain. The reduced dose was not associated
with a signiﬁcant diﬀerence in post-treatment AGC or rate of serious infection.
Keywords Breast cancer · Chemotherapy · Pegﬁlgrastim · Neutropenia
Anthracycline and taxane-based chemotherapy which is
commonly prescribed as adjuvant treatment of breast can-
cer is associated with high risk of neutropenia. Pegﬁlgrastim
is a covalent conjugate of recombinant human G-CSF (ﬁl-
grastim) and monomethoxypolyethylene glycol. Compared
to ﬁlgrastim, pegﬁlgrastim has a reduced renal clearance and
prolonged persistence in vivo . A single dose of pegﬁl-
grastim 6 mg administered after chemotherapy is equivalent
to ﬁlgrastim 5 mcg/kg/day in reducing the duration of severe
neutropenia and risk of neutropenic fever [2, 3]. The use
of colony-stimulating factors are recommended when the
risk of febrile neutropenia associated with chemotherapy is
≥ 20% based on age, medical history, disease characteristics,
and myelotoxicity of the chemotherapy regimen . Mild to
moderate bone pain is a commonly reported side eﬀect of
pegﬁlgrastim with an incidence of approximately 25–40%
[3, 5]. Additionally, hyperleukocytosis can occur with peg-
ﬁlgrastim treatment [6, 7].
Utilization of growth factors can help achieve optimal
dose delivery . Delivering optimal dose of chemotherapy
(more than 85% of the intended dose) has been shown to
be associated with improved survival, and suboptimal dose
delivery can lead to an inferior outcome [9–11]. The admin-
istration of pegﬁlgrastim can improve adherence to treat-
ment guidelines by reducing febrile neutropenic episodes
and maintaining dose intensity and timing. Patients may
decline growth factor support due to adverse events or the
high cost of pegﬁlgrastim. In one study, a series of case sce-
narios were presented to breast cancer patients undergoing
* Elyse E. Lower
Department of Medicine, University of Cincinnati Medical
Center, 200 Albert Sabin Way, Holmes Hospital Room 1001,
Cincinnati, OH 45267-0565, USA