Neutropenia

What is Neutropenia?

Neutropenia is an absolute neutrophil count below 1,500 per microliter of blood in adults. It is classed as mild (1,000 to 1,500), moderate (500 to 999) or severe (below 500).^[1] Neutrophils are the white blood cells that fight bacterial and fungal infections, so the lower the count, the higher the risk of serious infection.

Common symptoms

Neutropenia itself can cause no symptoms, and presentation ranges from none to severe illness needing hospital care.^[1] Problems usually show up as the infections it allows.

• Frequent or unusually severe infections of the skin, mouth or lungs
• Mouth sores or gum infections
• Fatigue or a general sense of being unwell
• Fever, which in someone with neutropenia is an emergency^[1]

Causes and risk factors

Neutropenia can be acquired or inherited. Acquired causes include chemotherapy, autoimmune neutropenia, chronic idiopathic neutropenia, blood cancers, drug reactions, infections, and shortage of vitamin B12, folate or copper. Inherited forms include cyclic neutropenia, severe congenital neutropenia and some bone marrow failure syndromes.^[1]

Chemotherapy is among the most common causes, and the risk of infection is highest when the count is lowest.^[1]

How it is diagnosed and treated conventionally

Diagnosis begins with a complete blood count, and further testing looks for the cause, including medicines, infections, nutrient levels, autoimmune disease and sometimes bone marrow or genetic tests.^[1]

Treatment depends on the cause. Acquired neutropenias are treated by addressing the underlying problem. Some patients with recurrent severe infections benefit from granulocyte colony-stimulating factor (G-CSF), and most inherited forms are treated with it.^[1] Filgrastim, a form of G-CSF, is used in people whose chemotherapy or radiation has reduced their neutrophils.^[2]

Febrile neutropenia is an oncologic emergency that needs emergent evaluation. Guidelines call for antibiotics within an hour of triage for patients with cancer, and only carefully selected low-risk patients are managed as outpatients.^{[1, 3]}

Why Neutropenia calls for a whole-person approach

Neutropenia is a finding in the blood with many possible causes, so the underlying cause shapes everything else. When it follows chemotherapy, the person is also dealing with fatigue, poor sleep, nausea, pain and worry about infection.^{[1, 4]}

Supportive care can address some of those effects. It does not replace the tests and treatments that find and manage the cause.

The underlying cause

The cause may be a drug, an infection, a nutrient shortage, an autoimmune process, a bone marrow disease or an inherited condition. Each is managed differently.^[1]

Infection risk

A low neutrophil count raises the risk of infection, which is why fever is treated as an emergency and why hygiene and early reporting of symptoms matter.^[1]

Treatment side effects and quality of life

An overview of systematic reviews of acupuncture in cancer-related conditions covered cancer-related pain, fatigue, insomnia, nausea and quality of life, as well as bone marrow suppression, although the reviews were mostly of low or very low methodological quality.^[4]

Acupuncture as supportive care in Neutropenia

What the research shows

No clinical trials of acupuncture in neutropenia from causes other than chemotherapy were found. For chemotherapy, a number of trials have looked at acupuncture for low white cell counts (leukopenia).

A 2022 meta-analysis of 15 randomized trials (1,130 patients) found that acupuncture was associated with higher white blood cell counts and less myelosuppression after chemotherapy, and recommended further research to confirm the result.^[5] A 2020 meta-analysis of 17 studies (1,206 patients) of acupuncture and moxibustion found higher white cell counts and better performance scores than with medical therapy, with trial quality rated moderate.^[6] A meta-analysis of 10 trials in 650 breast cancer patients found increases in white cell and neutrophil counts with acupuncture.^[7]

Moxibustion has been reviewed on its own. A systematic review of six trials found low-level evidence, all at high risk of bias, that it raised white cell counts more than drugs.^[8] A network meta-analysis of 30 trials (2,282 patients) compared types of moxibustion for this purpose.^[9]

These studies were done in people on chemotherapy, and the trials vary in quality; the moxibustion trials were all at high risk of bias. The result is not proven, and acupuncture should not be used instead of G-CSF or other treatment your oncology team prescribes.

How acupuncture may work

In a mouse study, electroacupuncture during cisplatin chemotherapy preserved bone marrow blood-cell production and white cell levels, through a nerve signaling pathway.^[10] This is animal research. It shows a possible mechanism, not an effect in people.

What treatment involves

Treatment uses fine, sterile, single-use needles, usually left in place for about 20 to 40 minutes. We plan a short course of visits and then reassess. Please tell the practitioner your latest blood results. Infection risk is higher when neutrophils are low, so whether and when to have treatment is best discussed with your physician or oncology team.

Serious problems from acupuncture are rare. In prospective studies, about 9 in 100 patients had a minor reaction such as brief bleeding, soreness or redness at a needle site, and serious events occurred in about 1 in 10,000 patients.^[11] Tell the practitioner first if you have a bleeding disorder or a low platelet count, take blood thinners or immune-suppressing medicines, are pregnant, or have a pacemaker (relevant to electroacupuncture).

Ayurvedic medicine as supportive care in Neutropenia

The Ayurvedic view

Ayurveda has no classical diagnosis equal to neutropenia. Traditional practitioners may describe weak resistance and repeated infections as low ojas, or reduced strength of the tissues (dhatus). This is a traditional framework, not a biomedical diagnosis.

Therapies that may be used

Once your count and cause are under medical management, supportive Ayurvedic care may include:

• Diet and daily routine aimed at regular, easily digested meals and steady sleep; because shortage of vitamin B12, folate or copper can cause neutropenia, diet is never a substitute for the blood tests your physician orders^[1]
• Gentle stress-reducing practices such as breathing exercises
• Individually prescribed herbs, chosen with attention to your medicines

Panchakarma is not appropriate: it is unsuitable during pregnancy, acute illness, frailty or while the immune system is weakened, and we do not offer it as a treatment for neutropenia.

What the research shows

There are no clinical trials of Ayurvedic treatment in people with neutropenia. The available research is in animals. In mice given the chemotherapy drug paclitaxel, extracts of shatavari (Asparagus racemosus) and ashwagandha (Withania somnifera) were associated with white cell and neutrophil counts staying closer to normal.^[12] Findings in mice do not show that these herbs help people, and no dose or product is supported by this work.

Herbal medicine as supportive care in Neutropenia

Herbs and formulas that have been studied

The human research concerns Chinese herbal medicine added to chemotherapy to treat low white cell counts. The formulas studied were varied and prescribed according to Chinese medicine pattern diagnosis.^[13]

What the research shows

A meta-analysis of 14 higher-quality trials (1,053 patients) found that Chinese herbal medicine plus chemotherapy was associated with higher white cell, neutrophil, hemoglobin and platelet counts than chemotherapy alone. It did not reduce the amount of G-CSF used, and when compared with placebo plus chemotherapy there was no significant difference in the rate of neutropenia. No severe adverse events were reported, but the authors called for larger, better trials.^[13]

These results apply to chemotherapy-induced low counts only. They do not show that herbs treat neutropenia from other causes.

Safety and herb-drug interactions

Herbs are active substances. They can interact with chemotherapy, immune-suppressing drugs and blood thinners, and some can affect the blood count or liver. Case reports describe herbs such as St John's wort lowering blood levels of ciclosporin and tacrolimus, and ginkgo, garlic and danshen affecting bleeding or clotting with warfarin or aspirin.^[14] Herbal and dietary supplements account for about one fifth of drug-induced liver injury cases in the United States.^[15]

About one fifth of Ayurvedic medicines bought online contained detectable lead, mercury or arsenic.^[16] Herbs should come from tested sources and be prescribed individually. Tell us if you are pregnant or breastfeeding, or have liver or kidney disease. If you are in cancer treatment, do not start any herb without your oncologist's approval.

Translating traditional medicine into modern biological language

This is interpretation, not equivalence. Chinese medicine may describe the weakness and fatigue after chemotherapy as deficiency of qi, blood or the spleen and kidney. The nearest biological idea is suppression of the bone marrow that makes blood cells, which researchers have studied in relation to acupuncture in animals.^[10]

Ayurveda's low ojas describes reduced resistance in general terms. No study has shown that it corresponds to a specific neutrophil process.

How this care fits with your medical care

Neutropenia needs a physician's evaluation to find its cause. For a condition like this, we ask that you are under a physician's care for it and that your treating team knows you are receiving complementary care. Our role is limited to supportive care for fatigue, stress, sleep and treatment side effects.

Do not stop or change chemotherapy, G-CSF, steroids, antibiotics or any prescribed treatment without your prescriber. We do not diagnose or manage the disease itself. Please bring your diagnosis, your latest blood counts, and a full list of medicines and supplements.

When to seek urgent medical care

Fever or signs of infection in someone with neutropenia is an emergency.^[1]

• A temperature of 100.4°F (38°C) or higher, or chills
• Sore throat, cough, shortness of breath or burning with urination
• A new mouth sore, skin infection, or redness, swelling or pus around a wound or catheter
• Severe diarrhea or abdominal pain
• Feeling suddenly very weak, dizzy or confused

If any of these occur, call 911 or go to the nearest emergency department, and tell the staff that you have neutropenia.