G-CSF in HiDAC Consolidation for AML: Evidence, Safety Concerns, and Evolving Practice Patterns

Granulocyte colony-stimulating factor (G-CSF) use during high-dose cytarabine (HiDAC) consolidation for acute myeloid leukemia has long been a point of debate, particularly around concerns that stimulating myeloid recovery could contribute to leukemic regrowth. Yet emerging data suggest meaningful benefits in reducing neutropenia-related complications without compromising relapse or survival outcomes.

In this interview at the Hematology/Oncology Pharmacists Association 2026 Annual Conference, Atrium Health Wake Forest Baptist oncology pharmacy resident Disha Patel, PharmD, shares insights from her ongoing research and explains how she approaches G-CSF decision-making, the nuances of institutional practice variation, and what future evidence could mean for standardizing care.

Disha Patel, PharmD: Hi. My name is Disha Patel. I'm a PGY2 oncology pharmacy resident at Atrium Health Wake Forest Baptist. My research is focusing on the use of granulocyte-colony stimulating factor (G-CSF) in high-dose cytarabine (HiDAC) consolidation in acute myeloid leukemia (AML). Some of the things my research is looking at are the rates of febrile neutropenia, duration of neutropenia, and duration of hospital stay. I'm really excited to talk to you about my research.

Q: G-CSF use during consolidation chemotherapy has been debated for years—some clinicians use it routinely, and others avoid it out of concern for stimulating leukemic regrowth. Where does the evidence currently stand, and has your own practice evolved on this question?

Patel: Yeah, so historically, G-CSF use in the consolidation phase for AML patients has been kind of debated, mainly because there is a concern that you might be at risk of further proliferating any disease if there is any residual disease that is left behind. On the other hand, I do think that current evidence has shown that there is a benefit that can be seen in using G-CSF in reducing neutropenia rates, reducing length of hospital stay, and other things. More current data have shown that it actually does not impact risk of relapse or overall survival. I do think that is still…hesitancy toward using it, because there is no definitive guideline suggesting if you should or should not use it. But I do think that current evidence has allowed providers and pharmacists to feel a little bit more comfortable using it in this space.

Q: High-dose cytarabine consolidation already carries significant myelosuppression risk. When you’re weighing the decision to add G-CSF, what clinical factors most influence that call?

Patel: Yeah, so it definitely does have a high myelosuppressive risk, and I think one of the first things I think about is our institutional practice. Like I've mentioned, some providers are very comfortable using it, and some are not. At my current institution, it's actually built into the treatment plans, and it's pretty routine practice that we use G-CSF for our HiDAC consolidation.

But I do think it's important to consider patient-specific factors, such as: Are they of elder age? Do they have comorbidities? Do they have an adverse risk profile? Other things to consider are, if they've already had HiDAC consolidation, how did they tolerate the first cycle? Did they experience any neutropenia? Did it cause any delays in their future cycles? I think these types of questions help us decide if using G-CSF as a supportive measure would be useful in allowing patients to continue getting adequate doses and maintaining dose intensity and ensuring that we're not having significant delays between cycles.

Q: One of the central concerns with G-CSF in AML is whether stimulating myeloid progenitor cells could theoretically drive relapse. How strong is the biological rationale for that concern, and does the clinical data support or refute it in the consolidation setting specifically?

Patel: Yeah, like I mentioned, I do think that historically this has been a concern, and I think it is still something that people are skeptical about. But I do think that current evidence, like I mentioned, has shown that there is no increased risk of relapse or decreased overall survival to refute using G-CSF in this space. On the other hand, we have seen that it helps decrease neutropenia rates.

In terms of the risk versus benefit discussion with neutropenia, you also have to consider the complications that can arise from that, such as febrile neutropenia and infection-related mortality. So I do think that this is a risk versus benefit concept you have to consider. But given the current evidence, people are feeling more and more comfortable using it. In terms of guidelines, the guidelines phrase it as something that can be considered in the consolidation space specifically. So although they do not provide a stance definitively saying that you should or should not use it, they do say it can be considered and it is reasonable to consider in the consolidation phase.

Q: Neutropenic fever and infection-related complications during consolidation can delay subsequent cycles and compromise outcomes. How do you think about the trade-off between reducing infectious complications with G-CSF versus the uncertainty around its oncologic safety in this population?

Patel: Yeah, I do think, like I mentioned, that there is some uncertainty, but with the risk versus benefit, it is something that you have to keep considering. Infection-related mortality is a huge consideration in this already immunocompromised population, so that is definitely one of the things we are weighing in this decision.

But it is something you have to consider for each patient to determine if it's appropriate to use. Given that the guidelines say it can be considered, I think it is relatively safe to consider for these patients, although there is that hesitancy. My research in particular is also aiming to analyze relapse rates and overall survival to help answer this question, because I do think it is still a little uncertain. That is something we are analyzing right now for my research. But yes, I think it is a risk versus benefit discussion, and infection-related mortality is a huge consideration for me personally.

Q: Practice patterns around G-CSF in AML consolidation vary considerably across institutions. Is this a case where you think the field needs prospective trial data to reach a consensus, or do you believe the existing retrospective and registry evidence is sufficient to guide standardized recommendations?

Patel: I think that with the guidelines saying that it can be considered, that still gives providers space to either use it or not use it. I think this has caused institutions to develop their own practice. Some do heavily use it, and some do not. So I do think that prospective data would really help unify everyone and create a consensus on supporting it or refuting it. I think it will help ensure that all patients getting consolidation with HiDAC get equal care across all institutions if we do have data to strongly support it or refute it.