DERBY-BURTON LOCAL CANCER NETWORK FILENAME ESHAP.DOC CONTROLLED DOC NO: HCCPG B44. ESHAP Regimen

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1 ESHAP Regimen Available for Routine Use in Burton in-patient Derby in-patient Burton day-case Derby day-case Burton community Derby community Burton out-patient Derby out-patient Indication Relapsed/ refractory lymphoma, multiple myeloma Treatment Intent Salvage or stem cell mobilisation (When IVE is contra-indicated or failure to mobilise with high dose Cyclophosphamide ) Anti-Emetics Pre-chemotherapy 3 (but no Dex premed) Post-chemotherapy C Frequency & Duration Every 21 days (or upon recovery of bone marrow) for 2 to 4 cycles Day 1 Urine output must be >100ml/hr before 6 0.9% 0.9% 1000ml Intravenous infusion over 2 (Via Line 1) 500ml Intravenous infusion over 30 (if urine output remains below 100 ml/hr) (Via Line 1) Ondansetron 8mg Oral or intravenous bolus as a (Via Line 1) filter over 24 (Via Line 1). 1000ml Intravenous infusion over 19 REVIEWED BY: K.Graham AUTHORISED BY: Dr J Addada PAGE 1 of 6

2 Aciclovir 400mg Oral twice daily for 21 days Omeprazole 20mg Oral once daily for 21 days Allopurinol 300mg Oral once daily for 1-2 cycles Cotrimoxazole 480mg Oral once daily for 21 days Fluconazole 100mg Oral once daily until neutrophils>1x10 9 /l Metoclopramide 10-20mg Oral four times daily for 4 days, then as required Day 2 Ondansetron 8mg Oral or intravenous bolus as a filter over 24 (Via Line 1) ml Intravenous infusion over 22 Day 3 Ondansetron 8mg Oral or intravenous bolus as a filter over 24 (Via Line 1) REVIEWED BY: K.Graham AUTHORISED BY: Dr J Addada PAGE 2 of 6

3 ml Intravenous infusion over 22 Day 4 Ondansetron 8mg Oral or intravenous bolus as a filter over 24 (Via Line 1) 6. Prednisolone (Predsol 0.5%) 1000ml Intravenous infusion over 22 1 drop Eye drops 4 times daily in each eye for 7 days Day 5 Ondansetron 8mg Oral or intravenous bolus as a REVIEWED BY: K.Graham AUTHORISED BY: Dr J Addada PAGE 3 of 6

4 Cytarabine 2000mg/m 2 Intravenous infusion in 500ml sodium chloride 0.9% over 3 0.9% + 20 mmol 1000ml Intravenous infusion over ml Intravenous infusion over 8 Day 6 Dexamethasone 4mg Oral twice daily for 2 days (Day 6) Stem cell mobilisation patients only G-CSF (Lenograstim ) 263 micrograms (BSA <1.8m 2 ) Or 368 micrograms (BSA >1.8m 2 ) Subcutaneous injection ONCE daily until adequate stem cell harvest Day 7 Filgrastim biosimilar 300micrograms Subcutaneous injection ONCE daily until neutrophils > 1x10 9 /l (supply 7 doses) Day 8 Dexamethasone 2mg Oral twice daily for 2 days Notes: For mobilising cycles of ESHAP, GCSF is commenced on day 6 and continued daily until adequate stem cells have been collected. Stem cells are harvested on day 15 provided the WCC exceeds 1 x 10 9 /l. Baseline investigations The 24 hour creatinine clearance prior to the first treatment should be > 40 ml/minute. Repeat 24 hour urine collections should be performed prior to each subsequent cycle to ensure a creatinine clearance of > 40 ml/minute. Dose modifications and toxicities 1. Haematological toxicity At the start of each cycle the neutrophil count should be > 1.0 x 10 9 /l and platelets > 100 x 10 9 /l unless cytopenias are considered to be disease-related. REVIEWED BY: K.Graham AUTHORISED BY: Dr J Addada PAGE 4 of 6

5 1. Renal impairment Cisplatin GFR ml/min Cisplatin Dose >60 100% % <40% Omit Cytarabine GFR ml/min Cytarabine Dose % % % 30 Omit Etoposide GFR ml/min Etoposide Dose >50 100% % <15 50% 2. Hepatic impairment Etoposide Bilirubin AST/ALT micromol/l IU/L Dose % >51 >180 omit Supportive care 1. Urine output should be maintained at > 100 ml/hour before (for at least 1 hour), during and chemotherapy (24 ). Accurate fluid balance must be kept. Mannitol 10% infusion is the preferred diuretic. If urine output remains <100ml/hr, a further dose of 100ml may be given by intravenous infusion over 10. Urine output should increase within 30 of commencing the infusion. If urine output remains <100ml/hr 30, a 10 mg stat IV bolus of furosemide may be given to increase urine output. If 30 the furosemide dose urine output has still not improved, the Consultant should be contacted for advice. 2. It is advisable to give allopurinol (300mg) once a day for the first 1 or 2 courses of therapy whilst there is bulky disease. Reduce dose to 100mg daily if GFR <10mls/min. REVIEWED BY: K.Graham AUTHORISED BY: Dr J Addada PAGE 5 of 6

6 3. All patients should receive Pneumocystis jirovecii prophylaxis throughout treatment: Co-trimoxazole 480mg ONCE daily. In cases of allergy to co-trimoxazole, consider dapsone 100mg daily. 4. Antifungal prophylaxis with Fluconazole 100mg daily until neutrophils >1x10 9 /l 5. Omeprazole 20mg once daily. 6. Aciclovir 400mg twice daily. References 1. Velasquez W.S. et al.; ESHAP An effective chemotherapy regimen in refractory and relapsing lymphoma: A 4-year follow-up study; J. Clin. Oncol.; 1994; 12 (6): REVIEWED BY: K.Graham AUTHORISED BY: Dr J Addada PAGE 6 of 6