Febrile neutropenia is a serious and important dose-limiting side effect of chemotherapy since it is myelosuppressive, possibly causing infections. Febrile neutropenia in cancer patients is defined as an oral temperature of 38.5 degrees Celsius for two consecutive readings of more than 38 degrees Celsius for 2 hours and an absolute neutrophil count of <500/L or a count that is expected to decrease to <1,000/L within 48 hours. Febrile neutropenia has been known to cause morbidity and mortality in cancer patients and cause patients receiving chemotherapy to be admitted to the hospital for infections.
Granulocyte colony-stimulating factor (GCSF) agents may be given to help prevent the incidence of febrile neutropenia. The American Society of Clinical Oncology and the National Comprehensive Cancer Network (NCCN) guidelines recommend prophylaxis for patients with a greater than 20% risk of febrile neutropenia; they also recommend taking therapy into consideration if the risk is 10% to 20% and note that GCSF agents should be administered 24 to 72 hours after chemotherapy. The Infectious Diseases Society of America and European Society for Medical Oncology reinforce these recommendations.
A retrospective analysis was performed to assess the use of growth factors at a large community cancer center, and this information was used to implement and develop a pharmacist standard reference for GCSF use to reduce cost. This study examined an inpatient oncology unit, five satellite clinics, and three outreach locations. Patients met inclusion criteria if they were ≥18 years of age with a cancer diagnosis and received a GCSF agent for the prevention of febrile neutropenia. Patients were excluded if they were pediatric, were receiving GCSF for stem-cell mobilization, and had nononcologic neutropenia diagnoses. Patients were monitored between January 2014 and December 2014 (looking only at filgrastim and pegfilgrastim). Patients were evaluated for three things: whether the patient received the agent correctly based on the NCCN guidelines, increased risk factors as described by the NCCN guidelines, and the timing of the GCSF agents 24 to 72 hours after chemotherapy.
A total of 476 patients were evaluated (406 in the pegfilgrastim arm and 70 in the filgrastim arm). It was found that 47.22% of the filgrastim patients did not meet NCCN guideline criteria. In the pegfilgrastim group, 8.2% of all administrations did not meet the NCCN guideline criteria. Due to these findings, a pharmacist reference was created using an extensive list of chemotherapeutic regimens with the incidence of febrile neutropenia and any high-risk factors.
These measures might save the institution a lot of money due to saving costs on GCSF agents administered inappropriately and, most importantly, they will provide better patient care. They will also help in a collaborative effort of pharmacists and physicians to develop protocols to use GCSF agents appropriately.
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