Filgrastim Regimen in Myelodysplastic Syndrome (MDS)

Clinical Context and Evidence Base

The American Society of Clinical Oncology recommends that filgrastim should be administered at low doses (0.5-2 mcg/kg/day subcutaneously) on an intermittent basis for MDS patients with severe neutropenia (ANC <0.5 × 10⁹/L) and recurrent infections, rather than as continuous long-term therapy, due to concerns about disease progression 1
Prolonged or continuous treatment with G-CSF cannot be recommended in patients with MDS, as it may lead to shorter overall survival in patients with refractory anemia and excess blasts 1

The National Comprehensive Cancer Network recommends starting with 0.5 mcg/kg/day subcutaneously for patients with severe neutropenia (ANC <0.5 × 10⁹/L) and recurrent infections, and adjusting doses to maintain neutrophil levels in the normal or low-normal range 2

Intermittent administration is preferred over continuous therapy, with daily, alternate-day, or thrice-per-week subcutaneous administration (1-3 mcg/kg/day) for patients with idiopathic and cyclic neutropenia patterns 2, 3
Treatment duration in responders has been continued for 2-14 months (median 6 months) with persistent response in most cases, and discontinuation is recommended if no response is achieved or if disease progression occurs 1

MDS patients with severe neutropenia (ANC <0.5 × 10⁹/L) and recurrent infections are appropriate candidates for filgrastim therapy 1
Patients with refractory anemia with excess blasts require caution, as they showed shorter overall survival with continuous G-CSF in randomized trials 1

The National Comprehensive Cancer Network recommends against using continuous, long-term prophylactic G-CSF in MDS patients, particularly those with excess blasts 1
Pegfilgrastim should not be used in MDS, as there is no evidence supporting its use in this population, and its long-acting nature prevents dose adjustment 4, 5
G-CSF should not be administered concurrently with chemotherapy if treating MDS with intensive therapy 2

Combination with erythropoietin is being evaluated in ongoing trials for patients with both neutropenia and anemia 1
Hematopoietic stem cell transplantation becomes the definitive alternative for patients progressing to AML 3