The Hell Shot – how to manage the pain

Published: 05 Sep 2018

If you’re about to start chemo you may have been told you need a Neulasta shot or patch. If this is your first chemotherapy treatment you’re unlikely to have heard of it before.  But it’s something that’s discussed a lot in the Facebook Chemotherapy Support Group – with many people referring to it as the ‘hell’ shot. 

We thought it was time we wrote a blog on the subject to try to dispel any fears you may have by explaining exactly what it is, what it does, what to expect and how to counter any side effects.

What is it?

Neulasta is the brand name for a pegfilgrastim, a colony-stimulating factor (or "G-CSF"), a man-made form of a protein that stimulates the growth of good white blood cells (which help to decrease the incidence of infection), by treating neutropenia, a lack of certain white blood cells.

Other brand names are Neupogen, Granix and Zarxio – but these are slightly different.  These are a filgrastim, also a colony-stimulating factor used to treat neutropenia but unlike a pegfilgrastim, they’re missing the ‘peg’ a polyethylene glycol, "PEG," unit which makes the molecule larger so that it stays in your system longer.

How is it administered?

Neulasta can be given as an injection or applied as a patch to your skin. The injection is usually given once during each chemotherapy cycle, at least 24 hours after the last dose of chemotherapy in the cycle and 14 days before the first dose of chemotherapy in the next cycle.
The Neulasta patch, called Neulasta Onpro, is applied by a healthcare professional right after your chemotherapy infusion.

The dose of pegfilgrastim you are prescribed is different for each person – it depends on many factors including the type of cancer and chemo drug regimen as well as your height, weight and general health.  

How does it work?

Blood cells are produced in the body's bone marrow (the soft, sponge-like material found inside bones).  There are three major types of blood cells; white blood cells, which fight infection; red blood cells, which carry oxygen to and remove waste products from organs and tissues; and platelets, which enable the blood to clot.  

Cancer treatments such as chemotherapy and radiation therapy can affect these cells, leaving you with an increased risk of developing infections, anaemia and bleeding problems.  Colony-stimulating factors such as pegfilgrastim and filgrastim are substances that stimulate the production of blood cells and promote their ability to function.   They do not directly affect tumors but through their role in stimulating blood cells they can be helpful as support your immune system during cancer treatment.

How to deal with side effects

Bone Pain

One of the most common side effects which can be very painful for some people (hence it being dubbed the ‘hell shot’) is bone pain. Experts believe this is because this treatment is a growth factor, which means it works by revving up the bone marrow to produce more white blood cells.  If you have bone or joint pain, talk to your medical team who should be able to prescribe you with something to help such as naproxen and ibuprofen.

Andrew Putnam, M.D. is a Palliative Care physician at Smilow Cancer Center at Yale New Haven Hospital and Yale University. He advises “If the ibuprofen or naproxen is not effective, ask your 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 to add a pure narcotic, such as morphine, oxycodone, or hydromorphone to the NSAID as a separate drug.”

Antihistamine for G-CSF–Induced Bone Pain:  The medical world is currently undertaking research into the effects of antihistamine (loratadine) on bone pain.  One case report in the Practical Pain Management journal describes a 67 year old patient who was given pegfilgrastim injections and consequently experienced severe pain in her legs and feet.  Normal pain relief, including naproxen, oxycodone and hydromorphone barely touched the pain.  Finally, her doctor prescribed 10 mg of loratadine (Claritin), which she was instructed to take the day before, the day of, and for 5 days after chemotherapy. With this therapy, she experienced no leg pain or myalgia. Loratadine use continued throughout the remainder of her treatment, and the bone pain stopped. 
Loratadine, in particular, is inexpensive, is dosed once daily, and is a well-tolerated over-the-counter antihistamine. It’s non-drowsy and considered safe – but always check with your doctor first before taking.

One of our members posted in the Chemotherapy Support Group also experienced success with loratadine:  

“I too had severe bone pain after each Neulasta injection. It was so severe that only-oxycodone wouldn’t even take the edge off. After reading about it on several blogs, I decided to give Claritin a try. The results were incredible! I took it the morning of my scheduled injection and for the following 3 days that I would normally have pain.”

Other side effects of the hell shot are:

Other reported side effects include pain in your arms or legs, injection site reactions including bruising swelling, pain, redness, or a hard lump, and breathing problems – but this is rare although serious so get help immediately.

Other treatments you can try to find relief from the side effects are:

But before you do anything or take anything outside of your normal regime always check with your doctor or medical team first to make sure it’s right for you and won’t conflict with your treatment. 

If you have any questions about the Nuelasta shot – or any other brands you’ve been prescribed – join the Chemotherapy Support Group with 1000s of members, many of whom will have already been through this treatment.