Pharmacokinetics and adverse events following 5-day repeated administration of lenograstim, a recombinant human granulocyte colony-stimulating factor, in healthy subjects

Stem Cells Collection and Mobilization in Adult Autologous/Allogeneic Transplantation: Critical Points and Future Challenges

Achieving successful hematopoietic stem cell transplantation (HSCT) relies on two fundamental pillars: effective mobilization and efficient collection through apheresis to attain the optimal graft dose. These cornerstones pave the way for enhanced patient outcomes. The primary challenges encountered by the clinical unit and collection facility within a transplant program encompass augmenting mobilization efficiency to optimize the harvest of target cell populations, implementing robust monitoring and predictive strategies for mobilization, streamlining the apheresis procedure to minimize collection duration while ensuring adequate yield, prioritizing patient comfort by reducing the overall collection time, guaranteeing the quality and purity of stem cell products to optimize graft function and transplant success, and facilitating seamless coordination between diverse entities involved in the HSCT process. In this review, we aim to address key questions and provide insights into the critical aspects of mobilizing and collecting hematopoietic stem cells for transplantation purposes.

Filgrastim-induced hemophagocytic lymphohistiocytosis in a patient with mantle cell lymphoma: A case report

Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening disease potentially induced by various causes. Very few reports have described HLH induced by granulocyte colony-stimulating factor (G-CSF) and those few previous reports have uniformly indicated that continuing G-CSF is unfeasible once HLH has been induced. A 52-year-old Japanese man who had been diagnosed with mantle cell lymphoma with systemic and central nervous system involvements received rituximab, hyper-fractionated cyclophosphamide, vincristine, Adriamycin and dexamethasone (R-HCVAD)/methotrexate and cytarabine. During the second cycle of R-HCVAD, the patient developed severe back pain, thrombocytopenia, elevated serum lactate dehydrogenase and ferritin levels, and hemophagocytosis in the bone marrow. Complete remission (CR) of mantle cell lymphoma was confirmed on whole-body computed tomography, brain magnetic resonance imaging, and bone marrow biopsy. The patient was diagnosed with HLH induced by filgrastim. HLH recovered with intravenous methylprednisolone at 1 g/day for 3 days, followed by oral prednisolone tapered off over 5 days. The patient continued chemotherapy with a change in the G-CSF formulation from filgrastim to lenograstim and prophylactic administration of corticosteroids. He safely completed scheduled chemotherapy without recurrence of HLH and successfully maintained CR of lymphoma. Although rare, G-CSF potentially induces HLH. Changing the G-CSF formulation and steroid prophylaxis may allow safe continuation of G-CSF.

Model-Based Optimal AML Consolidation Treatment

OBJECTIVE

Neutropenia is an adverse event commonly arising during intensive chemotherapy of acute myeloid leukemia (AML). It is often associated with infectious complications. Mathematical modeling, simulation, and optimization of the treatment process would be a valuable tool to support clinical decision making, potentially resulting in less severe side effects and deeper remissions. However, until now, there has been no validated mathematical model available to simulate the effect of chemotherapy treatment on white blood cell (WBC) counts and leukemic cells simultaneously.

METHODS

We developed a population pharmacokinetic/pharmacodynamic (PK/PD) model combining a myelosuppression model considering endogenous granulocyte-colony stimulating factor (G-CSF), a PK model for cytarabine (Ara-C), a subcutaneous absorption model for exogenous G-CSF, and a two-compartment model for leukemic blasts. This model was fitted to data of 44 AML patients during consolidation therapy with a novel Ara-C plus G-CSF schedule from a phase II controlled clinical trial. Additionally, we were able to optimize treatment schedules with respect to disease progression, WBC nadirs, and the amount of Ara-C and G-CSF.

RESULTS

The developed PK/PD model provided good prediction accuracies and an interpretation of the interaction between WBCs, G-CSF, and blasts. For 14 patients (those with available bone marrow blast counts), we achieved a median 4.2-fold higher WBC count at nadir, which is the most critical time during consolidation therapy. The simulation results showed that relative bone marrow blast counts remained below the clinically important threshold of 5%, with a median of 60% reduction in Ara-C.

CONCLUSION

These in silico findings demonstrate the benefits of optimized treatment schedules for AML patients.

SIGNIFICANCE

Until 2017, no new drug had been approved for the treatment of AML, fostering the optimal use of currently available drugs.

Immobilisation of Delta-like 1 ligand for the scalable and controlled manufacture of hematopoietic progenitor cells in a stirred bioreactor

Background

Umbilical cord blood provides a source of hematopoietic stem cells for transplantation with immunological and availability advantages over conventional bone marrow sources. Limited cell numbers and slower engraftment from umbilical cord blood units has led to the clinical development of immobilised Notch ligand Delta-Like 1 to promote ex vivo expansion of a rapidly engrafting cell population. However, current immobilisation methods are not simple to scale in a controlled manner.

Results

Delta-Like 1 was immobilised onto streptavidin coated magnetic particles via a heterobifunctionalised polyethylene glycol linker molecule to provide an easily manipulated format of surface protein presentation. CD34⁺ enriched cord blood cells were treated with Delta-Like 1 immobilised particles, and immunophenotypic markers measured to monitor population distributions using cluster identification, characterization, and regression software. The amenability of the approach to scalability was evaluated in a micro-scale stirred tank bioreactor. Surface concentration of Delta-Like 1 was well controlled used differing stoichiometric reagent ratios. Protein immobilisation was a cost effective process and particles were efficiently removed from the final cell product. Immobilised Delta-Like 1 is functional and stimulates qualitatively similar CD34^hi, CD38^lo, CD90^lo, CD133^hi, CD135^hi progenitor expansion in both static culture and scalable stirred culture platforms.

Conclusions

Immobilised Delta-Like 1 in this form has the potential to improve the manufacturing efficiency and control of final ex vivo expanded cell product through compatibility with highly controlled and characterised suspension culture systems.

Electronic supplementary material

The online version of this article (doi:10.1186/s12896-017-0383-0) contains supplementary material, which is available to authorized users.

Granulocyte colony-stimulating factor for the treatment of cardiovascular diseases: An update with a critical appraisal

Heart failure and acute myocardial infarction are conditions that are associated with high morbidity and mortality. Significant dysfunction of the heart muscle can occur as the consequence of end-stage chronic cardiovascular diseases or acute ischemic events that are marked by large infarction area and significant tissue necrosis. Despite the remarkable improvement of conventional treatments, a substantial proportion of patients still develops severe heart failure that can only be resolved by heart transplantation or mechanical device implantation. Therefore, novel approaches based on stem-cell therapy can directly modify the disease process and alter its prognosis. The ability of the stem-cells to modify and repair the injured myocardium is a challenging but intriguing concept that can potentially replace expensive and invasive methods of treatment that are associated with increased risks and significant financial costs. In that sense, granulocyte colony-stimulating factor (G-CSF) seems as an attractive treatment approach. Based on the series of pre-clinical experiments and a limited amount of clinical data, it was demonstrated that G-CSF agents possess the ability to mobilize stem-cells from bone marrow and induce their differentiation into cardiomyocytes or endothelial cells when brought into contact with injured regions of the myocardium. However, clinical benefits of G-CSF use in damaged myocardium remain unclear and are the topic of expert discussion. The main goal of this review is to present relevant and up-to-date evidence on G-CSF therapy use in pre-clinical models and in humans and to provide a rationale for its potential clinical applications in the future.

Four-Week Repeated Intravenous Dose Toxicity and Toxicokinetic Study of TS-DP2, a Novel Human Granulocyte Colony Stimulating Factor in Rats

TS-DP2 is a recombinant human granulocyte colony stimulating factor (rhG-CSF) manufactured by TS Corporation. We conducted a four-week study of TS-DP2 (test article) in repeated intravenous doses in male and female Sprague-Dawley (SD) rats. Lenograstim was used as a reference article and was administered intravenously at a dose of 1000 μg/kg/day. Rats received TS-DP2 intravenously at doses of 250, 500, and 1000 μg/kg/day once daily for 4 weeks, and evaluated following a 2-week recovery period. Edema in the hind limbs and loss of mean body weight and body weight gain were observed in both the highest dose group of TS-DP2 and the lenograstim group in male rats. Fibro-osseous lesions were observed in the lenograstim group in both sexes, and at all groups of TS-DP2 in males, and at doses of TS-DP2 500 μg/kg/day and higher in females. The lesion was considered a toxicological change. Therefore, bone is the primary toxicological target of TS-DP2. The lowest observed adverse effect level (LOAEL) in males was 250 μg/kg/day, and no observed adverse effect level (NOAEL) in females was 250 μg/kg/day in this study. In the toxicokinetic study, the serum concentrations of G-CSF were maintained until 8 hr after administration. The systemic exposures (AUC_0-24h and C₀) were not markedly different between male and female rats, between the administration periods, or between TS-DP2 and lenograstim. In conclusion, TS-DP2 shows toxicological similarity to lenograstim over 4-weeks of repeated doses in rats.

Mobilization and collection of CD34(+) cells for autologous transplantation of peripheral blood hematopoietic progenitor cells in children: analysis of two different granulocyte-colony stimulating factor doses

INTRODUCTION

The use of peripheral hematopoietic progenitor cells (HPCs) is the cell choice in autologous transplantation. The classic dose of granulocyte-colony stimulating factor (G-CSF) for mobilization is a single daily dose of 10μg/kg of patient body weight. There is a theory that higher doses of granulocyte-colony stimulating factor applied twice daily could increase the number of CD34(+) cells collected in fewer leukapheresis procedures.

OBJECTIVE

The aim of this study was to compare a fractionated dose of 15μg G-CSF/kg of body weight and the conventional dose of granulocyte-colony stimulating factor in respect to the number of leukapheresis procedures required to achieve a minimum collection of 3×10(6) CD34(+) cells/kg body weight.

METHODS

Patients were divided into two groups: Group 10 - patients who received a single daily dose of 10μg G-CSF/kg body weight and Group 15 - patients who received a fractioned dose of 15μg G-CSF/kg body weight daily. The leukapheresis procedure was carried out in an automated cell separator. The autologous transplantation was carried out when a minimum number of 3×10(6) CD34(+) cells/kg body weight was achieved.

RESULTS

Group 10 comprised 39 patients and Group 15 comprised 26 patients. A total of 146 apheresis procedures were performed: 110 (75.3%) for Group 10 and 36 (24.7%) for Group 15. For Group 10, a median of three (range: 1-7) leukapheresis procedures and a mean of 8.89×10(6) CD34(+) cells/kg body weight (±9.59) were collected whereas for Group 15 the corresponding values were one (range: 1-3) and 5.29×10(6) cells/kg body weight (±4.95). A statistically significant difference was found in relation to the number of apheresis procedures (p-value <0.0001).

CONCLUSIONS

To collect a minimum target of 3×10(6) CD34(+) cells/kg body weight, the administration of a fractionated dose of 15μg G-CSF/kg body weight significantly decreased the number of leukapheresis procedures performed.

The novel CXCR4 antagonist POL5551 mobilizes hematopoietic stem and progenitor cells with greater efficiency than Plerixafor

Mobilized blood has supplanted bone marrow (BM) as the primary source of hematopoietic stem cells for autologous and allogeneic stem cell transplantation. Pharmacologically enforced egress of hematopoietic stem cells from BM, or mobilization, has been achieved by directly or indirectly targeting the CXCL12/CXCR4 axis. Shortcomings of the standard mobilizing agent, granulocyte colony-stimulating factor (G-CSF), administered alone or in combination with the only approved CXCR4 antagonist, Plerixafor, continue to fuel the quest for new mobilizing agents. Using Protein Epitope Mimetics technology, a novel peptidic CXCR4 antagonist, POL5551, was developed. In vitro data presented herein indicate high affinity to and specificity for CXCR4. POL5551 exhibited rapid mobilization kinetics and unprecedented efficiency in C57BL/6 mice, exceeding that of Plerixafor and at higher doses also of G-CSF. POL5551-mobilized stem cells demonstrated adequate transplantation properties. In contrast to G-CSF, POL5551 did not induce major morphological changes in the BM of mice. Moreover, we provide evidence of direct POL5551 binding to hematopoietic stem and progenitor cells (HSPCs) in vivo, strengthening the hypothesis that CXCR4 antagonists mediate mobilization by direct targeting of HSPCs. In summary, POL5551 is a potent mobilizing agent for HSPCs in mice with promising therapeutic potential if these data can be corroborated in humans.

Mobilization of hematopoietic stem cells into the peripheral blood

Hematopoietic stem cells can be mobilized out of the bone marrow into the blood for the reconstitution of hematopoiesis following high-dose therapy. Methods to improve mobilization efficiency and yields are rapidly emerging. Traditional methods include chemotherapy with or without myeloid growth factors. Plerixafor, a novel agent that disrupts the CXCR4-CXCL12 bond, the primary hematopoietic stem cell anchor in the bone marrow, has recently been US FDA-approved for mobilizing hematopoietic stem cells in patients with non-Hodgkin lymphoma and multiple myeloma. Plerixafor and myeloid growth factors as single agents appear safe to use in family or volunteer hematopoietic stem cells donors. Plerixafor mobilizes leukemic stem cells and is not approved for use in patients with acute leukemia. Patients failing to mobilize adequate hematopoietic stem cells with myeloid growth factors can often be successfully mobilized with chemotherapy plus myeloid growth factors or with plerixafor and granulocyte colony-stimulating factor.

Cytokines and hematopoietic stem cell mobilization

Hematopoietic stem cell transplantation (HSCT) has become the standard of care for the treatment of many hematologic malignancies, chemotherapy sensitive relapsed acute leukemias or lymphomas, multiple myeloma; and for some non-malignant diseases such as aplastic anemia and immunodeficient states. The hematopoietic stem cell (HSC) resides in the bone marrow (BM). A number of chemokines and cytokines have been shown in vivo and in clinical trials to enhance trafficking of HSC into the peripheral blood. This process, termed stem cell mobilization, results in the collection of HSC via apheresis for both autologous and allogeneic transplantation. Enhanced understanding of HSC biology, processes involved in HSC microenvironmental interactions and the critical ligands, receptors and cellular proteases involved in HSC homing and mobilization, with an emphasis on G-CSF induced HSC mobilization, form the basis of this review. We will describe the key features and dynamic processes involved in HSC mobilization and focus on the key ligand-receptor pairs including CXCR4/SDF1, VLA4/VCAM1, CD62L/PSGL, CD44/HA, and Kit/KL. In addition we will describe food and drug administration (FDA) approved and agents currently in clinical development for enhancing HSC mobilization and transplantation outcomes.

Profound thrombocytopenia related to G-CSF

Severe thrombocytopenia in association with G-CSF therapy is extremely rare. Here we report a case of profound thrombocytopenia in a 57-year-old male with refractory cardiac ischemia, who received G-CSF during an angiogenesis trial. After 5 days of G-CSF therapy (10 microg/kg/day) the platelet count fell progressively to a nadir of 5x10(9)/L. The patient received steroid, immunoglobulin and platelet support and recovered without sequelae. Subsequent investigations suggested an underlying immune-mediated thrombocytopenia, which we hypothesize was exacerbated by G-CSF therapy.

Timely Withdrawal of G-CSF Reduces the Occurrence of Thrombocytopenia During Dose-dense Chemotherapy

BACKGROUND

Post chemotherapy Granulocyte colony stimulating factor (G-CSF) reduces leucopenia, while G-CSF priming shortly before chemotherapy increases myelotoxicity. We performed a trial with a two-schedule crossover design to determine the optimal G-CSF schedule for densified 2-weekly chemotherapy.

METHODS

During 2-weekly chemotherapy days 1 and 2, G-CSF was given on days 3-10, with a G-CSF-free interval before the next chemotherapy cycle of 5 days, or on days 3-13, with a G-CSF-free interval of 2 days. In schedule A, cycle II was preceded by a 5 days, cycle III and IV by a 2 days and cycle V by a 5 days G-CSF free interval. In schedule B, this was 2, 5, 5, and 2 days, respectively.

RESULTS

Intra-patient comparison for cycles II versus III and cycles IV versus V showed that platelet (PLT) nadir count was significantly lower for cycles preceded by a 2-days compared to a 5-days G-CSF free interval: mean difference 45.7 x 10(9)/l (95% CI 33.2-58.2, p = 0.0001). Neutrophil count did not differ significantly (p = 0.85).

CONCLUSION

Timely withdrawal of G-CSF in dose-dense chemotherapy reduces chemotherapy-related thrombocytopenia. Leucopenia was not aggravated, reflecting a protective effect of post-chemotherapy G-CSF.

Effect of Filgrastim on Serum Lactate Dehydrogenase and Alkaline Phosphatase Values in Early Breast Cancer Patients

To improve chemotherapy dose intensity and to optimize the use of granulocyte-colony stimulating factor, 506 patients with early breast cancer were randomly assigned to high dose epirubicin and cyclophospamide (EC) with or without prophylactic subcutaneously filgrastim, according to 5 different schedules: 480 microg or 300 microg daily or every other day, on day 8 through day 14, and 300 microg daily on days 8 and 12 of each chemotherapy course, Serum levels of lactate dehydrogenase (LDH) and alkaline phosphatase (AP) were significantly higher in patients given EC plus filgrastim than EC alone (P = 0.0001), the rate of G1-3 toxicity being 33.4% and 13.1% vs. 1.6% and 1%, respectively. No clinical evidence of filgrastim-related hepatic damage or significant difference in transaminase and gamma-GT elevation was seen between the two groups. LDH and AP closely resembled peripheral blood leukocytes count and increased with increasing leucocytosis, throughout the 5 schedules. Although no patient continued treatment for filgrastim-related side effects, and LDH and AP rises resolved spontaneously within 3 weeks following the chemotherapy course, physicians should be aware of the transient and innocuous change in serum chemistry associated to leucocytosis, since it could be misinterpreted as expression of disease activity.

Kinetics of G-CSF and CD34+ cell mobilization after once or twice daily stimulation with rHu granulocyte-stimulating factor (lenograstim) in healthy volunteers: an intraindividual crossover study

BACKGROUND

G-CSF given as split dose increased the harvested number of CD34+ cells in comparison to a once daily schedule, but the mechanism is poorly understood.

STUDY DESIGN AND METHODS

To investigate the schedule dependency of G-CSF in healthy volunteers with respect to CD34+ cell mobilization, the same dose of G-CSF was applied in four healthy volunteers in two different schedules (once daily vs. split doses twice daily) in a crossover design after a washout period of 3 months. CD34+ cell kinetics in serum were determined as well as G-CSF serum kinetics on Days 1 and 4 after stimulation.

RESULTS

In all volunteers, the twice daily schedule led to a higher CD34+ cell count after 4 days of G-CSF stimulation (median, 94.5 vs. 47/ microL; p = 0.05). On Days 1 and 4, there was a higher peak serum concentration of G-CSF serum level after the once daily application (15,175 vs. 6,859 pg/mL and 7440 vs. 2388 pg/mL, respectively) than after the twice daily schedule. In contrast, after the once daily application the minimum serum level of G-CSF serum level was lower than after the twice daily schedule (663 vs. 1361 pg/mL and 246 vs. 441 pg/mL, respectively). No difference of area under the curve for G-CSF was observed on Days 1 and 4 after G-CSF stimulation.

CONCLUSION

It is suggested that application of G-CSF twice daily leads to a higher CD34+ cell mobilization owing to a higher minimum serum level and therefore to a more continuous serum baseline level resulting in a more efficient CD34+ cell mobilization.

Clinical applications of granulocyte colony-stimulating factor: an update and summary

The discovery of granulocyte colony-stimulating factor (G-CSF) and its potential to regulate neutrophil production and function in the inflammatory process has opened an exciting new era for the supportive care of patients with hematological and malignant diseases. Extensive experience has been gained worldwide with G-CSF therapy, and G-CSF is widely employed clinically, primarily because the safety profile appears to be fairly innocuous. A broad consensus has emerged regarding the clinical utility of G-CSF in neutropenic conditions due to chemotherapy. Furthermore, much interest has focused on the use of G-CSF to mobilize CD34+ hematopoietic stem cells from the marrow to the peripheral blood for use in hematopoietic transplantation. The promising results with G-CSF have promoted further studies, e.g., in immunocompetent patients or in granulocyte transfusion therapy. Here, we review the potential clinical role of G-CSF and describe its future perspectives.

Glycosylated vs non-glycosylated granulocyte colony-stimulating factor (G-CSF)--results of a prospective randomised monocentre study

The discovery of the haematopoietic growth factor granulocyte colony-stimulating factor (G-CSF) has reduced infection-related morbidity in cancer patients by alleviating post-chemotherapy neutropenia. Two formulations of recombinant human (rh) G-CSF, one glycosylated and one non-glycosylated, are available. The glycosylated form, lenograstim, possesses at least 25% greater bioactivity in vitro. Some comparative studies into the preparation's potential to mobilise haematopoietic stem cells suggest a similar advantage. In the light of the great clinical importance of G-CSF, we have performed the first prospective, randomised, crossover study on children with chemotherapy-induced neutropenia. G-CSF (250 microg/m(2)) was started 1 day after the chemotherapy block, and was administered until a WBC >1500/microl was achieved on 3 successive days. Thirty-three G-CSF cycles from 11 patients (16 lenograstim, 17 filgrastim) were studied. They were investigated for duration of very severe (WBC <500/microl, 9 vs 9.5 days, lenograstim vs filgrastim, median) and severe leukopenia (WBC <1000/microl, 11 vs 11 days), infections (CRP >5 mg/dl, 5 vs 5.5 days), infection-related hospital stay (11 vs 9 days) and antibiotic treatment (9 vs 9 days). Statistical evaluation by paired analysis could not detect any difference between treatment groups; the median difference for all end-points was zero. In summary, at least at 250 microg/m(2), in terms of their clinical effect on neutropenia, the two G-CSF preparations appear to have identical activity.