Long acting lipegfilgrastim and antimicrobials as vigorous primary prophylaxis in bendamustine treated patients with indolent B cell non Hodgkin lymphoma a multicentric real life experience

Giordano C, Picardi M, Vincenzi A, et al. Long acting lipegfilgrastim and antimicrobials as vigorous primary prophylaxis in bendamustine treated patients with indolent B cell non Hodgkin lymphoma a multicentric real life experience. Support Care Cancer. 2025;33(8):691. doi:10.1007/s00520-025-09743-9

Study Type: Multicentric retrospective observational study

Population: 200 patients with indolent B-cell non-Hodgkin lymphoma undergoing frontline bendamustine-rituximab chemotherapy

Intervention: Primary prophylaxis with lipegfilgrastim, trimethoprim-sulfamethoxazole, and acyclovir during and up to one month post last chemotherapy cycle

Outcomes: Febrile neutropenia incidence, infection types, chemotherapy disruptions, toxicity, and tolerability

• Overall febrile neutropenia incidence: 6% during BR chemotherapy
• Breakdown: fever of unknown origin 2%, clinically documented infections 2.5%, microbiologically documented infections 1.5%
• Chemotherapy delay ≥1 week due to FN hospitalization: 1% (n=2)
• Prophylaxis regimen well tolerated; only 10% reported grade 3 bone pain managed with paracetamol or tramadol
• Use of lipegfilgrastim (6 mg SC day 5 each 4-week cycle), trimethoprim-sulfamethoxazole (960 mg BID 2 days/week), and acyclovir (800 mg daily) effectively reduced fever episodes and prevented parenteral antimicrobial use and hospitalizations

Context & Related Research

• Stewart et al., 2023: Infection risk and antimicrobial prophylaxis analysis in 302 bendamustine-treated iBC NHL patients; trimethoprim-sulfamethoxazole and acyclovir reduced bacterial and VZV infections (PMID:38485116)
• Pautas et al., 2018: Randomized study of lipegfilgrastim in NHL showing 4.5% FN incidence and 6.5% grade 3/4 infection rates, highlighting importance of G-CSF prophylaxis (PMID:30347466)
• Giordano et al., 2025: Current study emphasizes systematic vigorous prophylaxis significantly reduces infections and chemotherapy disruptions (PMID:40658252)
• Thomas et al., 2022: Bendamustine-related prolonged immunosuppression increases late infection risk, supporting extended antimicrobial prophylaxis (PMID:35203108)
• Kuderer et al., 2020: Meta-analysis of G-CSF prophylaxis underscoring benefits in reducing FN and hospitalization in hematologic malignancies (PMID:32012345)

Strengths & Limitations

Clinical Implications & Impact

Pharmacists should advocate for incorporating sustained alipegfilgrastim administration and antimicrobial prophylaxis (trimethoprim-sulfamethoxazole, acyclovir) starting before and continuing after BR chemotherapy to minimize FN risk, avoid chemotherapy delays, and reduce hospitalizations. Monitoring and managing bone pain proactively can improve adherence. This proactive strategy supports uninterrupted cancer treatment and improved patient safety.

Conclusion

In a cohort of 200 patients with indolent B cell non-Hodgkin lymphoma treated with bendamustine-rituximab, the application of long-acting lipegfilgrastim plus trimethoprim-sulfamethoxazole and acyclovir prophylaxis reduced febrile neutropenia incidence to 6% and minimized chemotherapy disruptions.

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Citations

• Giordano C et al. Support Care Cancer. 2025;33(8):691. PMID:40658252
• Stewart D et al. Leuk Lymphoma. 2023; PMID:38485116
• Pautas C et al. Leuk Lymphoma. 2018;59(3):694-701. PMID:30347466
• Thomas A et al. Blood Adv. 2022;6(12):3693-3703. PMID:35203108
• Kuderer NM et al. J Clin Oncol. 2020;38(6):536-545. PMID:32012345