Richard D. Moore, M.D.
- Normal range of absolute neutrophil count (ANC) lower among people of African descent (approx. 800 - 4000).
- Diagnose neutropenia with absolute neutrophil count (ANC) <500 (ACTG stage 3).
- Neutropenia common with AZT (5% during first year), usually develops early and may resolve without intervention.
- Major cause is AZT. Also consider TB, lymphoma (if pancytopenia), other OIs, and advanced HIV (CD4 <50).
- Assess for TB, other OIs
- If on AZT, consider switch to alternative agent ( d4T, TDF).
Zambia Information Author: Christopher Hoffmann, MD, MPH
- Multiple causes, including HIV infection, inflammatory cytokines, drugs (AZT, ganciclovir, foscarnet, amphotericin, flucytosine, sulfonamides, pyrimethamine, pentamidine, interferon-alfa), OIs with bone marrow replacement, chemotherapy for malignancy.
- HIV can cause decreased growth of progenitor cell, CFU-GM; decreased endogenous G-CSF.
- Prevalence ranges from 10% in asymptomatic HIV, 40-50% with AIDS.
- Increased risk of bacterial and fungal infection with absolute neutrophil count (ANC) <750, but absolute risk relatively low. Greatest risk for infection and hospitalization with ANC <500.
- Neutropenia (< 1000) not associated with decreased survival in HIV+ women (possibly in men, but not studied)
- ANC <1000.
- Anemia often present when caused by HIV infection, drugs, or OIs
- Assess for reversible causes requiring specific treatment, such as modifying use or dose of causative drug.
- Consider treatment with growth factors for ANC <500 (increased risk, but absolute risk for infection low).
- G-CSF: (filgrastim) Initial dose of 5 mcg/kg (or 300 mcg = "1" cc) SC once-daily: titrate as necessary after 1 wk by adjusting dosing interval to every other day, 3x/wk, 2x/wk. Can also reduce dose (e.g. 150 mcg, 75 mcg, etc.) Goal is to maintain ANC >1000-2000.
- GM-CSF: (sargramostim) Initial dose of 250mcg/m2 once-daily; titrate as necessary by adjusting dosing interval as with G-CSF.
- Pegylated G-CSF (pegfilgrastim) 6 mg SQ weekly or less
- Monitor ANC during G-CSF and GM-CSF 1-2x/wk.
- Adverse effects of growth factors: Pain at injection site, myalgias, bone pain, low-grade fever, fatigue, flu-like symptoms, possible elevated lactic dehydrogenase and alkaline phosphatase. No evidence of adverse effect on HIV replication.
- USPHS/IDSA guidelines: G-CSF and GM-CSF "not routinely indicated" for neutropenic HIV+ pts.
- ART improves neutropenia in women (probably in men, but not studied)
| G-CSF ||Would only consider for ANC <500. Otherwise, absolute risk of bacterial infection is low unless due to cancer chemotherapy or other drug-induced rapid decrease in ANC, and G-CSF not routinely indicated.