G-CSF plus preemptive plerixafor vs hyperfractionated CY plus G-CSF for autologous stem cell mobilization in multiple myeloma: effectiveness, safety and cost analysis

Abstract

The optimal stem cell mobilization regimen for patients with multiple myeloma (MM) remains undefined. We retrospectively compared our experience in hematopoietic cell mobilization in 83 MM patients using fractionated high-dose CY and G-CSF with G-CSF plus preemptive plerixafor. All patients in the CY group (n = 56) received fractionated high-dose CY (5 g/m 2 divided into five doses of 1 g/m 2 every 3 h) with G-CSF. All patients in the plerixafor group (n = 27) received G-CSF and plerixafor preemptively based on an established algorithm. Compared with plerixafor, CY use was associated with higher total CD34+ cell yield (7.5 × 10 6 vs 15.5 × 10 6 cells/kg, P = 0.005). All patients in both groups yielded ⩾ 4 × 10 6 CD34+ cells/kg. Conversely, CY use was associated with high frequency of febrile neutropenia, blood and platelet transfusions need and hospitalizations. The average total cost of mobilization in Lebanon was slightly higher in the plerixafor group ($7886 vs $7536; P = 0.16). Our data indicate robust stem cell mobilization in MM patients with either fractionated high-dose CY and G-CSF or G-CSF alone with preemptive plerixafor. The chemo-mobilization approach was associated with twofold stem cell yield, slightly lower cost but significantly increased toxicity.

Comparison and cost analysis of three protocols for mobilization and apheresis of haematopoietic progenitor cells

“…Initially, plerixafor was used to rescue patients who experienced mobilization failure by administration together with G‐CSF and later as a preventive in patients likely to experience failure. Despite its cost, plerixafor may be more effective than CP‐based protocols . However, the right timing for administration of plerixafor is unknown: preventively on the day before the start of collection or “on demand” (rescue) in cases of poor apheresis results.…”

“…The efficacy of plerixafor combined with G‐CSF has been demonstrated, and the possibilities of using this agent are preventively, by identifying those patients who are at risk of mobilization failure, or “on demand” (rescue) when the usual therapy with G‐CSF alone is ineffective. There is some consensus that the most relevant criterion that defines a “poor mobilizer” is a peripheral blood level of CD34+ cells <10 to 15 cells/μL on day 4 or day 5 before the beginning of apheresis .…”

“…Despite its cost, plerixafor may be more effective than CP-based protocols. 9 However, the right timing for administration of plerixafor is unknown: preventively on the day before the start of collection or "on demand" (rescue) in cases of poor apheresis results. Thus, identifying candidate patients who are "poor mobilizers" is important, and numerous types of biological and clinical data have been proposed to be useful for identifying these patients, but there is no consensus on the use of these indicators.…”

“…Despite the available options to achieve an optimal mobilization protocol, there are many aspects that are not yet clear, such as the timing and indications for plerixafor, the dose of G‐CSF, the use of LVL, the addition of standard chemotherapeutic agents or the introduction of other agents …”

“…2,[6][7][8] Despite the available options to achieve an optimal mobilization protocol, there are many aspects that are not yet clear, such as the timing and indications for plerixafor, the dose of G-CSF, the use of LVL, the addition of standard chemotherapeutic agents or the introduction of other agents. [9][10][11][12][13][14] The aim of this study is to compare three mobilization protocols from clinical and economic points of view: (a) a standard protocol using 10 μg/kg/day of G-CSF, (b) 10 μg/kg/day of G-CSF with plerixafor as preventive or rescue agent, and (c) 20 μg/kg/day of G-CSF with plerixafor as preventive or rescue agent plus LVL.…”