Is bone pain from Neulasta common? If so, how can bone pain be prevented or treated?

A fellow caregiver asked...

My father’s been given a combination of Taxol/Carb and Neulasta one day later and is suffering excruciating bone pain. The doctor prescribed acetominophen, and, finally after I insisted, he prescribed Vicodin. Is this really all anyone can offer? Also, would waiting another day or two for the Neulasta have made the pain less? How can I talk to the doctor and get a more proactive response?

Expert Answer

Andrew Putnam, M.D. is a Palliative Care physician at Smilow Cancer Center at Yale New Haven Hospital and Yale University.

Neulasta is an effective medication to help shorten, but not prevent, post-chemotherapy neutropenia (low white blood cell count). Unfortunately, one common side effect is severe bone pain. It's a growth factor, which means it works by revving up the bone marrow to produce more white blood cells. Since this is the cause of the pain, according to most experts, the intensity of the pain doesn't change based on how many days after chemotherapy it’s given.

Neulasta is a time release form of Neupogen and is the equivalent of ten successive days of injections of the latter medication. Some oncologists try to reduce the pain by giving seven successive days of Neupogen (rather than the usual ten) in place of the Neulasta. The idea being that less total drug would mean less total pain but still be effective to support the white blood cell count. The downside is that daily home injections are required, rather than a one-time Neulasta dose lasting ten days.

Pain medication is important in this situation, and acetominophen is not the most effective choice because it doesn't work to reduce inflammation. A better choice would be an NSAID (non-steroidal anti-inflammatory drug) such as ibuprofen or naproxen. NSAIDS relieve inflammation and swelling and so can be very effective for most types of bone pain. Acetaminophen is not an NSAID and while helpful for many types of pain, it doesn't reduce inflammation and so is less effective here. NSAIDs must be used with care because they can cause stomach pain or ulcers, kidney problems, and bleeding problems, but surprisingly may be more effective than narcotic pain meds for bone pain.

If the ibuprofen/naproxen is not effective, ask your dad's doctor about trying a medication that combines an NSAID with a narcotic such as Combunox (oxycodone and ibuprofen), Percodan (oxycodone and aspirin) or Vicoprofen (hydrocodone and ibuprofen). The other choice is too add a pure narcotic, such as morphine, oxycodone, or hydromorphone to the NSAID as a separate drug. The disadvantage is more pills, but doing this allows you and your father to control separately the amounts of NSAID and narcotic, thereby reducing the possible side effects. Neulasta is an effective medication to help shorten, but not prevent, post-chemotherapy neutropenia (low white blood cell count). Unfortunately, one common side effect is severe bone pain. It’s a growth factor, which means it works by revving up the bone marrow to produce more white blood cells. Since this is the cause of the pain, according to most experts, the intensity of the pain doesn't change based on how many days after chemotherapy it’s given.