Hematopoietic Growth Factors

Hematopoietic growth factors are a family of glycoproteins responsible for the proliferation and differentiation of hematopoietic progenitor cells in the bone marrow Bone marrow Bone marrow, the primary site of hematopoiesis, is found in the cavities of cancellous bones and the medullary canals of long bones. There are 2 types: red marrow (hematopoietic with abundant blood cells) and yellow marrow (predominantly filled with adipocytes). Composition of Bone Marrow. Pharmacologic erythropoietin Erythropoietin Glycoprotein hormone, secreted chiefly by the kidney in the adult and the liver in the fetus, that acts on erythroid stem cells of the bone marrow to stimulate proliferation and differentiation. Erythrocytes, thrombopoietin, granulocyte colony-stimulating factor (G-CSF), and granulocyte macrophage colony-stimulating factor Granulocyte macrophage colony-stimulating factor An acidic glycoprotein of mw 23 kda with internal disulfide bonds. The protein is produced in response to a number of inflammatory mediators by mesenchymal cells present in the hemopoietic environment and at peripheral sites of inflammation. GM-CSF is able to stimulate the production of neutrophilic granulocytes, macrophages, and mixed granulocyte-macrophage colonies from bone marrow cells and can stimulate the formation of eosinophil colonies from fetal liver progenitor cells. GM-CSF can also stimulate some functional activities in mature granulocytes and macrophages. White Myeloid Cells ( GM-CSF GM-CSF An acidic glycoprotein of mw 23 kda with internal disulfide bonds. The protein is produced in response to a number of inflammatory mediators by mesenchymal cells present in the hemopoietic environment and at peripheral sites of inflammation. GM-CSF is able to stimulate the production of neutrophilic granulocytes, macrophages, and mixed granulocyte-macrophage colonies from bone marrow cells and can stimulate the formation of eosinophil colonies from fetal liver progenitor cells. GM-CSF can also stimulate some functional activities in mature granulocytes and macrophages. White Myeloid Cells) are used in certain cases in which normal hematopoiesis is impaired owing to treatment (e.g., chemotherapy) or underlying disease (e.g., aplastic anemia Aplastic Anemia Aplastic anemia (AA) is a rare, life-threatening condition characterized by pancytopenia and hypocellularity of the bone marrow (in the absence of any abnormal cells) reflecting damage to hematopoietic stem cells. Aplastic anemia can be acquired or inherited, however, most cases of AA are acquired and caused by autoimmune damage to hematopoietic stem cells. Aplastic Anemia). Commonly, erythropoiesis Erythropoiesis Erythropoiesis starts with hematopoietic stem cells, which develop into lineage-committed progenitors and differentiate into mature RBCs. The process occurs in stages, and extrusion of the nuclei and organelles occurs prior to maturation. Thus, mature RBCs lack nuclei and have a biconcave shape. Erythrocytes-stimulating agents (ESAs) are given as part of the treatment of chemotherapy-induced anemia and anemia secondary to CKD CKD Chronic kidney disease (CKD) is kidney impairment that lasts for ≥ 3 months, implying that it is irreversible. Hypertension and diabetes are the most common causes; however, there are a multitude of other etiologies. In the early to moderate stages, CKD is usually asymptomatic and is primarily diagnosed by laboratory abnormalities. Chronic Kidney Disease. G-CSF and GM-CSF GM-CSF An acidic glycoprotein of mw 23 kda with internal disulfide bonds. The protein is produced in response to a number of inflammatory mediators by mesenchymal cells present in the hemopoietic environment and at peripheral sites of inflammation. GM-CSF is able to stimulate the production of neutrophilic granulocytes, macrophages, and mixed granulocyte-macrophage colonies from bone marrow cells and can stimulate the formation of eosinophil colonies from fetal liver progenitor cells. GM-CSF can also stimulate some functional activities in mature granulocytes and macrophages. White Myeloid Cells are administered to treat chemotherapy-induced neutropenia Neutropenia Neutrophils are an important component of the immune system and play a significant role in the eradication of infections. Low numbers of circulating neutrophils, referred to as neutropenia, predispose the body to recurrent infections or sepsis, though patients can also be asymptomatic. Neutropenia. Thrombopoiesis-stimulating agents are used in the prevention or treatment of thrombocytopenia Thrombocytopenia Thrombocytopenia occurs when the platelet count is < 150,000 per microliter. The normal range for platelets is usually 150,000-450,000/µL of whole blood. Thrombocytopenia can be a result of decreased production, increased destruction, or splenic sequestration of platelets. Patients are often asymptomatic until platelet counts are < 50,000/µL. Thrombocytopenia.

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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Overview

Definition

Hematopoietic growth factors are glycoproteins that regulate the proliferation, differentiation, and maturation of progenitor cells, as well as the function of the mature cells.

Hematopoiesis

  • Hematopoiesis is the formation of blood cells:
    • Blood cells have a limited life span, so the ability to produce such cells is an important function of the body for continual renewal.
    • Adult hematopoiesis occurs in the bone marrow Bone marrow Bone marrow, the primary site of hematopoiesis, is found in the cavities of cancellous bones and the medullary canals of long bones. There are 2 types: red marrow (hematopoietic with abundant blood cells) and yellow marrow (predominantly filled with adipocytes). Composition of Bone Marrow
    • Fetal hematopoiesis occurs in different organs as the fetus develops: 
      • Yolk sac: 3–8 weeks
      • Liver: 6 weeks–birth
      • Spleen Spleen The spleen is the largest lymphoid organ in the body, located in the LUQ of the abdomen, superior to the left kidney and posterior to the stomach at the level of the 9th-11th ribs just below the diaphragm. The spleen is highly vascular and acts as an important blood filter, cleansing the blood of pathogens and damaged erythrocytes. Spleen: 10–28 weeks
      • Bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones marrow: after 18 weeks
  • Hematopoietic stem cells (HSCs) develop in a complex microenvironment consisting of extracellular matrix and stromal cells: 
    • Undergo a series of steps → give rise to the common lymphoid progenitors Common lymphoid progenitors Stem cells from which B-lymphocytes; T-lymphocytes; natural killer cells; and some dendritic cells derive. Composition of Bone Marrow and common myeloid progenitors Common myeloid progenitors Stem cells derived from hematopoietic stem cells. Derived from these myeloid progenitor cells are the megakaryocytes; erythroid cells; myeloid cells; and some dendritic cells. Composition of Bone Marrow (which are colonies of mixed blood cell lineage)
    • Common myeloid progenitors give rise to committed progenitors → colony-forming units (CFUs), which undergo proliferation and differentiation
  • CSFs impact development at the most mature stage.

Major hematopoietic growth factors and pharmacologic agents

Table: Major hematopoietic growth factors and pharmacologic agents
Cytokines/growth factors Activities Pharmacologic agent(s)
Erythropoietin ( EPO EPO Glycoprotein hormone, secreted chiefly by the kidney in the adult and the liver in the fetus, that acts on erythroid stem cells of the bone marrow to stimulate proliferation and differentiation. Erythrocytes) Stimulates erythropoiesis Erythropoiesis Erythropoiesis starts with hematopoietic stem cells, which develop into lineage-committed progenitors and differentiate into mature RBCs. The process occurs in stages, and extrusion of the nuclei and organelles occurs prior to maturation. Thus, mature RBCs lack nuclei and have a biconcave shape. Erythrocytes, including differentiation
  • Epoetin alfa
  • Darbepoetin alfa
  • Methoxy polyethylene glycol–epoetin beta
Granulocyte macrophage colony-stimulating factor Macrophage colony-stimulating factor A mononuclear phagocyte colony-stimulating factor (M-CSF) synthesized by mesenchymal cells. The compound stimulates the survival, proliferation, and differentiation of hematopoietic cells of the monocyte-macrophage series. M-CSF is a disulfide-bonded glycoprotein dimer with a mw of 70 kda. It binds to a specific high affinity receptor. White Myeloid Cells ( GM-CSF GM-CSF An acidic glycoprotein of mw 23 kda with internal disulfide bonds. The protein is produced in response to a number of inflammatory mediators by mesenchymal cells present in the hemopoietic environment and at peripheral sites of inflammation. GM-CSF is able to stimulate the production of neutrophilic granulocytes, macrophages, and mixed granulocyte-macrophage colonies from bone marrow cells and can stimulate the formation of eosinophil colonies from fetal liver progenitor cells. GM-CSF can also stimulate some functional activities in mature granulocytes and macrophages. White Myeloid Cells) Stimulates myeloid progenitor cells Sargramostim
Granulocyte colony-stimulating factor (G-CSF) Stimulates neutrophil precursor cells
  • Filgrastim
  • Pegfilgrastim
Thrombopoietin (TPO) Stimulates thrombopoiesis
  • Romiplostim
  • Eltrombopag
  • Avatrombopag
  • Lusutrombopag
IL-11 Stimulates thrombopoiesis Oprelvekin
Bone marrow hematopoiesis

Bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones marrow hematopoiesis: proliferation and differentiation of the formed elements of blood.
IL-3: interleukin-3
CFU-GEMM: colony-forming unit–granulocyte, erythrocyte, monocyte, megakaryocyte
IL-2: interleukin-2
IL-6: interleukin-6
CFU-GM: colony-forming unit–granulocyte-macrophage
GM-CSF GM-CSF An acidic glycoprotein of mw 23 kda with internal disulfide bonds. The protein is produced in response to a number of inflammatory mediators by mesenchymal cells present in the hemopoietic environment and at peripheral sites of inflammation. GM-CSF is able to stimulate the production of neutrophilic granulocytes, macrophages, and mixed granulocyte-macrophage colonies from bone marrow cells and can stimulate the formation of eosinophil colonies from fetal liver progenitor cells. GM-CSF can also stimulate some functional activities in mature granulocytes and macrophages. White Myeloid Cells: granulocyte- macrophage colony-stimulating factor Macrophage colony-stimulating factor A mononuclear phagocyte colony-stimulating factor (M-CSF) synthesized by mesenchymal cells. The compound stimulates the survival, proliferation, and differentiation of hematopoietic cells of the monocyte-macrophage series. M-CSF is a disulfide-bonded glycoprotein dimer with a mw of 70 kda. It binds to a specific high affinity receptor. White Myeloid Cells
M-CSF M-CSF A mononuclear phagocyte colony-stimulating factor (M-CSF) synthesized by mesenchymal cells. The compound stimulates the survival, proliferation, and differentiation of hematopoietic cells of the monocyte-macrophage series. M-CSF is a disulfide-bonded glycoprotein dimer with a mw of 70 kda. It binds to a specific high affinity receptor. White Myeloid Cells: macrophage colony-stimulating factor Macrophage colony-stimulating factor A mononuclear phagocyte colony-stimulating factor (M-CSF) synthesized by mesenchymal cells. The compound stimulates the survival, proliferation, and differentiation of hematopoietic cells of the monocyte-macrophage series. M-CSF is a disulfide-bonded glycoprotein dimer with a mw of 70 kda. It binds to a specific high affinity receptor. White Myeloid Cells
G-CSF: granulocyte colony-stimulating factor
IL-5: interleukin-5
NK: natural killer
TPO: thrombopoietin
EPO EPO Glycoprotein hormone, secreted chiefly by the kidney in the adult and the liver in the fetus, that acts on erythroid stem cells of the bone marrow to stimulate proliferation and differentiation. Erythrocytes: erythropoietin Erythropoietin Glycoprotein hormone, secreted chiefly by the kidney in the adult and the liver in the fetus, that acts on erythroid stem cells of the bone marrow to stimulate proliferation and differentiation. Erythrocytes

Image by Lecturio. License: CC BY-NC-SA 4.0

Erythropoiesis-Stimulating Agents

Definition

Erythropoiesis-stimulating agents (ESAs) are pharmacologic substances that stimulate the production of RBCs and are used to treat anemia due to a variety of conditions.

Agents

  • Epoetin alfa: recombinant human erythropoietin Erythropoietin Glycoprotein hormone, secreted chiefly by the kidney in the adult and the liver in the fetus, that acts on erythroid stem cells of the bone marrow to stimulate proliferation and differentiation. Erythrocytes
  • Darbepoetin alfa: erythropoietin Erythropoietin Glycoprotein hormone, secreted chiefly by the kidney in the adult and the liver in the fetus, that acts on erythroid stem cells of the bone marrow to stimulate proliferation and differentiation. Erythrocytes analog with additional oligosaccharide chains
  • Methoxy polyethylene glycol–epoetin beta: long-acting erythropoietin Erythropoietin Glycoprotein hormone, secreted chiefly by the kidney in the adult and the liver in the fetus, that acts on erythroid stem cells of the bone marrow to stimulate proliferation and differentiation. Erythrocytes receptor activator
Table: Mechanism of action, pharmacokinetics Pharmacokinetics Pharmacokinetics is the science that analyzes how the human body interacts with a drug. Pharmacokinetics examines how the drug is absorbed, distributed, metabolized, and excreted by the body. Pharmacokinetics and Pharmacodynamics and indications for erythropoiesis Erythropoiesis Erythropoiesis starts with hematopoietic stem cells, which develop into lineage-committed progenitors and differentiate into mature RBCs. The process occurs in stages, and extrusion of the nuclei and organelles occurs prior to maturation. Thus, mature RBCs lack nuclei and have a biconcave shape. Erythrocytes-stimulating agents
Agent Mechanism of action Pharmacokinetics Indications
Epoetin alfa
  • Stimulate the proliferation and differentiation of progenitor cells
  • Bring about the release of reticulocytes
  • Increase hemoglobin and hematocrit
  • IV, SC
  • Slow SC absorption Absorption Absorption involves the uptake of nutrient molecules and their transfer from the lumen of the GI tract across the enterocytes and into the interstitial space, where they can be taken up in the venous or lymphatic circulation. Digestion and Absorption
  • ↑ Reticulocyte in 10 days
  • Peak effect: ↑ hemoglobin in 2–6 weeks
  • Distribution similar to extracellular plasma
  • Half-life elimination:
    • ≤ 67 hours (SC)
    • 4–13 hours (IV): CKD CKD Chronic kidney disease (CKD) is kidney impairment that lasts for ≥ 3 months, implying that it is irreversible. Hypertension and diabetes are the most common causes; however, there are a multitude of other etiologies. In the early to moderate stages, CKD is usually asymptomatic and is primarily diagnosed by laboratory abnormalities. Chronic Kidney Disease
  • Anemia Anemia Anemia is a condition in which individuals have low Hb levels, which can arise from various causes. Anemia is accompanied by a reduced number of RBCs and may manifest with fatigue, shortness of breath, pallor, and weakness. Subtypes are classified by the size of RBCs, chronicity, and etiology. Anemia: Overview 2 degrees to:
    • CKD CKD Chronic kidney disease (CKD) is kidney impairment that lasts for ≥ 3 months, implying that it is irreversible. Hypertension and diabetes are the most common causes; however, there are a multitude of other etiologies. In the early to moderate stages, CKD is usually asymptomatic and is primarily diagnosed by laboratory abnormalities. Chronic Kidney Disease
    • Chemotherapy
    • Medication (zidovudine)
  • ↓ Allogeneic transfusion for elective noncardiac, nonvascular surgery
Darbepoetin alfa
  • IV, SC
  • Slow SC absorption Absorption Absorption involves the uptake of nutrient molecules and their transfer from the lumen of the GI tract across the enterocytes and into the interstitial space, where they can be taken up in the venous or lymphatic circulation. Digestion and Absorption
  • Peak effect: ↑ hemoglobin in 2–6 weeks
  • IV: longer half-life than epoetin alfa
  • Half-life elimination:
    • 21 hours (IV)
    • 70 hours (SC); shorter in dialysis Dialysis Renal replacement therapy refers to dialysis and/or kidney transplantation. Dialysis is a procedure by which toxins and excess water are removed from the circulation. Hemodialysis and peritoneal dialysis (PD) are the two types of dialysis, and their primary difference is the location of the filtration process (external to the body in hemodialysis versus inside the body for PD). Overview and Types of Dialysis
Anemia Anemia Anemia is a condition in which individuals have low Hb levels, which can arise from various causes. Anemia is accompanied by a reduced number of RBCs and may manifest with fatigue, shortness of breath, pallor, and weakness. Subtypes are classified by the size of RBCs, chronicity, and etiology. Anemia: Overview 2 degrees to:
  • CKD CKD Chronic kidney disease (CKD) is kidney impairment that lasts for ≥ 3 months, implying that it is irreversible. Hypertension and diabetes are the most common causes; however, there are a multitude of other etiologies. In the early to moderate stages, CKD is usually asymptomatic and is primarily diagnosed by laboratory abnormalities. Chronic Kidney Disease
  • Chemotherapy
Methoxy polyethylene glycol–epoetin beta
  • IV, SC
  • Peak effect: ↑ hemoglobin in 7–15 days
  • Half-life elimination:
    • 119 hours (IV)
    • 124 hours (SC)
Anemia Anemia Anemia is a condition in which individuals have low Hb levels, which can arise from various causes. Anemia is accompanied by a reduced number of RBCs and may manifest with fatigue, shortness of breath, pallor, and weakness. Subtypes are classified by the size of RBCs, chronicity, and etiology. Anemia: Overview 2 degrees to CKD CKD Chronic kidney disease (CKD) is kidney impairment that lasts for ≥ 3 months, implying that it is irreversible. Hypertension and diabetes are the most common causes; however, there are a multitude of other etiologies. In the early to moderate stages, CKD is usually asymptomatic and is primarily diagnosed by laboratory abnormalities. Chronic Kidney Disease

Adverse effects

  • Cardiovascular:
    • Hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension
    • ↑ Risk of MI MI MI is ischemia and death of an area of myocardial tissue due to insufficient blood flow and oxygenation, usually from thrombus formation on a ruptured atherosclerotic plaque in the epicardial arteries. Clinical presentation is most commonly with chest pain, but women and patients with diabetes may have atypical symptoms. Myocardial Infarction
    • Cerebrovascular accident Cerebrovascular accident An ischemic stroke (also known as cerebrovascular accident) is an acute neurologic injury that occurs as a result of brain ischemia; this condition may be due to cerebral blood vessel occlusion by thrombosis or embolism, or rarely due to systemic hypoperfusion. Ischemic Stroke (stroke)
    • Venous thromboembolism
    • Thrombosis of vascular access
  • Nausea and vomiting
  • Arthralgia
  • Rash, pruritus, and in severe cases: toxic epidermal necrolysis (TEN), Stevens-Johnson syndrome Stevens-Johnson syndrome Stevens-Johnson syndrome (SJS) is a cutaneous, immune-mediated hypersensitivity reaction that is commonly triggered by medications, including antiepileptics and antibiotics. The condition runs on a spectrum with toxic epidermal necrolysis (TEN) based on the amount of body surface area (BSA) involved. Stevens-Johnson Syndrome ( SJS SJS Stevens-Johnson syndrome (SJS) is a cutaneous, immune-mediated hypersensitivity reaction that is commonly triggered by medications, including antiepileptics and antibiotics. The condition runs on a spectrum with toxic epidermal necrolysis (TEN) based on the amount of body surface area (BSA) involved. Stevens-Johnson Syndrome)
  • Tumor progression in certain cancers
  • Seizures Seizures A seizure is abnormal electrical activity of the neurons in the cerebral cortex that can manifest in numerous ways depending on the region of the brain affected. Seizures consist of a sudden imbalance that occurs between the excitatory and inhibitory signals in cortical neurons, creating a net excitation. The 2 major classes of seizures are focal and generalized. Seizures

Contraindications

  • Hypersensitivity reactions
  • Uncontrolled hypertension Uncontrolled hypertension Although hypertension is defined as a blood pressure of > 130/80 mm Hg, individuals can present with comorbidities of severe asymptomatic or "uncontrolled" hypertension (≥ 180 mm Hg systolic and/or ≥ 120 mm Hg diastolic) that carries with it a significant risk of morbidity and mortality. Uncontrolled Hypertension
  • Pure RBC aplasia after treatment with ESAs
  • Formulations containing benzoyl peroxide are contraindicated in neonates and during the peripartum and breastfeeding Breastfeeding Breastfeeding is often the primary source of nutrition for the newborn. During pregnancy, hormonal stimulation causes the number and size of mammary glands in the breast to significantly increase. After delivery, prolactin stimulates milk production, while oxytocin stimulates milk expulsion through the lactiferous ducts, where it is sucked out through the nipple by the infant. Breastfeeding periods.

Myeloid Growth Factors

Definition

Myeloid growth factors are agents that stimulate proliferation and differentiation of ≥ 1 myeloid cell types and are used to treat low neutrophil counts. 

Agents

  • Recombinant G-CSF:
    • Filgrastim (Neupogen)
    • Pegfilgrastim (Neulasta) is a pegylated form of G-CSF: formulation allows longer half-life.
  • Recombinant GM-CSF GM-CSF An acidic glycoprotein of mw 23 kda with internal disulfide bonds. The protein is produced in response to a number of inflammatory mediators by mesenchymal cells present in the hemopoietic environment and at peripheral sites of inflammation. GM-CSF is able to stimulate the production of neutrophilic granulocytes, macrophages, and mixed granulocyte-macrophage colonies from bone marrow cells and can stimulate the formation of eosinophil colonies from fetal liver progenitor cells. GM-CSF can also stimulate some functional activities in mature granulocytes and macrophages. White Myeloid Cells: sargramostim
Table: Mechanism of action, pharmacokinetics Pharmacokinetics Pharmacokinetics is the science that analyzes how the human body interacts with a drug. Pharmacokinetics examines how the drug is absorbed, distributed, metabolized, and excreted by the body. Pharmacokinetics and Pharmacodynamics and indications for myeloid growth factors
Agent Mechanism of action Pharmacokinetics Indications
Filgrastim
  • Stimulate CFU-G
  • ↑ Neutrophil production
  • IV, SC
  • Time to peak: 2–8 hours (SC)
  • Half-life elimination: approximately 3.5 hours
  • Systemically degraded
  • AML AML Acute myeloid leukemia (AML) is a hematologic malignancy characterized by the uncontrolled proliferation of myeloid precursor cells. Seen predominantly in older adults, AML includes an accumulation of myeloblasts and a replacement of normal marrow by malignant cells, which leads to impaired hematopoiesis. Acute Myeloid Leukemia (after induction)
  • Myelosuppression from chemotherapy
  • Bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones marrow transplantation (BMT) (↓ neutropenia Neutropenia Neutrophils are an important component of the immune system and play a significant role in the eradication of infections. Low numbers of circulating neutrophils, referred to as neutropenia, predispose the body to recurrent infections or sepsis, though patients can also be asymptomatic. Neutropenia)
  • Peripheral blood progenitor cell for apheresis collection
  • Hematopoietic radiation injury syndrome
  • Severe chronic neutropenia Neutropenia Neutrophils are an important component of the immune system and play a significant role in the eradication of infections. Low numbers of circulating neutrophils, referred to as neutropenia, predispose the body to recurrent infections or sepsis, though patients can also be asymptomatic. Neutropenia
Pegfilgrastim
  • IV, SC
  • Time to peak: 24 hours
  • Half-life elimination: 15–80 hours
  • Excreted by binding to neutrophils
  • Hematopoietic radiation injury syndrome
  • Prevent neutropenia Neutropenia Neutrophils are an important component of the immune system and play a significant role in the eradication of infections. Low numbers of circulating neutrophils, referred to as neutropenia, predispose the body to recurrent infections or sepsis, though patients can also be asymptomatic. Neutropenia in chemotherapy
Sargramostim
  • CSF
  • ↑ Myelopoiesis (proliferation, differentiation, and activity of neutrophils, eosinophils, macrophages, monocytes)
  • IV, SC
  • Time to peak: up to 4 hours (SC)
  • ↑ WBC in 1–2 weeks
  • ↓ WBC in 2–10 days after discontinuation
  • Half-life elimination: 3.8 hours (IV), 1.4 hours (SC)
  • AML AML Acute myeloid leukemia (AML) is a hematologic malignancy characterized by the uncontrolled proliferation of myeloid precursor cells. Seen predominantly in older adults, AML includes an accumulation of myeloblasts and a replacement of normal marrow by malignant cells, which leads to impaired hematopoiesis. Acute Myeloid Leukemia (after induction)
  • Allogeneic or autologous BMT
  • To mobilize autologous peripheral blood progenitor cells for collection (by leukapheresis)
  • Speed up myeloid reconstitution after BMT
  • Hematopoietic radiation injury syndrome
BMT: bone marrow Bone marrow Bone marrow, the primary site of hematopoiesis, is found in the cavities of cancellous bones and the medullary canals of long bones. There are 2 types: red marrow (hematopoietic with abundant blood cells) and yellow marrow (predominantly filled with adipocytes). Composition of Bone Marrow transplantation
CFU-G: colony-forming unit-granulocyte

Adverse effects

  • Filgrastim and pegfilgrastim:
    • Bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
    • Diarrhea Diarrhea Diarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea, nausea, vomiting
    • Splenic rupture Splenic rupture Splenic rupture is a medical emergency that carries a significant risk of hypovolemic shock and death. Injury to the spleen accounts for nearly half of all injuries to intra-abdominal organs. The most common reason for a rupture of the spleen is blunt abdominal trauma, specifically, motor vehicle accidents. Rupture of the Spleen
    • ARDS ARDS Acute respiratory distress syndrome is characterized by the sudden onset of hypoxemia and bilateral pulmonary edema without cardiac failure. Sepsis is the most common cause of ARDS. The underlying mechanism and histologic correlate is diffuse alveolar damage (DAD). Acute Respiratory Distress Syndrome, alveolar hemorrhage
    • Aortitis, chest pain Chest Pain Chest pain is one of the most common and challenging complaints that may present in an inpatient and outpatient setting. The differential diagnosis of chest pain is large and includes cardiac, gastrointestinal, pulmonary, musculoskeletal, and psychiatric etiologies. Chest Pain
    • Nephrotoxicity
    • Cutaneous vasculitis
    • Capillary leak syndrome
    • Sweet syndrome: acute febrile neutropenia Neutropenia Neutrophils are an important component of the immune system and play a significant role in the eradication of infections. Low numbers of circulating neutrophils, referred to as neutropenia, predispose the body to recurrent infections or sepsis, though patients can also be asymptomatic. Neutropenia with dermatologic findings
    • Sickle cell crisis
    • Leukocytosis (WBCs ≥ 100,000/mm³)
    • Myelodysplastic syndrome, AML AML Acute myeloid leukemia (AML) is a hematologic malignancy characterized by the uncontrolled proliferation of myeloid precursor cells. Seen predominantly in older adults, AML includes an accumulation of myeloblasts and a replacement of normal marrow by malignant cells, which leads to impaired hematopoiesis. Acute Myeloid Leukemia
  • Sargramostim:
    • Cardiac dysrhythmias, hypertension, edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema, chest pain Chest Pain Chest pain is one of the most common and challenging complaints that may present in an inpatient and outpatient setting. The differential diagnosis of chest pain is large and includes cardiac, gastrointestinal, pulmonary, musculoskeletal, and psychiatric etiologies. Chest Pain
    • Nausea, vomiting, diarrhea, abdominal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, ↑ bilirubin
    • ↑ Creatinine
    • Capillary leak syndrome
    • Intraocular hemorrhage
    • Leukocytosis
    • Infusion reaction
    • Tumor growth (especially myeloid malignancies)

Contraindications

  • Severe allergic/hypersensitivity reaction
  • For sargramostim: contraindicated with > 10% leukemic myeloid blasts (in BM or peripheral blood)

Thrombopoietic Growth Factors

Definition

Thrombopoietic growth factors stimulate thrombopoiesis via the action of IL-11 or through the activation of TPO receptor.

Agents

  • Oprelvekin: recombinant IL-11
  • Romiplostim: peptide TPO receptor agonists
  • Eltrombopag, lusutrombopag, avatrombopag: nonpeptide TPO receptor agonists
Table: Mechanism of action, pharmacokinetics Pharmacokinetics Pharmacokinetics is the science that analyzes how the human body interacts with a drug. Pharmacokinetics examines how the drug is absorbed, distributed, metabolized, and excreted by the body. Pharmacokinetics and Pharmacodynamics and indications for thrombopoietic growth factors
Agent Mechanism of action Pharmacokinetics Indications
Oprelvekin Stimulates megakaryocytopoiesis and thrombopoiesis
  • IV, SC
  • Half-life: approximately 7 hours
  • ↑ Platelets in 5–9 days
Prevent severe thrombocytopenia Thrombocytopenia Thrombocytopenia occurs when the platelet count is < 150,000 per microliter. The normal range for platelets is usually 150,000-450,000/µL of whole blood. Thrombocytopenia can be a result of decreased production, increased destruction, or splenic sequestration of platelets. Patients are often asymptomatic until platelet counts are < 50,000/µL. Thrombocytopenia in those undergoing chemotherapy for nonmyeloid cancer
Romiplostim ↑ Platelets by binding TPO receptor
  • SC
  • Half-life: 3.5 days (median); up to 34 days
  • Peak platelet increase: 12–16 days
  • Immune thrombocytopenia Thrombocytopenia Thrombocytopenia occurs when the platelet count is < 150,000 per microliter. The normal range for platelets is usually 150,000-450,000/µL of whole blood. Thrombocytopenia can be a result of decreased production, increased destruction, or splenic sequestration of platelets. Patients are often asymptomatic until platelet counts are < 50,000/µL. Thrombocytopenia
  • Hematopoietic syndrome of acute radiation syndrome
Eltrombopag
  • Oral
  • Half-life: approximately 32 hours
  • Peak platelet increase: 1–2 weeks
  • Fecal excretion
  • Immune thrombocytopenia Thrombocytopenia Thrombocytopenia occurs when the platelet count is < 150,000 per microliter. The normal range for platelets is usually 150,000-450,000/µL of whole blood. Thrombocytopenia can be a result of decreased production, increased destruction, or splenic sequestration of platelets. Patients are often asymptomatic until platelet counts are < 50,000/µL. Thrombocytopenia
  • Severe aplastic anemia Aplastic Anemia Aplastic anemia (AA) is a rare, life-threatening condition characterized by pancytopenia and hypocellularity of the bone marrow (in the absence of any abnormal cells) reflecting damage to hematopoietic stem cells. Aplastic anemia can be acquired or inherited, however, most cases of AA are acquired and caused by autoimmune damage to hematopoietic stem cells. Aplastic Anemia
  • Chronic hepatitis C Hepatitis C Hepatitis C is an infection of the liver caused by the hepatitis C virus (HCV). The infection can be transmitted through infectious blood or body fluids and may be transmitted during childbirth or through IV drug use or sexual intercourse. Hepatitis C virus can cause both acute and chronic hepatitis, ranging from a mild to a serious, lifelong illness including liver cirrhosis and hepatocellular carcinoma (HCC). Hepatitis C Virus–associated thrombocytopenia Thrombocytopenia Thrombocytopenia occurs when the platelet count is < 150,000 per microliter. The normal range for platelets is usually 150,000-450,000/µL of whole blood. Thrombocytopenia can be a result of decreased production, increased destruction, or splenic sequestration of platelets. Patients are often asymptomatic until platelet counts are < 50,000/µL. Thrombocytopenia

Adverse effects

  • Oprelvekin:
    • Nausea, vomiting, diarrhea
    • Dyspnea Dyspnea Dyspnea is the subjective sensation of breathing discomfort. Dyspnea is a normal manifestation of heavy physical or psychological exertion, but also may be caused by underlying conditions (both pulmonary and extrapulmonary). Dyspnea, cough, pleural effusions
    • Atrial arrhythmias
    • Edema
    • Conjunctival injection
    • Blurred vision
    • Injection-site reaction
  • Romiplostim:
    • Thromboembolism
    • Upper respiratory infection (URI)
    • Dizziness, headache
    • Abdominal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, diarrhea
    • Arthralgias
    • Rash
    • Progression of myelodysplastic syndrome → AML AML Acute myeloid leukemia (AML) is a hematologic malignancy characterized by the uncontrolled proliferation of myeloid precursor cells. Seen predominantly in older adults, AML includes an accumulation of myeloblasts and a replacement of normal marrow by malignant cells, which leads to impaired hematopoiesis. Acute Myeloid Leukemia
    • Neutralizing antibodies Antibodies Immunoglobulins (Igs), also known as antibodies, are glycoprotein molecules produced by plasma cells that act in immune responses by recognizing and binding particular antigens. The various Ig classes are IgG (the most abundant), IgM, IgE, IgD, and IgA, which differ in their biologic features, structure, target specificity, and distribution. Immunoglobulins against romiplostim
  • Eltrombopag:
    • Thromboembolism
    • URI
    • Cough, pharyngitis Pharyngitis Pharyngitis is an inflammation of the back of the throat (pharynx). Pharyngitis is usually caused by an upper respiratory tract infection, which is viral in most cases. It typically results in a sore throat and fever. Other symptoms may include a runny nose, cough, headache, and hoarseness. Pharyngitis
    • Diarrhea Diarrhea Diarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea, vomiting
    • Myalgia
    • Anemia Anemia Anemia is a condition in which individuals have low Hb levels, which can arise from various causes. Anemia is accompanied by a reduced number of RBCs and may manifest with fatigue, shortness of breath, pallor, and weakness. Subtypes are classified by the size of RBCs, chronicity, and etiology. Anemia: Overview
    • Cataract 
    • Hepatotoxicity
    • Progression of myelodysplastic syndrome → AML AML Acute myeloid leukemia (AML) is a hematologic malignancy characterized by the uncontrolled proliferation of myeloid precursor cells. Seen predominantly in older adults, AML includes an accumulation of myeloblasts and a replacement of normal marrow by malignant cells, which leads to impaired hematopoiesis. Acute Myeloid Leukemia

Contraindications

For all agents, hypersensitivity to drug or components is a contraindication.

References

  1. Medscape Drug Information. (2020). Darbepoetin alfa (Rx). Retrieved June 25, 2021, from https://reference.medscape.com/drug/aranesp-darbepoetin-alfa-342150#5
  2. DeVita, V. T., Jr., Lawrence, T. S., Rosenberg, S. A. (2019). Devita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology, 11th ed. Philadelphia: Wolters Kluwer, pp. 1746–1748.
  3. Elliott, S., Pham, E., Macdougall, I.C. (2008). Erythropoietins: a common mechanism of action. Exp Hematol 36:1573–1584. https://pubmed.ncbi.nlm.nih.gov/18922615/
  4. Medscape Drug Information. (2020). Epoetin alfa (Rx). Retrieved June 25, 2021, from https://reference.medscape.com/drug/epogen-procrit-epoetin-alfa-342151#5
  5. Medscape Drug Information. (2020). Filgrastim (Rx). Retrieved June 26, 2021, from https://reference.medscape.com/drug/g-csf-neupogen-filgrastim-342164#4
  6. Ghanima, W., Cooper, N., Rodeghiero, F., Godeau, B., Bussel, J. B. (2019). Thrombopoietin receptor agonists: ten years later. Haematologica 104:1112–1123. https://doi.org/10.3324/haematol.2018.212845
  7. Hubulashvili, D., Marzella, N. (2009). Romiplostim (Nplate), a treatment option for immune (idiopathic) thrombocytopenic purpura. Pharmacy and Therapeutics 34:482–485. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2799136/
  8. Kuter, D. (2021). Clinical applications of thrombopoietin growth factors. UpToDate. Retrieved September 13, 2021, from https://www.uptodate.com/contents/clinical-applications-of-thrombopoietic-growth-factors
  9. Medscape Drug Information. (2019). Methoxy polyethylene glycol/epoetin beta (Rx). Retrieved June 25, 2021, from https://reference.medscape.com/drug/mircera-methoxy-polyethylene-glycol-epoetin-beta-342153#5
  10. Medscape Drug Information. (2019). Oprelvekin (Rx). Retrieved June 26, 2021, from https://reference.medscape.com/drug/neumega-interleukin-11-oprelvekin-342165#4
  11. Medscape Drug Information. (2021). Pegfilgrastim (Rx). Retrieved June 26, 2021, from https://reference.medscape.com/drug/neulasta-fulphila-pegfilgrastim-342167#4
  12. Medscape Drug Information. (2021). Romiplostim (Rx). Retrieved September 14, 2021, from https://reference.medscape.com/drug/nplate-romiplostim-342177#5
  13. Medscape Drug Information. (2019). Sargramostim (Rx). Retrieved September 14, 2021, from https://reference.medscape.com/drug/leukine-sargramostim-342166#4
  14. Schoener, B., Borger, J. (2021). Erythropoietin. StatPearls. Retrieved June 25, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK536997/
  15. Zehnder, J. L. (2017). Agents used in cytopenias; hematopoietic growth factors. In: Katzung, B. G., et al. (Eds.), Basic & Clinical Pharmacology. New York: McGraw-Hill Medical, pp. 600–606. 

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