Treatment of AIDS-related Neutropenia

Author: V. Dimov, M.D., Cleveland Clinic

A 40 yo AAM with end-stage HIV/AIDS has a WBC of 1.66, ANC 498, Hgb 13.7, platelets 61.

PMH:
Hypertension, HIV, h/o esophageal candidiasis, h/o HZV face

Medications:
Acyclovir, doxycycline, esomeprazole, azithromycin, dapsone, Truvada, Norvir, Atazanavir

Laboratory results:


Neutropenia and thrombocytopenia in AIDS

ID suggests starting G-CSF. Which one should you choose? Neulasta or Neupogen?

Neupogen is FDA-approved for use in AIDS neutropenia. It is given daily and the effect can be titrated, e.g. the administration can be stopped when the desired effect is achieved (ANC >1000 x3 days). Neulasta is given just once, in a single dose. In chemotherapy-induced neutropenia, a single dose of Neulasta is as effective as 16 doses of Neupogen.

In the patient described above, Neupogen is a better choice.

Granulocyte Colony-Stimulating Factor (G-CSF) is a glycoprotein growth factor which stimulates bone marrow to produce granulocytes. The recombinant human G-CSF synthesised in an E. coli expression system is called filgrastim. Filgrastim (Neupogen®) and PEG-filgrastim (Neulasta®) are two commercially-available forms of rhG-CSF (recombinant human G-CSF). The PEG (polyethylene glycol) form has a much longer half-life, reducing the necessity of daily injections (modified from source: Wikipedia).

Neupogen (Epocrates link)
filgrastim
AIDS neutropenia
1-10 mcg/kg SC qd
Check CBC baseline and 2x/wk; may D/C if ANC >1000 x3 days.

Neulasta (Epocrates link)
pegfilgrastim
Neutropenia, post-chemo
6 mg SC x1
Monitor CBC, plt

What happened?
The patient was evaluated by Hematology/Oncology who also recommeded treatment with Neupogen. ANC improved with Neupogen, the patient was asymptomatic and was discharged home with ID follow-up.

Final diagnosis: AIDS-related neutropenia

References:
Neutropenia. eMedicine.
Recombinant granulocyte colony-stimulating factor in the long-term treatment of AIDS-related neutropenias. Recenti Prog Med. 1993 Jul-Aug;84(7-8):526-30.

Created: 02/01/2007
Updated: 02/13/2008

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