Hematopoietic progenitor cell mobilization with “just-in-time” plerixafor approach is a cost-effective alternative to routine plerixafor use

Abstract

Hematopoietic progenitor cell (HPC) mobilization with granulocyte-colony stimulating factor (G-CSF) and plerixafor results in superior CD34+ cell yield, when compared to mobilization with G-CSF alone in patients with myeloma and lymphoma. However, plerixafor-based approaches are associated with high costs. To circumvent this, several institutions use a so-called “just-in-time” plerixafor (JIT-P) approach, where plerixafor is only administered to patients likely to fail mobilization with G-CSF alone. Whether such a JIT-P approach is cost effective has not been confirmed to date. We present here, results of 136 patients with myeloma or lymphoma who underwent mobilization with two different approaches of plerixafor utilization. Between Jan 2010-Oct 2012 (n=76) patients uniformly received mobilization with G-CSF and plerixafor (routine G+P cohort). To reduce mobilization costs, between Nov 2012-Jun 2014 (n=60) patients were mobilized with JIT-P where plerixafor was only administered to patients likely to fail mobilization with G-CSF alone. Patients in routine G+P group had a higher median peak peripheral blood CD34+ cell count (62 vs. 29 cells/μL, p<0.001) and a higher median day 1 CD34+ cell yield (2.9 × 106 CD34+ cells/kg vs. 2.1 × 106 CD34+ cells/kg, p=0.001). The median total CD34+ cell collection was also higher in routine G+P group (5.8 × 106 CD34+ cells/kg vs. 4.5 × 106 CD34+ cells/kg, p=0.007). In the JIT-P group 40% (n=24) completed adequate HPC collection without plerixafor. There was no difference in mobilization failure rates. The mean number of plerixafor doses utilized in JIT-P was lower (1.3 vs. 2.1, p=0.0002). The mean estimated cost in the routine G+P group was higher than that in the JIT-P group (USD 27,513 vs. USD 23,597, p=0.01). Our analysis demonstrates that mobilization with a JIT-P approach is a safe, effective and cost efficient strategy for HPC collection.

A single center’s experience using four different front line mobilization strategies in lymphoma patients planned to undergo autologous hematopoietic cell transplantation

“…However, 45% (27/60) of patients required >2 apheresis sessions. 21 In our study, the rescue plerixafor (i.e. G+d5 P) cohort had the lowest mobilization outcomes despite being younger and less treated.…”

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

“…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 .…”

“…A similar protocol has not been reported in the literature; Gasová et al used LVL and doses of 10 to 15 μg/kg/day of G‐CSF without plerixafor. The most similar scheme is the one used by Veltri et al, who used LVL, plerixafor (preventive or as a rescue agent) and G‐CSF at a dose of 10 μg/kg/day, with a failure rate of 5.4%. In our opinion, all these factors contribute to the achieving adequate mobilization because our percentage of failures with protocol 3 (in which the only difference from the study mentioned above was the dose of G‐CSF) was 0%, even though this protocol was used for patients who experienced previous failure with protocols 1 and 2, namely, those with very poor prognosis.…”

“…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.…”