"With more than 30 years of experience in granulocyte-colony stimulating factor (G-CSF) research,
One of the most common side effects of myelosuppressive chemotherapy (chemotherapy that decreases the activity of the bone marrow) is a low white blood cell count, or neutropenia. Febrile neutropenia (neutropenia with fever) is a life-threatening complication of myelosuppressive chemotherapy that is associated with an increased risk of hospitalization that is costly to treat.1
The Neulasta Onpro Kit includes a specifically designed Neulasta pre-filled syringe along with a single use OBI. The small, lightweight OBI is applied to a patient's skin on the same day of chemotherapy. The OBI is intended to facilitate timed delivery of the correct dose of Neulasta and to improve the quality of life of patients as it removes the burden to return to a healthcare setting the day following chemotherapy, providing advantages over the standard manual injection pre-filled syringe.
Following the CHMP positive opinion, the centralized European marketing authorization of Neulasta will be updated to include the delivery system of the OBI in its label. Norway, Iceland and Liechtenstein, as members of the European Economic Area (EEA), will take corresponding decisions on the basis of the opinion of the
About Febrile Neutropenia
One of the most common side effects of myelosuppressive chemotherapy is a low white blood cell count. An abnormally low level of neutrophils, an important infection-fighting white blood cell, is called neutropenia. The fewer neutrophils a patient has – and the longer the neutrophil count remains low – the greater the risk of developing a potentially serious infection.2
Febrile neutropenia is neutropenia complicated by a fever. Fever is frequently a sign of infection and, in patients receiving myelosuppressive chemotherapy, it can sometimes be the only sign. Febrile neutropenia is a medical emergency and is associated with several potential downstream consequences.
About Neulasta® (pegfilgrastim)
Neulasta was approved for use in
Neulasta was also approved for use in the U.S. in 2002, and is indicated to decrease the incidence of infection, as manifested by febrile neutropenia, in patients with non-myeloid malignancies receiving myelosuppressive anti-cancer drugs associated with a clinically significant incidence of febrile neutropenia. Neulasta is also indicated to increase survival in patients acutely exposed to myelosuppressive doses of radiation. Neulasta is not indicated for the mobilization of peripheral blood progenitor cells for hematopoietic stem cell transplantation.
EU Important Safety Information
Special warnings and precautions for use
In order to improve the traceability of G-CSFs, the trade name of the administered product should be clearly recorded in the patient file.
Limited clinical data suggest a comparable effect on time to recovery of severe neutropenia for pegfilgrastim to filgrastim in patients with de novo acute myeloid leukaemia (AML) (see section 5.1). However, the long-term effects of Neulasta have not been established in AML; therefore, it should be used with caution in this patient population.
G-CSF can promote growth of myeloid cells in vitro and similar effects may be seen on some non-myeloid cells in vitro.
The safety and efficacy of Neulasta have not been investigated in patients with myelodysplastic syndrome, chronic myelogenous leukaemia, and in patients with secondary AML; therefore, it should not be used in such patients. Particular care should be taken to distinguish the diagnosis of blast transformation of chronic myeloid leukaemia from AML.
The safety and efficacy of Neulasta administration in de novo AML patients aged < 55 years with cytogenetics (15;17) have not been established.
The safety and efficacy of Neulasta have not been investigated in patients receiving high dose chemotherapy. This medicinal product should not be used to increase the dose of cytotoxic chemotherapy beyond established dosage regimens.
Pulmonary adverse events
Pulmonary adverse reactions, in particular interstitial pneumonia, have been reported after G-CSF administration. Patients with a recent history of pulmonary infiltrates or pneumonia may be at higher risk (see section 4.8).
The onset of pulmonary signs such as cough, fever, and dyspnoea in association with radiological signs of pulmonary infiltrates, and deterioration in pulmonary function along with increased neutrophil count may be preliminary signs of Acute Respiratory Distress Syndrome (ARDS). In such circumstances Neulasta should be discontinued at the discretion of the physician and the appropriate treatment given (see section 4.8).
Glomerulonephritis has been reported in patients receiving NEUPOGEN (filgrastim) and Neulasta. Generally, events of glomerulonephritis resolved after dose reduction or withdrawal of NEUPOGEN and Neulasta. Urinalysis monitoring is recommended.
Capillary leak syndrome
Capillary leak syndrome has been reported after G-CSF administration and is characterised by hypotension, hypoalbuminaemia, oedema and hemoconcentration. Patients who develop symptoms of capillary leak syndrome should be closely monitored and receive standard symptomatic treatment, which may include a need for intensive care (see section 4.8).
Splenomegaly and splenic rupture
Generally asymptomatic cases of splenomegaly and cases of splenic rupture, including some fatal cases, have been reported following administration of Neulasta (see section 4.8). Therefore, spleen size should be carefully monitored (e.g. clinical examination, ultrasound). A diagnosis of splenic rupture should be considered in patients reporting left upper abdominal pain or shoulder tip pain.
Thrombocytopenia and anaemia
Treatment with Neulasta alone does not preclude thrombocytopenia and anaemia because full dose myelosuppressive chemotherapy is maintained on the prescribed schedule. Regular monitoring of platelet count and haematocrit is recommended. Special care should be taken when administering single or combination chemotherapeutic agents which are known to cause severe thrombocytopenia.
Medication error as a result of device failure
There is a risk of medication error, particularly a partial or missed dose of Neulasta, in the event of a device failure or malfunction with the on-body injector. In the event of a partial or missed dose, patients may be at increased risk of events such as neutropenia, febrile neutropenia and/or infection than if the dose had been correctly delivered. The healthcare professional must ensure the patient receives appropriate training about the on-body injector and understands that if they suspect a device failure or malfunction the patient must immediately inform a healthcare professional as they may need a replacement dose. Comprehensive instructions for use for healthcare professionals and patients are given in the package leaflet. The patient should also be given the Patient Alert Card.
Sickle cell anaemia
Sickle cell crises have been associated with the use of Neulasta in patients with sickle cell trait or sickle cell disease (see section 4.8). Therefore, physicians should use caution when prescribing Neulasta in patients with sickle cell trait or sickle cell disease, should monitor appropriate clinical parameters and laboratory status and be attentive to the possible association of this medicine with splenic enlargement and vaso-occlusive crisis.
White blood cell (WBC) counts of 100 x 109/L or greater have been observed in less than 1% of patients receiving Neulasta. No adverse events directly attributable to this degree of leukocytosis have been reported. Such elevation in white blood cells is transient, typically seen 24 to 48 hours after administration and is consistent with the pharmacodynamic effects of this medicine. Consistent with the clinical effects and the potential for leukocytosis, a WBC count should be performed at regular intervals during therapy. If leukocyte counts exceed 50 x 109/L after the expected nadir, this medicine should be discontinued immediately.
Hypersensitivity, including anaphylactic reactions, occurring on initial or subsequent treatment have been reported in patients treated with Neulasta. Permanently discontinue Neulasta in patients with clinically significant hypersensitivity. Do not administer Neulasta to patients with a history of hypersensitivity to Neulasta or NEUPOGEN. If a serious allergic reaction occurs, appropriate therapy should be administered, with close patient follow-up over several days.
As with all therapeutic proteins, there is a potential for immunogenicity. Rates of generation of antibodies against Neulasta is generally low. Binding antibodies do occur as expected with all biologics; however, they have not been associated with neutralising activity at present.
The safety and efficacy of Neulasta for the mobilisation of blood progenitor cells in patients or healthy donors has not been adequately evaluated.
The needle cap of the pre-filled syringe contains dry natural rubber (a derivative of latex), which may cause allergic reactions.
The on-body injector uses an acrylic adhesive. For patients who have reactions to acrylic adhesives, use of this product may result in an allergic reaction.
Increased haematopoietic activity of the bone marrow in response to growth factor therapy has been associated with transient positive bone imaging findings. This should be considered when interpreting bone-imaging results.
Neulasta contains sorbitol. Patients with rare hereditary problems of fructose intolerance should not take this medicine.
Neulasta contains less than 1 mmol (23 mg) sodium per 6 mg dose, i.e. essentially 'sodium-free'.
Please refer to the Summary of Product Characteristics for full European prescribing information.
U.S. Important Safety Information
Do not administer Neulasta® to patients with a history of serious allergic reactions to pegfilgrastim or filgrastim.
Splenic rupture, including fatal cases, can occur following the administration of Neulasta®. Evaluate for an enlarged spleen or splenic rupture in patients who report left upper abdominal or shoulder pain after receiving Neulasta®.
Acute Respiratory Distress Syndrome
Acute respiratory distress syndrome (ARDS) can occur in patients receiving Neulasta®. Evaluate patients who develop fever and lung infiltrates or respiratory distress after receiving Neulasta for ARDS. Discontinue Neulasta® in patients with ARDS.
Serious Allergic Reactions
Serious allergic reactions, including anaphylaxis, can occur in patients receiving Neulasta®. The majority of reported events occurred upon initial exposure. Allergic reactions, including anaphylaxis, can recur within days after the discontinuation of initial anti-allergic treatment. Permanently discontinue Neulasta® in patients with serious allergic reactions.
Allergies to Acrylics
The on-body injector for Neulasta® uses acrylic adhesive. For patients who have reactions to acrylic adhesives, use of this product may result in a significant reaction.
Use in Patients with Sickle Cell Disorders
Severe sickle cell crises can occur in patients with sickle cell disorders receiving Neulasta®. Severe and sometimes fatal sickle cell crises can occur in patients with sickle cell disorders receiving filgrastim, the parent compound of pegfilgrastim.
Glomerulonephritis has been reported in patients receiving Neulasta®. The diagnoses were based upon azotemia, hematuria (microscopic and macroscopic), proteinuria, and renal biopsy. Generally, events of glomerulonephritis resolved after withdrawal of Neulasta®. If glomerulonephritis is suspected, evaluate for cause. If causality is likely, consider dose-reduction or interruption of Neulasta®.
White blood cell counts of 100 x 109/L or greater have been observed in patients receiving pegfilgrastim. Monitoring of CBCs during pegfilgrastim therapy is recommended.
Capillary Leak Syndrome
Capillary leak syndrome has been reported after granulocyte colony-stimulating factor (G-CSF) administration, including Neulasta®, and is characterized by hypotension, hypoalbuminemia, edema, and hemoconcentration. Episodes vary in frequency, severity and may be life-threatening if treatment is delayed. Patients who develop symptoms of capillary leak syndrome should be closely monitored and receive standard symptomatic treatment, which may include a need for intensive care.
Potential for Tumor Growth Stimulatory Effects on Malignant Cells
The granulocyte colony-stimulating factor (G-CSF) receptor, through which pegfilgrastim and filgrastim act, has been found on tumor cell lines. The possibility that pegfilgrastim acts as a growth factor for any tumor type, including myeloid malignancies and myelodysplasia, diseases for which pegfilgrastim is not approved, cannot be excluded.
The most common adverse reactions (≥ 5% difference in incidence) in placebo-controlled clinical trials are bone pain and pain in extremity.
Please see additional Neulasta® Safety Information, by visiting www.amgen.com/medpro/products.html.
Please see the Neulasta Full Prescribing Information by clicking here.
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Weycker D, et al. Cost of neutropenic complications of chemotherapy. Annals of Oncology. 2008:19(3):454-460.
American Cancer Society. Low white blood cell (neutrophil) counts and the risk of infection. https://www.cancer.org/treatment/treatments-and-side-effects/physical-side-effects/infections/infections-in-people-with-cancer/low-wbc-and-weak-immune-system.html. Accessed Feb. 22, 2018.
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