BETA - What is neutropenia?

What is Neutropenia and is it managed? Neutropenia is a low white blood cell count, specifically an absolute neutrophil count or granulocyte number. Less than 500 is the strict diagnosis of Neutropenia. Anything under 1,000 is also neutropenic. It can be managed by growth factor, so GCSF or a hormone that stimulates white blood cell production. That's really the only way to improve upon anemia other than fixing what the cause is, which can be related to drug therapy, can be related to the disease. Neutropenia is a very common phrase that you'll hear in the realm of multiple myeloma. It's our medical fancy word to say that your neutrophils are low. Neutrophils are a type of white cells and they primarily fight against bacterial infections. We want to keep that at a normal level while you're going through any sort of treatment for multiple myeloma to help prevent those bad infections that can happen while you're on treatment. Neutropenia is measured by your absolute neutrophil count, so that's a part of your complete blood count or CBC, which is monitored routinely while you are being treated for multiple myeloma or in the process of a stem cell transplant. We will order it as a complete blood count or CBC with a differential where it breaks down the white cells into those components and we're measuring out how many cells there are. So the big value you're going to be hearing about is ANC or absolute neutrophil count. And if it's less than normal, that's going to cue to them that you're neutropenic. If you become neutropenic, this could be addressed by your healthcare physician by a numerous amount of things, so you'll want to follow their recommendations. They may adjust the dose of the treatment that you are getting, whether that's Revlimid or whatever it is. You know, I've seen that regularly where we just decrease the dose a little bit so that we decrease the incidence of neutropenia. Other things that could happen is we could administer a growth stimulating factor called filgrastim, different than the PEG filgrastim that you'd get in stem cell transplant. Filgrastim is a longer acting one. A couple of those could be called nulasta. There's a lot of different brand names that you could get, but the filgrastim is the generic name that you would typically hear. You could also be on prophylactic medications. So typically when you initiate treatment, we're going to put patients on acyclovir, which is an antiviral to prevent shingles. Your doctor could put you on a Bactrim or a Dapsone or potentially pantamidine for preventing PJP pneumonia, which is just an opportunistic community acquired pneumonia that's pretty dangerous but we want to prevent it. They could potentially put you on a fluconazole, which is an antifungal or a levoquin, which would be an antibacterial while you're neutropenic. There's not a whole lot of specific signs or symptoms to neutropenia that happen other than you will find that you have an infection. So those symptoms of infection, fever, is usually the first sign of infection, which is your body's way of saying, hey, there's something foreign and it raises up your body temperature as it's trying to fight off that infection. So that's cue number one typically that you need to get in contact with your provider. Specifically in stem cell transplant, neutropenia occurs because of the high dose chemotherapy that is received as part of the pre-transplant sort of conditioning that happens before you get a transplant. What we're doing is essentially wiping out your bone marrow so that your new stem cells can go in there and regenerate. Once we give that high dose chemotherapy, all of those neutrophils that were in your bloodstream are going to essentially go away. So it'll trend down within the first couple of days after getting your therapy and then also your stem cells until about day four after getting your stem cells, and then they'll hit bottom where they're not detectable anymore. That's what we call your nadir in the middle of stem cell transplant. We'll go about a couple of days while your stem cells make their way from the bloodstream into the bone marrow, and then around day nine, your team, either in the hospital or in an outpatient clinic, they'll start to administer a growth stimulating factor, and that's called Pegfilgrastim, and that's an injection to help stimulate that new stem cell to start creating your white cells, which are your neutrophils, and then they track your labs daily to make sure that those neutrophils come back. So when patients receive their high dose malphaline for transplant, the neutropenia is expected somewhere around day five to seven after the chemotherapy. So the stem cells will already have been re-infused at that point. It takes them a few days to get pulled back into the bone marrow environment and start doing what they're supposed to do. So usually for patients during transplant, there's about a seven to ten day window of neutropenia. During this time, patients are monitored very closely. They should check themselves or have their caregiver monitor them for signs of infection, which is going to be a fever. A neutropenic fever is defined as a temperature of 100.4 or above. Also patients during transplant, since we know they're going to become neutropenic, we put them on antibacterial and antifungal prophylaxis. So taking an antibiotic and an antifungal for that period of time should help prevent some infections. Also watching contact, so avoiding actively sick people. Good hand washing is very important during this time. And then the dietary recommendations, which is interesting, have really probably shifted a lot more recently with studies showing that following a low microbial or neutropenic diet doesn't necessarily decrease the risk for infection. So I think it can vary from institution to institution. Here we generally ask patients to just avoid large groups of people, open areas, food that has been sitting out for too long. So for this window of time we ask them not to eat at restaurants, avoid buffets at family's houses or picnics, and really just clean their food well. If they want to eat fruits, raw fruits and vegetables, they're allowed to do so. We just ask that they are cleaned. How long does neutropenia usually last while going through transplant? So the neutropenia period is typically 7 to 10 days long. At our institution we start giving patients growth factor on day 6, so 6 days from the stem cell infusion. And we usually see white blood cell recovery, think our average is around day 12. And once the white blood cells start building back up they sort of increase exponentially because of the help of the neupogen or the growth factor. And then that drug can get stopped once their ANC is above 500, which is 0.5 for 3 days in a row. How common is neutropenia outside of an autologous stem cell transplant? It can still happen quite often and we see this as an effect of the drugs we're giving. So usually most of the 3 drugs for sure, a lot of the 4 drug regimens do cause neutropenia. It really depends on what drugs you're on as to what the guidelines are for how to manage it. And we were just talking recently that we need to maybe set up new algorithms because with the approval of giving daratumab with Revlimid or daratumab with pomalidomide, we know that patients are going to experience neutropenia and leukopenia within the first few cycles of treatment. And so not holding treatment when they really need it for these reasons and managing the side effect otherwise is our goal of therapy to keep people on the drugs when they need them. Neutropenia can occur because of the treatment that you are getting. It's a pretty known side effect when you're being treated for your multiple myeloma. If it's before stem cell transplant with a general treatment, whatever that may have you, if your doctor notices that, they may adjust your dosing or may increase your preventative infection medications. What precautions should you take if you are neutropenic? So if a patient were to be neutropenic, we're always going to encourage them to have good hygiene, making sure that they're washing their hands regularly, that they are avoiding being around sick people. Typically, you know, we want patients to live their life, but we also want them to be cautious knowing that there is a risk of contracting an infection. So just being more cautious.