François Lefrère ()Service de Biothérapie, Groupe Hospitalier Necker-Enfants Malades, 149-161 Rue de Sèvres 75743 Paris Cedex 15, France. Email: francois.lefrere@nck.aphp.fr

François Lefrère · Anne-Colette Brignier · Jean-Antoine Ribeil · Michael Bernimoulin · Charbel Aoun · Liliane Dal Cortivo · Marina Cavazzana-Calvo Service de Biothérapie, Hôpital Necker, APHP, Paris, France

Caroline Elie Université Paris Descartes, Service de Biostatique, Hôpital Necker, APHP, Paris, France

Richard Delarue · Olivier Hermine Service d’Hématologie Adultes, Hôpital Necker, APHP, Paris, France

Adv Ther (2011)DOI 10.1007/s12325-011-0009-1

ORIGINAL RESEARCH

First Experience of Autologous Peripheral Blood Stem Cell Mobilization with Biosimilar Granulocyte Colony-Stimulating Factor

François Lefrère · Anne-Colette Brignier · Caroline Elie · Jean-Antoine Ribeil · Michael Bernimoulin · Charbel

Aoun · Liliane Dal Cortivo · Richard Delarue · Olivier Hermine · Marina Cavazzana-Calvo

Received: February 1, 2011 / Published online: March 10, 2011 © Springer Healthcare 2011

ABSTRACT

Introduction: Mobilization techniques for autologous peripheral blood stem cell (PBSC) collection include chemotherapy followed by hematopoietic growth factors, such as granulocyte colony-stimulating factor (G-CSF). Biosimilar versions of G-CSF are now available in Europe. Methods: In this study, 40 patients with a hematological malignancy scheduled to receive biosimilar G-CSF (Zarzio®,Sandoz Biopharmaceuticals, Paris, France) following first-cycle chemotherapy for treatment and autologous PBSC mobilization

were prospectively included at a single center. These patients were compared with a historical control group who had been treated with G-CSF (Neupogen®, Amgen, Paris, France) at the same center according to the same clinical protocol. PBSC harvesting was considered successful if at least 3×106 CD34+ cells/kg were collected. If three consecutive CD34+ tests were below 10/μL then PBSC harvesting was not performed. Results: Patient characteristics were similar in both groups with no significant differences in age, diagnosis, previous chemotherapy, or chemotherapy mobilization regimen. No significant differences were observed between groups in median CD34+ cells mobilized and collected, or the number of G-CSF injections and leukaphereses required to obtain the minimal CD34+ cell count. Proportion of failures was also similar in both groups. Conclusion: Zarzio® is comparable to Neupogen® for PBSC mobilization and collection after chemotherapy and so may provide a more cost-effective strategy.

Keywords: autologous transplantation; biosimilars; G-CSF; hematological malignancies; leukapheresis; stem cell mobilization; Zarzio

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INTRODUCTION

R e c o m b i n a n t g r a n u l o c y t e c o l o n y -stimulating factors (G-CSFs) such as f i lgrastim (Neupogen®, Amgen, Paris , France) or lenograst im (Granocyte ®,Chugai Pharma, Paris, France) are widely used to treat chemotherapy-induced neutropenia and to mobilize peripheral blood stem cells (PBSC).1-5 Recent and pending patent expiry of a number of biopharmaceuticals, including G-CSF, have prompted the development of alternative versions. Due to the complex nature of biopharmaceuticals, these products, referred to as biosimilars, are comparable but not identical to their originator (reference) product. As such, biosimilars differ from simple generic versions of drugs.6 It is to be hoped that the development of biosimilars may result in reduced costs compared with the originator products and so help to provide cost savings in their indicated uses.

Recently, several forms of biosimilar nonglycosylated recombinant human G-CSF expressed in Escherichia coli have been clinically developed.7-16 These drugs have been approved by the European Medicines Agency (EMA) for the same indications as the reference filgrastim product (Neupogen®) on the basis of comparable quality, efficacy, and safety.

These biosimilar G-CSFs have shown comparable efficacy and safety to Neupogen® in ameliorating severe neutropenia and febrile neutropenia in patients with cancer receiving chemotherapy.7-11 However, to the best of our knowledge, there are no previously published data on the use of biosimilar G-CSF for autologous PBSC mobilization and collection in patients with hematological disease. The present study compares the use of a biosimilar G-CSF with its reference product for the mobilization and collection of PBSC in patients with hematological malignancy.

METHODS

A total of 40 consecutive patients with a hematological malignancy (lymphoma or mult iple myeloma) scheduled to receive biosimilar G-CSF (Zarzio®, Sandoz Biopharmaceuticals, Paris, France) following chemotherapy for treatment and autologous PBSC mobilization were prospectively included at a single center (Hôpital Necker, Paris) between March and September 2010. These patients were compared with a historical control group of 41 patients matched for age, diagnosis, previous chemotherapy, and mobilization who had been treated with Neupogen® at the same center between 2007 and 2009.

Patients in both groups were treated according to the same clinical protocol with chemotherapy administered on day 1 and Zarzio® strictly administered according to previous clinical practice with Neupogen®. Patients with lymphoma were primarily treated with a chemotherapy regimen of CHOP (day 1 doxorubicin 50 mg/m2,cyclophosphamide 750 mg/m2, vincristine 2 mg, plus prednisone 100 mg, days 1-5) or DHAP (day 1 cisplatinum 100 mg/m2, day 2 cytarabine (Ara-C) 4 g/m2, plus dexamethasone 40 mg/m2, days 1-4) with G-CSF administered subcutaneously at a dose of 5 μg/kg/day from day 9 until white blood cell (WBC) recovery and the end of PBSC collection. The majority of patients with multiple myeloma were treated with bortezomib 1.3 mg/m2/day (Velcade®, Janssen, Paris, France) plus dexamethasone 40 mg/day in a first front-line therapy on days 1, 3, 6, and 11 with G-CSF 10 μg/kg/day administered from day 16 for 5 consecutive days. Patients with a previous history of PBSC mobilization were excluded from this study.

Monitoring of peripheral blood (PB) CD34+ cell concentrations began as soon as WBC

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recovery reached 1x109/L following a course of CHOP or DHAP and on the fifth day of G-CSF administration following a course of bortezomib. Leukapheresis (Cobe® Spectra, Caridian BCT®, Lakewood, CO, USA) was initiated when the CD34+ cell concentration reached 10/μL. The total blood volume processed in each leukapheresis varied according to PB CD34+ cell concentration; for CD34+ cell concentrations of 10-50/μL, 51-100/μL, and >100/μL, three, two, or one blood volumes, respectively, were processed during each leukapheresis. Leukapheresis and G-CSF administration were performed daily until a minimal count (3x106 CD34+ cells/kg) was collected. If three consecutive PB CD34+ tests were below 10/μL then PBSC harvesting was not performed.

The quantity of stem cells harvested was evaluated through CD34+ cell quantification performed as previously described.3 Briefly, CD34+ cell quantification was performed by fluorescence analysis, 1x106 mononuclear cells were incubated for 30 minutes at 4°C with the fluorescein isothiocyanate-conjugated

monoclonal antibody HPCA-2 (CD34) (Beckton-Dickinson, Le Pont-de-Claix, France). Cells were quantified by a fluorescence-activated cell scanner (FACS).

Short-term hematological reconstitution following autologous PBSC reinfusion was evaluated in both groups for all grafted patients.

Statistical Analysis

Continuous data are presented as the median (range), and categorical data as numbers (proportions). Comparisons of the two groups were performed using chi-square tests or Fisher’s exact for categorical variables, and using Wilcoxon’s test for continuous variables. A value of P<0.05 was considered statistically significant. All statistical analyses were performed by using the R software package (version V2.6.2).17

RESULTS

Patient characteristics were similar in both the Zarzio® and Neupogen® treatment groups with

Biosimilar G-CSF (Zarzio®)

Filgrastim (Neupogen®)

P value

Number of patients 40 41Median age (years) 57.5 (28-67) 54.0 (27-65) 0.10Diagnosis: Lymphoma Multiple myeloma

21 (53%) 19 (48%)

21 (51%) 20 (49%)

0.91

Median weight (kg) 70 (47-112) 71 (43-110) 0.67Median number of previous chemotherapy courses

4 (2-9) 4 (2-9) 0.35

PBSC mobilization regimen: CHOP DHAP Bortezomib-dexamethasone Others

11 (28%) 5 (13%) 15 (38%) 9 (23%)

14 (34%) 2 (5%) 20 (49%) 5 (12%)

0.35

Values in parentheses indicate range or percentage. CHOP=cyclophosphamide/doxorubicin/vincristine/prednisone; DHAP=cisplatin/cytarabine/dexamethasone; PBSC=peripheral blood stem cell.

Table 1. Patient characteristics.UNAUTHORIZED U

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no significant differences with regard to age, diagnosis, previous chemotherapy regimens administered, and chemotherapy mobilization regimen (Table 1).

In both groups, a median of five consecutive G-CSF injections were required to complete PBSC mobilization and collection (P=0.62) (Table 2). The median PB WBC count before leukapheresis reached 31x109/L (range 4.5-91) in the Zarzio® group compared with 28.2x109/L (range 2.9-93) in the Neupogen® group (P=0.68). The median PB CD34+ cell concentration evaluated before the first leukapheresis was 55.5/μL (range 1-196) with Zarzio® and 60/μL (range 13-432) with Neupogen® (P=0.71). The median number of leukapheresis necessary to harvest a minimal count of 3x106 CD34+/kg was 1 (range 1-3) for both groups (P=0.10). Only three patients (7.5%) failed to mobilize enough CD34+ cells in the Zarzio® group compared with one patient (2.4%) in the Neupogen® group. This difference was not statistically significant (P=0.36).

Bone pain and/or headache were reported for 14 patients in the Zarzio® group (11 patients receiving 10 μg/kg/day and three patients

receiving 5 μg/kg/day). None of these patients required opioid-based pain relief treatment. The frequency of side effects in the control group could not be retrospectively evaluated.

Short-term hematological reconstitution could be evaluated in 31 patients in the Zarzio® group and 33 patients in the Neupogen® group. The median number of days to recover to an absolute neutrophil count above 0.5x109/L following PBSC infusion was 14 days (range 9-21) in the Zarzio® group and 15 days (range 7-20) in the Neupogen® group. The median delay to recover to a platelet count above 20x109/L was 12 days (range 6-19) and 11 days (range 7-26) in the Zarzio® and Neupogen® groups, respectively.

DISCUSSION

Mobilization of PBSC in patients with malignant diseases is routine practice in high-dose therapy and autologous stem cell transplantation. Two forms of recombinant human G-CSF, filgrastim (Neupogen®) and lenograstim (Granocyte®), are currently used in Europe to enhance PBSC mobilization following

Biosimilar G-CSF (Zarzio®)

Filgrastim (Neupogen®)

P value

Median number days of G-CSF administration 5 (5-12) 5 (5-9) 0.62Median preleukapheresis PB white cell count (109/L)

31.0 (4.5-91) 28.2 (2.9-93) 0.68

Median preleukapheresis PB CD34+ (/μL) 55.5 (1-196) 60.0 (13-432) 0.71Median number of blood masses processed by leukapheresis

3 (1-3) 3 (1-3) 0.65

Median 106 CD34+/kg collected for first leukapheresis (from collected patients)

5.50 (1.1-20) 4.49 (0.9-25) 0.26

Median number of leukapheresis to collect 3x106 CD34+/kg

1 (1-3) 1 (1-3) 0.10

Number of PBSC mobilization failures 3 (7.5%) 1 (2.4%) 0.36

Values in parentheses indicate range or percentage. G-CSF=granulocyte colony-stimulating factor; PB=peripheral blood; PBSC=peripheral blood stem cell.

Table 2. PBSC collection.

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chemotherapy.1-5 In addition, a number of biosimilar nonglycosylated G-CSFs have been clinically developed and approved in Europe. These biosimilars have shown comparable physicochemical and biologic characteristics with their reference product (Neupogen®)15,16 and have also shown equivalence with Neupogen® in reducing the duration of severe neutropenia and the incidence of febrile neutropenia following chemotherapy in some groups of patients with cancer.7-11 In a meta-analysis of three clinical studies including 608 patients with breast cancer, lung cancer, and non-Hodgkin’s lymphoma, biosimilar G-CSF (XM02) (n=363) was noninferior to Neupogen® (n=245) regarding the incidence of febrile neutropenia during the first chemotherapy cycle, irrespective of the myelotoxicity of the chemotherapy regimen, and presented a similar safety profile.9 Another biosimilar G-CSF, Zarzio®, has been shown to have comparable pharmacodynamics and pharmacokinetics to Neupogen® in healthy volunteers and to be effective and safe for the primary prophylaxis of severe neutropenia in patients with breast cancer.11

To the best of our knowledge, no studies have previously investigated the impact of biosimilar G-CSF on PSBC mobilization and collection in patients treated for hematological disease. In the current single-center study, we compared a biosimilar form of filgrastim (Zarzio®) with its reference product Neupogen® for PBSC mobilization and collection following chemotherapy in patients with various hematological malignancies. A total of 40 consecutive patients with lymphoma or multiple myeloma were evaluated following chemotherapy plus Zarzio® administration and compared with a historical control group of 41 patients treated with Neupogen®. This control group was matched for the main

characteristics that can affect the capacity of PBSC mobilization, including age, diagnosis, previous chemotherapy, and mobilization regimen. A high proportion of our patients were mobilized following a limited number of courses of chemotherapy. Patients with multiple myeloma or aggressive ß-cell lymphoma today represent the majority of those indicated for autologous PBSC transplantation with stem cells generally collected during the first-line of therapy.18,19

Our study shows that Zarzio® administered following chemotherapy is equivalent to Neupogen® for mobilization and PBSC collection when used with the same schedules and doses. The median number of consecutive days for Zarzio® administration was the same as with the control group and was comparable with our previous experience with other G-CSFs.20,21

The median counts for both WBC and CD34+ cells before leukapheresis were also similar between the study group and the control group. Moreover, the median total CD34+ yield from the first leukapheresis seemed to be superior with Zarzio® compared with Neupogen®, although this was not statistically significant. The proportion of PBSC mobilization and collection failures was also comparable between groups. The high proportion of success in PBSC mobilization for both groups (more than 90%) contrasts with previous studies.22,23 This success may be explained by the inclusion of a high proportion of patients who had received only a limited number of chemotherapy courses before PBSC mobilization.

A comparison of side effects between the two groups of patients could not be performed because a retrospective evaluation for the historical Neupogen® group was not available. However, the frequency and the severity of side effects such as headache and/or bone pain observed in the Zarzio® group was

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comparable to both our previous experience

and other published studies of G-CSF at 5 and

10 μg/kg/day doses.24

CONCLUSION

In our study, the short-term hematological

recovery after PBSC reinfusion following

intensive chemotherapy presented no clinically

relevant differences between the Zarzio® group

and the Neupogen® group. These results confirm

the quality of stem cells harvested regardless of

the G-CSF product being used.

Today in France, the biosimilar form of G-CSF

represents a reduced cost of approximately 20%

compared with Neupogen® (€95 vs. €119 per

300 μg/dose, €150 vs. €187 per 480 μg/dose).25

So, in the limits of this study, the benefit of

biosimilar G-CSF in PBSC mobilization with

regard to cost savings was unquestionable

due to the identical median consumption of

G-CSF doses and leukapheresis procedures

noted to reach the target of a minimal count

of 3x106 CD34+/kg. Increased administration

of biosimilars for PBSC mobilization may

strongly help to reduce the high cost of such

procedures. Further prospective studies are

required to investigate the use of biosimilar

G-CSF in PBSC mobilization and collection.

ACKNOWLEDGMENTS

Dr. François Lefrère acts as a consultant for

Sandoz Biopharmaceuticals, Holzkirchen,

Germany. Journal page charges were paid

by Sandoz Biopharmaceuticals. The other

authors have declared no conflicts of interest.

Dr. François Lefrère is the guarantor for this

article, and takes responsibility for the integrity

of the work as a whole.

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