Pegfilgrastim (Neulasta) and Vasospasms
Yes, pegfilgrastim (Neulasta) can cause vasospasms, particularly in the form of large-vessel vasculitis, which has been documented as a rare but significant adverse effect.
Mechanism and Evidence
Pegfilgrastim is a pegylated form of filgrastim, a granulocyte-colony stimulating factor (G-CSF) used primarily to prevent febrile neutropenia in patients receiving myelosuppressive chemotherapy. While the exact mechanism of vasculitis induction is not fully understood, it's believed to involve inflammatory cytokine production triggered by G-CSF 1.
Recent evidence documents several cases of large-vessel vasculitis (LVV) following pegfilgrastim administration:
A 59-year-old female with diffuse large B-cell lymphoma developed fever, neck and chest pain after pegfilgrastim administration during R-CHOP treatment. Radiological imaging confirmed inflammation of large vessels, diagnosed as drug-associated vasculitis 2.
A 56-year-old woman with breast cancer developed intermittent fever and was found to have wall thickening of the aortic arch and proximal subclavian artery after pegfilgrastim administration 1.
A 75-year-old woman with small-cell lung cancer experienced back pain ten days after pegfilgrastim initiation, with CT revealing soft tissue thickening around the descending aorta and brachiocephalic artery 3.
Clinical Considerations
The NCCN guidelines for myeloid growth factors list cardiovascular symptoms among the warnings for these agents, noting "occasional transient supraventricular arrhythmia" and advising caution "in patients with preexisting cardiac disease" 4. While vasospasms aren't specifically mentioned in the main guidelines, the documented cases suggest this is a potential concern.
Additionally, pegfilgrastim has been associated with severe sickle cell crises in patients with sickle cell disease or trait, which may involve vascular complications 5. This further supports the potential for vascular effects with this medication.
Management Recommendations
For patients receiving pegfilgrastim who develop:
- Unexplained fever
- Neck, chest, or back pain
- Other nonspecific body pain
Consider:
- Prompt radiological evaluation with contrast-enhanced CT to assess for vascular inflammation
- Differential diagnosis to rule out infection, cancer progression, or other causes
- If vasculitis is confirmed, treatment with corticosteroids may be effective 1
Risk Mitigation
When administering pegfilgrastim:
- Follow proper timing guidelines (24-72 hours after chemotherapy completion) 4
- Never administer on the same day as chemotherapy 4
- Use with caution in patients with preexisting vascular or cardiac disease
- Monitor for symptoms that could indicate vascular complications
Alternative Considerations
For patients at high risk of vascular complications, consider:
- Daily filgrastim instead of pegfilgrastim, which may allow for dose adjustment if side effects occur
- Tbo-filgrastim, which has comparable efficacy and safety to original filgrastim 6
While vasospasms/vasculitis are rare complications of pegfilgrastim, clinicians should maintain vigilance for these potential adverse effects, especially when patients present with unexplained pain or fever following administration.