How to prevent the use of white needles? These high-risk chemotherapy regimens are particularly important!

One of the most common side effects of tumor chemotherapy is bone marrow suppression, and patients may have a decline in leukocytes, platelets, and red blood cells. Among them, leucopenia is the most common. Dealing with leucopenia is a common problem in chemotherapy.
According to the degree of leukocyte reduction, it can be divided into four levels:
Grade I: lower limit of leukocyte normal value ~3.0 × 109/l or lower limit of neutrophil normal value ~1.5 × 109/L；
Grade II: leukocyte 2.0~3.0 × 10⁹/l or neutrophils 1.0~1.5 × 10⁹/L；
Grade III: leukocyte 1.0~2.0 × 10⁹/l or neutrophils 0.5~1.0 × 10⁹/L；
Grade IV: leukocyte lower than 1.0 × 10⁹/l or neutrophils less than 0.5 × 10⁹/L；
Leukopenia enhancing drugs are the main means to treat leukopenia, and their mechanism of action is mainly reflected in two aspects:
Promote the release of mature granulocytes in bone marrow blood pool;
Stimulate the proliferation, differentiation, maturation and release of bone marrow granulocyte hematopoietic progenitor cells into peripheral blood.
After the use of Shengbai needle, the peak value of peripheral blood leukocytes will appear in 2-3 days, which is due to the release of mature leukocytes in the bone marrow blood pool. After 8-9 days, there was a second peak, which was caused by the stimulation of new leucopoiesis by leukogenic drugs. Therefore, after the use of Shengbai needle, the white blood cells in peripheral blood will show bimodal fluctuations.

Journal of clinical oncology 1009-0460 (2021) 07-0638-11
According to the use purpose of whitening needle, it can be generally divided into therapeutic whitening and preventive whitening. As the name suggests, therapeutic leukopenia is to treat leukopenia after leukopenia, and preventive leukopenia is to give leukopenia drugs before leukopenia.
1、 Therapeutic whitening
NCCN guidelines only recommend whitening treatment for patients with febrile neutropenia (FN).

FN patients who have used prophylactic whitening are not recommended to use short acting whitening needles. If FN patients without prophylactic whitening are at risk of CO infection, whitening treatment is recommended.
It is generally not recommended to inject white needles on the day after chemotherapy, and it is not suitable to inject chemotherapy on the day after injection. The interval between the two is better than 24 hours. This can avoid the damage of new neutrophils by chemotherapy drugs and increase the risk of bone marrow suppression to the greatest extent.
2、 Preventive whitening
The use of prophylactic whitening depends on the risk of chemotherapy drugs.

1. High risk chemotherapy regimen: it is recommended to give whitening treatment at the beginning of the course of treatment, such as the three drug regimen for gastric cancer chemotherapy: Docetaxel + cisplatin + fluorouracil.
2. Medium risk chemotherapy regimens: such as mfolfox6 regimen, irinotecan / cisplatin, epirubicin + cisplatin + 5-fluorouracil / capecitabine, etc., whether to prevent whitening should be considered according to the situation of patients. If the patient has any one or more of the following factors, preventive whitening treatment is recommended:
Previously received radiotherapy / chemotherapy;
Persistent neutropenia;
The tumor involved bone marrow;
Recent surgery or open wound;
Abnormal liver and kidney function;
Patients over 65 years old received full dose chemotherapy;
FN occurred in the past;
Malignant hematolymphatic diseases;
Chronic immunosuppression such as HIV;
Poor nutrition / physical condition.
3. Low risk chemotherapy regimen: generally, preventive whitening is not required. However, it should be noted that blood routine should be re evaluated after each chemotherapy course to decide whether whitening treatment is needed.
In preventive treatment, the comparison between long-acting Shengbai needle (pegylated recombinant human granulocyte stimulating factor, PEG rhG CSF) and short-acting Shengbai needle (recombinant human granulocyte stimulating factor, rhG CSF):

3、 Treatment of adverse reactions related to whitening therapy
1. Mild to moderate bone pain is the main adverse reaction. Acetaminophen and non steroidal anti-inflammatory drugs are the first-line drugs to prevent and treat adult acupuncture related bone pain. In addition, antihistamines and opioid analgesics can also be selected.
2. Neutrophils increase temporarily, and a few patients have the phenomenon of immature granulocytes, and some patients have the aggregation of immature granulocytes. Leukemoid reaction caused by Shengbai needle often disappears after drug withdrawal, and generally does not need special treatment.
3. Patients who need prophylactic whitening, if neutrophils > 30 before chemotherapy × 10⁹/l or leukocyte count > 50 × 10⁹ / L, it is recommended to reduce peg rhG CSF to 3mg and rhG CSF to 2.5 during prevention in this cycle μ g/kg/d。
Attached table: specific scheme for the risk level of FN in various tumors.
1. Breast cancer

2. Lung cancer

3. Digestive tract tumor

4. Tumor of female reproductive system

5. Urogenital system tumor

6. Hematological tumor

7. Osteosarcoma and soft tissue sarcoma

8. Melanoma

Reference：
Guidelines Working Committee of Chinese society of clinical oncology Chinese society of Clinical Oncology (CSCO) guidelines for the standardized management of neutropenia associated with radiotherapy and chemotherapy (2021) Journal of Clinical Oncology, 2021, 26 (7): 638-648
Original link:
https://www.medsci.cn/article/show_article.do?id=9199e31570b1