How to manage Neupogen (filgrastim)-induced pain?

From the Guidelines

To manage Neupogen (filgrastim)-induced pain, nonsteroidal anti-inflammatory drugs (NSAIDs) such as naproxen 500 mg twice per day starting on the day of pegfilgrastim administration and continuing for 5 to 8 days may reduce the incidence, duration, and severity of bone pain among CSF-treated patients. When considering management options for Neupogen-induced pain, it's essential to prioritize strategies that minimize morbidity, mortality, and improve quality of life.

• The use of NSAIDs like naproxen has been supported by a randomized trial 1, which demonstrated a reduction in bone pain among patients treated with CSFs.
• The mechanism of Neupogen-induced pain involves rapid bone marrow expansion and neutrophil production, activating pain receptors in the bone marrow cavity, typically affecting the lower back, pelvis, sternum, and long bones.
• Pain management should be initiated before and during filgrastim treatment, with NSAIDs being a viable option for reducing the incidence, duration, and severity of bone pain.
• It's crucial to note that while other management strategies like acetaminophen, opioids, warm compresses, and gentle stretching exercises may be beneficial, the most recent and highest-quality evidence supports the use of NSAIDs like naproxen 1.
• Patients should be advised to consult their healthcare provider if pain remains uncontrolled despite these measures, as dose adjustments or alternative growth factors might be considered.

From the Research

Management of Neupogen-Induced Pain

To manage Neupogen (filgrastim)-induced pain, several options can be considered:

• Traditional analgesics, such as non-steroidal anti-inflammatory drugs (NSAIDs) and opioids, although they can be ineffective in severe cases 2
• Antihistamines, such as loratadine, which may be a promising option for severe, resistant Neupogen-induced bone pain 2
• Multidisciplinary conservative care and nonopioid medications, such as tricyclic antidepressants, serotonin norepinephrine reuptake inhibitors, gabapentanoids, topicals, and transdermal substances, as first-line therapy 3
• Combination therapy, tramadol, and tapentadol as second-line therapy 3
• Interventional therapies, such as neural blockade, spinal cord stimulation, and intrathecal medication, for patients with refractory pain 4

Treatment of Neuropathic Pain

For the treatment of neuropathic pain, the following options can be considered:

• First-line trials of anticonvulsants, tricyclic antidepressants, and serotonin-norepinephrine reuptake inhibitors, alone or in certain combinations 5
• Opioid medications, particularly methadone, for refractory cases, although they should be used with caution due to concerns for short- and long-term safety 5
• Selective serotonin-norepinephrine reuptake inhibitors (SNRIs), gabapentin, tricyclic antidepressants, topical lidocaine, and transcutaneous electrical nerve stimulation as primary treatments 6
• Pregabalin as a first-line treatment according to international guidelines, but second-line in the more recent French guidelines 6
• High-concentration capsaicin patches, botulinum toxin A, and psychotherapy as adjuncts for focal peripheral neuropathic pain 6