This study analyzed the use of the biosimilar granulocyte colony-stimulating factor (GCSF) Ratiograstim for peripheral blood stem cell mobilization and engraftment compared to the originator GCSF Neupogen. Data were collected for 154 patients mobilized with Ratiograstim and 131 historical controls mobilized with Neupogen. There were no statistically significant differences between the two groups in CD34+ stem cell collection parameters, number of days required for collection, or time to engraftment. This represents one of the largest direct comparisons of a biosimilar GCSF to the originator for stem cell mobilization, and found no differences, suggesting biosimilar GCSF can be used

1. Use of a biosimilar granulocyte colony-stimulating factor for
peripheral blood stem cell mobilization: an analysis of
mobilization and engraftment
Amy Publicover, Deborah S. Richardson,
Andrew Davies, Kate S. Hill,
Carol Hurlock, David Hutchins,
Matthew W. Jenner, Peter W. Johnson,
Jane Lamb, Harriet Launders,
Nikki McKeag, Joan Newman and
Kim H. Orchard
Wessex Blood and Marrow Transplantation
Unit, Department of Haematology, University
Hospital Southampton, Southampton, UK
Received 9 January 2013; accepted for
publication 12 February 2013
Correspondence: Amy Publicover, Wessex
Blood and Marrow Transplantation Unit,
Department of Haematology, University
Hospital Southampton, Tremona Road,
Southampton SO16 6YD, UK.
E-mail: amy.publicover@uhs.nhs.uk
Summary
Peripheral blood haematopoietic progenitor cell mobilization has become a
standard procedure prior to autologous stem cell transplantation. Biosimi-
lar granulocyte colony-stimulating factors (GCSF) have recently been
awarded European Union (EU) licences for stem cell mobilization but data
for their use in this context remain limited. The biosimilar GCSF, Ratiogra-
stimâ
(Ratiopharm, Ulm, Germany) was granted an EU licence in Septem-
ber 2008 and incorporated into clinical practice in the Wessex Blood and
Marrow Transplantation Programme in December 2008. Data were retro-
spectively collected for 154 consecutive patients undergoing peripheral
blood stem cell harvest between January 2009 and December 2011 using
the biosimilar GCSF. 131 consecutive patients from the preceding 3 years,
who had received Neupogenâ
, were used as a control. We analysed both
parameters relevant to stem cell collection and engraftment data, where
patients proceeded to transplantation. We found no statistically significant
difference between the two groups when comparing CD34 predictors, total
number of CD34+
stem cells collected, number of days required for collec-
tion, or for time to engraftment. This is, to our knowledge, the largest
direct comparison of a biosimilar GCSF with originator GCSF for stem cell
mobilization. The use of biosimilar GCSF can produce a significant cost
saving, allowing investment in other areas of stem cell transplantation.
Keywords: granulocyte colony-stimulating factor, mobilization, biosimilar,
stem cell harvest, engraftment.
Mobilization of peripheral blood haematopoietic progenitor
cells (PBPCs) has become a standard procedure in patients
prior to an autologous stem cell transplant. In September
2008, the biosimilar granulocyte colony-stimulating factor
(GCSF) Ratiograstimâ
was granted an European Union
(EU) licence for use in chemotherapy-induced neutropenia,
post-bone marrow transplantation, mobilization of PBPCs,
congenital and cyclical neutropenia and for neutropenia asso-
ciated with human immunodeficiency virus. Biological agents
that are used as pharmaceuticals could potentially display
altered biological activity due to subtle differences in charac-
teristics, such as glycosylation and protein folding, or have
different immunological properties. As manufacturing pro-
cesses for these products are proprietary, it is more difficult
to infer their equivalence to the innovator product than for
standard generic products. For this reason, there have been
concerns about the use of biosimilar products for stem cell
mobilization, especially in normal allogeneic donors. The
World Health Organization (WHO Expert Committee on
Biological Standardization, 2009) stated that, ‘The clinical
performance of biotherapeutics can also be much influenced
by the manufacturing process and so some clinical studies
will also be required to support the safety and efficacy of an
SBP (similar biotherapeutic product)’. Currently there are
few published data regarding the use of biosimilar GCSF in
the context of PBPC mobilization. The World Marrow
Donor Association (WMDA; Shaw et al, 2011) concluded
that biosimilars should only be used in normal donors where
the donor is entered into a clinical study looking at the use
of biosimilar GCSF. In 2009 the European Group for Blood
and Marrow Transplantation (EBMT) Executive Committee
issued a letter stating that, ‘Until studies have been
ª 2013 John Wiley & Sons Ltd First published online 25 April 2013
British Journal of Haematology, 2013, 162, 107–111 doi:10.1111/bjh.12345
research paper

2. performed to provide the required efficacy and safety data,
the EBMT does not recommend the use of biosimilar GCSFs
for mobilization of stem cells in healthy donors for stem
cell transplantation’ (http://www.worldmarrow.org/fileadmin/
Committees/CLWG/Biosimilars/Biosimilars_9Jan09.pdf).
There are few publications regarding use of biosimilar
GCSF when used for PBSC mobilization. Ferro et al (2009)
reported their successful experience of stem cell mobilization
and engraftment in 414 patients using Neutromaxâ
(Biosidus, Buenos Aires, Argentina), a biosimilar GCSF not
licenced in the EU, although there was no direct comparator
group. A small study of 14 patients (Andreola et al, 2012)
showed successful mobilization and engraftment using Pler-
ixaforâ
(Genzyme Corporation, Cambridge, MA, USA) and
Filgrastim XM02â
(Teva Pharmaceutical Industries Ltd.,
Petach Tikva, Israel), another biosimilar GCSF. No signifi-
cant difference was found between the biosimilar GCSF
Zarzioâ
(Sandoz International GmbH, Holzkirchen, Ger-
many) and Neupogenâ
(Amgen, Thousand Oaks, CA, USA)
for stem cell mobilization in 40 patients compared to an his-
torical control (Lefrere et al, 2011). Our group presented
data at EBMT (Publicover et al, 2010) that compared mobili-
zation in 29 patients who underwent PBPC harvest using
Ratiograstimâ
with 34 patients where standard GCSF was
used and found no significant difference between the two.
Ratiograstimâ
was used to mobilize stem cells in 22 healthy
sibling donors for allogeneic stem cell transplantation
(Schmitt et al, 2013) and no significant differences in mobili-
zation or engraftment were found.
Ratiograstimâ
was incorporated into clinical use for PBPC
mobilization in the autologous setting in the Wessex Blood
and Marrow Transplantation (WBMT) Programme in Decem-
ber 2008, following a regional pharmacy purchasing decision.
As is required by the WBMT Quality Management Programme
following a change in practice, an audit of stem cell harvests
was performed for the periods January 2006–September 2008
originator GCSF (Neupogenâ
) and January 2009–December
2011 with the biosimilar GCSF, comparing a number of
important parameters of stem cell mobilization efficiency. In
addition, we compared engraftment data for the two groups
following high dose chemotherapy and autologous stem cell
transplantation (ASCT) using the harvested stem cells.
Methods
Data were retrospectively collected for 154 consecutive
patients undergoing PBPC harvest at University Hospital
Southampton (UHS) between January 2009 and December
2011 using the biosimilar GCSF; 131 consecutive patients
who underwent the procedure between January 2006 and
September 2008 were used as a comparator group. Patient
characteristics and underlying diseases are shown in Table I.
The protocols for stem cell priming were essentially the
same throughout. With one exception, all the patients with
myeloma were primed with cyclophosphamide and GCSF.
The lymphoma patients were either harvested with cyclo-
phosphamide and GCSF, or following a cycle of chemother-
apy including R- ICE (rituximab, ifosfamide, carboplatin,
etoposide), R- IVE (rituximab, ifosfamide, etoposide, epiru-
bicin), etoposide and cytarabine.
The Shapiro-Wilk test was used to establish that the data
were not normally distributed. The P-values were calculated
using a Mann–Whitney U-test, and were considered statisti-
cally significant when 0Á05. Data were analysed using SPSS
version 19 software (IBM, Armonk, NY, USA).
Results
Mobilization
Our target CD34+
stem cell dose is 2 9 106
/kg for a single
autograft procedure. For patients with multiple myeloma, it
is our practice to attempt to harvest sufficient CD34+
cells
for two autograft procedures.
A ‘collection’ is taken as all the cells harvested from a sin-
gle priming procedure, regardless of the number of days
Table I. Patient demographics and indication for stem cell harvest.
Originator Biosimilar
Number of patients 131 154
Median age, years (range)
P = 0Á79
57Á5 (20–70) 58 (18–72)
Sex
P = 0Á28
89 male 42 female 97 male 57 female
Previous courses of chemotherapy (%)
P = 0Á23
1 2 3 4 4 1 2 3 4 4
56 31 7 4 2 46* 42 5 3 3
Myeloma 61 76
Lymphoproliferative diseases 65 71
Myelofibrosis 1 0
Non-haematological malignancies 4 6
Non-malignant disease 0 1
*One patient had received no prior treatment.
108 ª 2013 John Wiley Sons Ltd
British Journal of Haematology, 2013, 162, 107–111
A. Publicover et al

3. required to collect the required cell dose. The numbers
of attempted and actual collections are shown in Table II.
A collection can fail when either the apheresis procedure is
never attempted because the peripheral CD34+
count was
deemed too poor – 0Á010 9 109
/l – or because the patient
was unwell. In addition, apheresis may be performed, but
insufficient CD34+
cells collected.
From the perspective of the patient and for economic
reasons, the number of days of apheresis required to reach
the target total CD34+
count is an important parameter of
harvest efficiency (Fig 1).
In the originator group, apheresis was not attempted in
15/140 (11%) priming procedures. In three cases (2%) the
patient was unwell, 11 patients (8%) had poor predictors
and the reason was not recorded in one case. In the biosimi-
lar group, apheresis was not attempted in 12/172 (7%) prim-
ing procedures. All of these were due to poor predictors.
Two of the patients using originator and three of the patients
using biosimilar GCSF subsequently harvested successfully. In
the biosimilar group this was achieved with the addition of
Plerixaforâ
(which was not available at the time of the
harvests using originator GCSF). In the originator group, 11
out of 89 (12%) harvests were ‘inadequate’, although in three
cases sufficient cells were collected for one procedure and
seven were part of a second collection that resulted in a
cumulative success. In the biosimilar group, 26 out of 160
(16%) harvests were ‘inadequate’. Twelve patients collected
sufficient cells for one procedure and 14 were part of a
cumulative success.
Engraftment
Of those patients audited, 111 patients in the biosimilar
GCSF group and 84 in the originator group proceeded to
high dose therapy and ASCT. The difference in percentage of
patients proceeding to ASCT reflected a move away from a
‘harvest and save’ policy in the department. Engraftment data
were compared for the two groups until day of discharge
(i.e. until they were no longer having daily platelet counts;
Table III).
Discussion
The potential for functional differences between biosimilars
and their innovator products has led to the production of
specific guidelines by the European Medicines Agency (EMA)
detailing the minimum requirements for the approval of
biosimilars (EMA Committee for Medicinal Products for
Human Use (CHMP), 2005, 2006a,b). In the guidelines, as a
basic premise, biosimilars must demonstrate comparable
efficacy and safety to the innovator product. The guidelines
require evidence of the pre-clinical pharmacodynamic and
toxicity, clinical pharmacokinetic and pharmacodynamic data
and clinical efficacy (phase III) studies. The EMA recom-
mended that for GCSF, efficacy is demonstrated in the set-
ting of chemotherapy-induced neutropenia, extrapolation to
other indications is then allowed. Clinical safety data should
be collected for a minimum of 6 months and the importance
of ongoing pharmacovigilance is stressed.
There is on-going controversy regarding the use of
biosimilars, especially in the normal donor setting. As healthy
donors gain no personal benefit from the procedure, avoid-
ing any harm to them is of the highest importance. A review
of biosimilars (Mellstedt et al, 2008), stated that (with
regards to healthy donors), ‘safety data can only be obtained
Table II. Stem cell collections, peak peripheral CD34+
count and CD34+
total collection values.
Attempted
collections, n
Actual
collections, n (%)
Apheresis not
attempted, n (%)
Peak peripheral CD34+
in blood, 9109
/l
Median (range)
Total CD34 collection,
9106
/kg
Median (range)
Originator (n = 131) 140 125 (89) 15 (11) 0Á031 (0Á002–0Á802) 4Á4 (0Á5–56)
Biosimilar (n = 154) 172 160 (93) 12 (7) 0Á038 (0–0Á516) 4Á5 (0Á2–43)
P-value 0Á25 0Á65
Table III. Time to neutrophil and platelet engraftment.
Originator Biosimilar P-value
Patients 131 154
Proceeded to SCT 84 (64%) 111 (72%)
Median days to neutrophils
0Á5 9 109
/l (range)
13 (9–23) 13 (9–22) 0Á13
Median days to platelets
20 9 109
/l (range)
12 (8–24) 12 (7–35) 0Á64
0
17·5
35·0
52·5
70·0
One Two Three Four
Number of harvest days required
Ratiograstim Neupogen
Days of harvest
Percentage
Fig 1. Proportions of patients who collected in 1–4 d.
ª 2013 John Wiley Sons Ltd 109
British Journal of Haematology, 2013, 162, 107–111
Use of a Biosimilar GCSF

4. by performing an adequate number of stem cell mobilization
procedures and conducting long-term follow up in patients
undergoing autologous stem cell transplantation’. Which
parameters should be analysed was not specified. Currently
both the WMDA and EBMT advise against the use of bio-
similar GCSF in the normal donor setting. In the autologous
setting, however, although limited, all data published at pres-
ent have shown equivalence for biosimilars when used for
stem cell mobilization. Long-term follow-up data is not, to
our knowledge, available.
One of the other concerns frequently raised about biosimi-
lars is the potential for immunogenicity. Any protein used as a
drug has the potential to cause immunogenicity. Some pub-
lished data (Wadhwa et al, 2003) suggest that GCSF is non-
immunogenic. Conversely, anti-GCSF antibodies were found
in 15/135 healthy individuals who had never been exposed to
GCSF (Laricchia-Robbio et al, 1997). As discussed above, bio-
similar products must demonstrate equivalence to the innova-
tor product. Data submitted to the EMA found no significant
difference between another biosimilar (Nivestimâ
; Hospira
Inc., Lake Forest, IL, USA) and Neupogenâ
in terms of immu-
nogenicity (http://www.ema.europa.eu/docs/en_GB/document_
library/EPAR_-_Public_assessment_report/human/001142/WC
500093664.pdf). There may be data from unpublished studies
available, but a thorough literature search found few data
relating to immunogenicity for any type of GCSF.
Changing to a biosimilar G-CSF has significant cost
advantages for a transplant unit. When first introduced in
2008, biosimilars were approximately 15% cheaper than the
originator. The price of biosimilars, however, has reduced
rapidly, so that today biosimilars may be up to 80% lower in
cost. For a unit performing 100 stem cell harvests per year,
with an average patient weight of 80 kg, and using 10 lg/kg
of GCSF for 10 d, the cost saving would be approximately
£93 000 in our region, which can be re-invested in the
service.
This is, to our knowledge, the largest direct comparison
of a biosimilar and originator GCSF used to mobilize
PBSCs and showed no statistically significant difference
between the two for the key parameters measured for PBPC
harvest. In addition this study found no significant differ-
ence in time to engraftment between the two groups. Our
study looked only at chemotherapy-based mobilization and
cannot be extrapolated to G-CSF alone, or for use with
Plerixaforâ
. This is a retrospective audit and one of its limi-
tations is that toxicity data were not formally collected,
although no increase in toxicity was noted after changing to
the biosimilar. As with any study involving historical con-
trols, there is the possibility that the results could have been
influenced by other changes of practice within the unit.
There were, however, no intentional changes in harvest
indications or priming protocols, nor any change in equip-
ment or equipment settings during the time period audited.
The disease indications were also similar in the two groups.
The future collection of long-term safety data is important,
especially if biosimilar GCSF is to be used in the normal
donor setting.
Acknowledgements
The authors would like to thank Bronwen Shaw for her
comments in preparing this manuscript.
Author contributions
AP collated the data and wrote the first draft. HL provided
financial data. HL, DH, JL and CH provided patient data.
DR treated patients and contributed to writing the manu-
script. AD, KH, MJ, PJ, NM, JN treated patients. KO
planned the study and revised the manuscript. All authors
participated in discussion of results and approved the
manuscript.
Disclosure
AP was supported by an unrestricted educational award from
Teva. KO has received support for travel and honoraria from
Teva. There were no other competing financial interests.
References
Andreola, G., Babic, A., Rabascio, C., Negri, M.,
Martinelli, G. Laszlo, D. (2012) Plerixafor and
Filgrastim XM02 (tevagastrim) as a first line
peripheral blood stem cell mobilisation strategy
in patients with multiple myeloma and lym-
phoma candidated to autologous bone marrow
transplantation. European Journal of Haematolo-
gy, 88, 154–158.
EMEA Committee for Medicinal Products for
Human Use (CHMP) (2005) Guideline on Simi-
lar Biological Medicinal Products. CHMP/437/
04. European Medicines Agency, London.
Available at: http://www.emea.europa.eu/docs/
en_GB/document_library/Scientific_guideline/20
09/09/WC500003517.pdf.
EMEA Committee for Medicinal Products for
Human Use (CHMP) (2006a) Guideline on Simi-
lar Biological Medicinal Products Containing Bio-
technology-Derived Proteins as Active Substance:
Non-Clinical and Clinical Issues. EMEA/CHMP/
BMWP/42832/2005. European Medicines Agency,
London. Available at: http://www.ema.europa.eu/
docs/en_GB/document_library/Scientific_guideline/
2009/09/WC500003920.pdf.
EMEA Committee for Medicinal Products for
Human Use (CHMP) (2006b) Annex to Guide-
line on Similar Biological Medicinal Products
Containing Biotechnology-Derived Proteins as
Active Substance: Non-Clinical and Clinical
Issues. Guidance on Similar Medicinal Products
Containing Recombinant Granulocyte-Colony
Stimulating Factor. EMEA/CHMP/BMWP/
31329/2005. European Medicines Agency,
London. Available at: http://www.ema.europa.eu/
docs/en_GB/document_library/Scientific_guidel
ine/2009/09/WC500003955.pdf.
Ferro, H., Juni, M., Bello, R., Vidal, A., Diez, R.
Pavlovsky, S. (2009) Utilization study of filgra-
stim (Neutromax) during autologous haemato-
poietic precursor transplantation for myeloma
and lymphoma patients. Transfusion and Apher-
esis Science, 41, 87–93.
Laricchia-Robbio, L., Moscato, S., Genua, A., Liberati,
A. Revoltella, R. (1997) Naturally occurring and
therapy-induced antibodies to human granulocyte
colony-stimulating factor (G-CSF) in human
serum. Journal of Cellular Physiology, 173, 219–226.
Lefrere, F., Brignier, A., Elie, C., Ribeil, J.,
Bernimoulin, M., Aoun, C., Dal Cortivo, L.,
110 ª 2013 John Wiley Sons Ltd
British Journal of Haematology, 2013, 162, 107–111
A. Publicover et al

5. Delarue, R., Hermine, O. Cavazzana-Calvo,
M. (2011) First experience of autologous periph-
eral blood stem cell mobilization with biosimilar
granulocyte colony-stimulating factor. Advances
in Therapy, 28, 304–310.
Mellstedt, H., Niederwieser, D. Ludwig, H.
(2008) The challenge of biosimilars. Annals of
Oncology, 19, 411–419.
Publicover, A., Richardson, D.S., Hill, K., Hurlock,
C., Casey, P., Newman, J., Davies, A.
Orchard, K. (2010) Use of biosimilar granulo-
cyte colony stimulating factor (GCSF) for
peripheral blood progenitor cell mobilisation
prior to autologous stem cell transplant: a single
centre experience. Bone Marrow Transplantation,
45, S158–S159.
Schmitt, M., Xu, X., Hilgendorf, I., Schneider, C.,
Borchert, K., Gl€aser, D., Freund, M. Schmitt,
A. (2013) Mobilization of PBSC for allogeneic
transplantation by the use of the G-CSF biosim-
ilar XM02 in healthy donors. Bone Marrow
Transplantation, doi:10.1038/bmt.2012.270.
Shaw, B., Confer, D., Hwang, W., Pamphilon, D.
Pulsipher, M. (2011) Concerns about the
use of biosimilar granulocyte colony-stimulat-
ing factors for the mobilization of stem cells
in normal donors: position of the World Mar-
row Donor Association. Haematologica, 96,
942–947.
Wadhwa, M., Bird, C., Dilger, P., Gaines-Das, R.
Thorpe, R. (2003) Strategies for detection,
measurement and characterization of unwanted
antibodies induced by therapeutic biologi-
cals. Journal of Immunological Methods, 278,
1–17.
WHO Expert Committee on Biological Standardi-
zation (2009) Guidelines on Evaluation of
Similar Biotherapeutic Products (SBPs). World
Health Organization, Geneva, Switzerland.
ª 2013 John Wiley Sons Ltd 111
British Journal of Haematology, 2013, 162, 107–111
Use of a Biosimilar GCSF

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