Standard Regimens for Haematology

Size: px

Start display at page:

Download "Standard Regimens for Haematology"

Godfrey Nichols
6 years ago
Views:

1 Regimens for Haematology ChlVPP Chlorambucil 6mg/m 2 PO D1 to 14 Vinblastine 6mg/m 2 (max 10mg) IV on D1 & 8 Procarbazine 100mg/m 2 PO on D1 to 14 Prednisolone 40mg PO D1 to 14 ABVD Doxorubicin 25mg/m 2 IV on D1 & 15 Bleomycin 10,000iu/m 2 IV on D1 & 15 Vinblastine 6mg/m 2 (max 10mg) IV on D1 & 15 Dacarbazine 375mg/m 2 IV on D1 & 15 VEPEMB Vinblastine 6mg/m 2 (max 10mg) IV on D1 Cyclophosphamide500mg/m 2 IV D1 Procarbazine 100mg/m 2 po D1 to 5 Etoposide 60mg/m 2 po D15 to 19 Mitoxantrone 6mg/m 2 IV D15 Bleomycin 10,000iu/m 2 IV D15 Mini-BEAM Carmustine 60mg/m 2 IV D1 Etoposide 75mg/m 2 IV D2 to 5 Cytarabine 100mg/m 2 IV BD D2 to 5 Melphalan 30mg/m 2 IV D6 R-CVP Cyclophosphomide 750mg/m 2 IV D1 Prednisolone 40mg/m 2 PO D1 to 5 Rituximab (Maintenance) CVP Prednisolone 40mg/m 2 PO D1 to 5 4/52 Cycle HD 4/52 Cycle 4/52 Cycle HD Hodgkin s Lymphoma first line. Early stage favourable disease 2 cycles followed by RT. Early stage unfavourable disease 4 cycles followed by RT. Stage 3 or 4 or bulky disease 6 to 8 cycles may be followed by RT. Option for elderly pts unsuitable for ABVD 4/52 Cycle HD 12/52 cycles x 8 8/52 cycles x 12 (Follicular) Symptomatic Stage III/IV First Line option, and at first relapse (or at second relapse if not offered maintenance R at first relapse). (follicular) After induction therapy at first relapse (or second relapse if not offered at first relapse) (Follicular) after first line induction therapy. Low Grade Page 1 of 8 Historic standard. Cycle details updated at NSSG 17 th Oct NICE approval for first line use renewed Jan 2012 (TA243) / approved July for re-induction February 2008 (TA137) / approved October February 2008 (TA137) / approved October June 2011 (TA226) / approved Sept 2011

2 Rituximab (Single agent), 8, 15 & 21 CHOP Doxorubicin 50mg/m 2 IV D1 Prednisolone 100mg PO D1 to 5 RCHOP Doxorubicin 50mg/m 2 IV D1 Prednisolone 100mg PO D1 to 5 CEOP Etoposide 50mg/m 2 IV D1* then 100mg/m 2 PO D2 & 3. Prednisolone 100mg PO D1 to 5 (*D1 etoposide may also be given as PO 100mg/m 2 at Consultants discretion) R-CEOP Etoposide 50mg/m 2 IV D1* then 100mg/m 2 PO D2 & 3. Prednisolone 100mg PO D1 to 5 (*D1 etoposide may also be given as PO 100mg/m 2 at Consultants discretion) CODOX-M/IVAC CODOX-M Cyclophosphamide 800mg/m 2 IV IV D1 Doxorubicin 40mg/m 2 IV D1 Vincristine 1.5mg/m 2 (max 2mg) IV D1 & D8 Cytarabine 70mg IT D1&3 Cyclophosphamide 200mg/m 2 IV D2-D5 Methotrexate 3g/m 2 IV D10 Methotrexate 12.5mg IT D15 IVAC Etoposide 60mg/m 2 IV D1-D5 Ifosfamide (&mesna) 1500mg/m 2 IVD1-D5 Cytarabine 2000mg/m 2 IV BD D1-D2 Methotrexate 12.5mg IT D5 IMVP16 Ifosfamide 1g/m 2 IV D1 to 5 Mesna 1g/m 2 IV D1 to 5 Methotrexate 30mg/m 2 IV D3 & 10 Etoposide 100mg/m 2 IV D1 to 3 Single cycle On marow recovery (usually N>1; Plt>75) Administer 2 alternating cycles of each regimen. (follicular) Last line High Grade Diffuse Large B-cell Lymphoma 1 st line for Stages II-IV. Follicular Lymphoma 1 st line alternative to RCVP for symptomatic Stage III & IV High Grade Alternative to CHOP for relapsed patients who cannot tolerate anthracyclines. Diffuse large B-cell Lymphoma Alternative to R-CHOP for patients who cannot tolerate anthracyclines. First line for Burkitts Lymphoma or Burkitt-like Lymphoma. Relapsed NICE approval renewed Feb 2008 (TA137). Sept 2003 (TA65) Jan 2012 (TA243) approved July approved July approved September Page 2 of 8

3 PMitCEBO Prednisolone 50mg/day week 1 to 4, then 50mg alt days weeks 5 to end. Mitoxantrone 7mg/m 2 IV D1 Cyclophosphamide 300mg/m 2 IV D1 Etoposide 150mg/m 2 IV D1 Vincristine 1.4mg/m 2 (max 2mg) IV D8 Bleomycin 10,000iu/m 2 IV D8 Etoposide p.o. a) 25-50mg/m 2 PO D1 to 21 b) mg PO for 3 to 10 days ESHAP Etoposide 40mg/m 2 IV D1 to 4 Cisplatin 25mg/m 2 24 hour IV D1 to 4 Methylprednisolone 500mg IV D1 to 5 Cytarabine 2g/m 2 IV D1 or 5 (reduce Cytarabine to 1g/m 2 if >70 yrs) High Dose Methotrexate Methotrexte 3g/m 2 IV Ibritumomab (RIT) Rituximab 250mg/m 2 IV D1 + 8 Ibritumomab 11-15*MBq/kg IV D8 *max 1200MBq Chlorambucil Intermittent: 10mg PO for 7 14 days or 30mg PO for 3-4 days : 2 8mg/day PO Rituximab+Chlorambucil Chlorambucil 10mg/ m 2 PO D1 to 7 Bendamustine Bendamustine 100mg/m 2 IV Inf D1+2 FCR PO Rituximab 500*mg/m 2 Inf D1 Cyclophosphamide 150mg/m 2 PO (breakfast) D1 to 5 Fludarabine 25mg/m 2 PO (mid-day) D1 to 5 *1 st cycle 375mg/m 2. ** Fludarabine is given 4hrs after cyclo. 2/52 Cycle Relapsed a) 4-5/52 Cycle b) PRN Salvage regimen for elderly patients 3-4/52 Cycle 4/52 Cycle Single Treatment High grade with cerebral involvement (rituximab relapsed / refractory) 4/52 (intermittent) CLL 4/52 cycle 4/52 cycle 4/52 cycle (max 6) ( approved Sept 07 available for 5 pts per annum) (Follicular) Symptomatic Stage III/IV First Line alternative to RCVP. Max 6 cycles of Rituximab. CLL 1 st line option for Binet stage B or C, in patients for whom FCR chemotherapy is not appropriate. CLL First line or in relapsed/refractory patients who are not fludarabine refractory and who have not previously received rituximab. Suitable for patients with CrCl>30ml/min and without significant co-morbidities. Jan 2012 (TA243) / approved July Regimen details agreed NSSG 17 th Oct Feb approved Mar st line NICE approved and approved Nov nd line NICE approved and approved Nov 2010 Page 3 of 8

4 FCR IV Rituximab 500*mg/m 2 Inf D1 Cyclophosphamide 250mg/m 2 IV D1 to 3 Fludarabine** 25mg/m 2 IV D1 to 3 *1 st cycle 375mg/m 2. ** Fludarabine is given 4hrs after cyclo. Fludarabine Intravenous 25mg/m 2 (max 50 mg) IV D1 to 5 Oral 40mg/m 2 (max 80mg) PO D1 to 5 Fludarabine-Cyclophosphamide Intravenous Cyclophosphamide 250mg/m 2 IV D1 to 3 Fludarabine 25mg/m 2 IV (4hr later) D1 to 3 Oral Cyclophosphamide 150mg/m 2 PO (breakfast) D1 to 5 Fludarabine 25mg/m 2 PO (mid-day) D1 to 5 Alemtuzumab Alemtuzumab 30mg* SC D1, 3 & 5 * 3mg D1, 10mg D2, 30mg D3 & 5 in week 1 4/52 cycle (max 6) 4/52 Cycle 4/52 Cycle 1/52 cycle (max 18) CLL First line or in relapsed/refractory patients who are not fludarabine refractory and who have not previously received rituximab. Suitable for patients with CrCl>30ml/min and without significant co-morbidities. B-CLL Second line B-CLL Second line (Needs funding) (single agent) (Needs funding) B-CLL 1 st line in pts with p53 abnormality. 2 nd line for pts within defined criteria (low beta2 microglobulin, platelets > 50, < 3cm lymphadenopathy, < 3 prior s, < 65yrs and good PS all indicative of good response). T-PLL 1 st line use. Must be discussed with RMH. One cycle funded. Need PCT approval for subsequent doses. 1 st line NICE approved and approved Nov nd line NICE approved and approved Nov 2010 approved Oct st line use. 2 nd line criteria agreed March 2010 (but no funding agreed therefore only). Funding restrictions not applicable whilst available on compassionate use programme Oct Page 4 of 8

5 Alemtuzumab/MethyPred (CAMPRED) Alemtuzumab 30mg* SC/IV** D1,3,5,8,10,12,15,17,19,22,24,26 Methylprednisolone 1g IV D1 to 5 * 3mg D1, 10mg D2 in cycle 1 only. ** IV for cycle 1 only, then SC. Cladribine 0.1mg/kg 2hr or 24 hr IV or SC D1 to 7 OR 0.14mg/kg 2hr IV or SC D1 to 5 OR 0.15mg/kg 2hr IV or SC weekly for 6 weeks Deoxycoformycin (Pentostatin) Deoxycoformycin 4mg/m 2 IV 5 minutes UKALL 14 As per MRC trial protocol AML 17 arm as per protocol AML 16 (intensive) arm as per protocol PETHEMA Maintenance Protocol Mercaptopurine 50mg/m 2 OD PO continuously starting D1 (omit during ATRA days) Methotrexate 15mg/m 2 weekly PO starting D28 (omit during ATRA days) ATRA 45mg/m 2 /day PO split BD D1 to 15 every 3 months starting D112. 4/52 cycle (max 4) Single course B-CLL Pts with bulky lymphadenopathy (>5cm diameter) or massive splenomegaly. 1 st line in pts with p53 abnormality. 2 nd line for pts within defined criteria (low beta2 microglobulin, platelets > 50, < 3cm lymphadenopathy, < 3 prior s, < 65yrs and good PS all indicative of good response). HCL 2/52 Cycle HCL / Named Patient (Unfunded) / (Unfunded) Refer to protocol ALL Refer to protocol Refer to protocol AML and APML patients (most suitable for patients <60yrs or older fit patients with no co-morbidities). AML and APML patients (most suitable for patients >60yrs). 2 years High risk APML approved Oct st line use. 2 nd line criteria agreed March 2010 (but no funding agreed therefore only). Funding restrictions not applicable whilst available on compassionate use programme Oct arm of trial is standard outside of trial. arm of trial is standard outside of trial. As per AML 15 results. 400mg 1 st line for chronic phase. NICE approval renewed April 2012 (TA251). Imatinib Imatinib mg/day PO CML 600mg for accelerated phase and blast crisis (not previously treated in chronic phase). Page 5 of 8 Oct 2003 (TA70)

6 400mg 2 nd line chronic phase resistant/intolerant to nilotinib Nilotinib Nilotinib mg PO BD Interferon Interferon 3mu SC thrice weekly titrated to response Busulfan 2-4mg PO OD or STAT doses of mg PO Hydroxyurea 0.5 2g OD PO titrated to response Anagrelide Anagrelide 0.5 3mg/day PO titrated to response SC Cytarabine Cytarabine 20mg SC BD D1-10 Azacitidine Azacitidine 75mg/m 2 SC OD D1-7* *Can be given Days 1-5 & 8-9 to avoid weekend administration. Melphalan Melphalan 7mg/m 2 PO for 4 days or 10mg PO OD for 5 to 10 days or 30mg/m 2 IV D1 MPT Melphalan 4mg/m 2 PO D1-7 Prednisolone 40mg/m 2 PO D1-7 Thalidomide 100mg PO ON D1 28 (cont) C-weekly Cyclophosphamide 400mg/m 2 PO once weekly (or mg/m 2 IV weekly, maximum 500mg) (Prednisolone 40mg PO alt days first 6/52 then tailed for 2/52) Thalidomide (Single agent) Thalidomide mg PO OD titrated to response CML CML/MPD Young/Pregnant patients 600mg 2 nd line accelerated phase resistant or intolerant to nilotinib (given in chronic phase). 300mg 1 st line alternative to imatinib in chronic phase 400mg 2 nd line for chronic and accelerated phases for imatinib intolerant or resistant patients. CML/MPD CML/MPD CML/MPD ( approved Sept 07) 4 6/52 AML/MDS 3/52 cycle 4-6/52 Cycle 4/52 cycles AML/MDS first line as per licence / NICE guidance Not suitable for thalidomide. 1 st line elderly Page 6 of 8 approved October 2012 April 2012 (TA251) with PAS. Needs to go to. Jan 2012 (TA241) with PAS. approved March March 2011 approved May 2011 ( approved April 08) 1/52 Cycle Relapsed / Refractory

7 CThalDex Cyclophosphamide 500mg po days 1, 8, 15 Thalidomide 200*mg/day PO D1 to 21 Dexamethasone 40mg od po days 1-4 & /52 1 st line for good PS ( approved April 08) *Thalidomide 100mg/day cycle 1 CThalDex (attenuated) Cyclophosphamide 500mg PO D1, 8, 15 & 22 Thalidomide 50*mg/day PO D1-28 (cycle 1) Dexamethasone 20mg od po days 1-4 & 15 to 18 4/52 1 st line for poorer PS ( approved April 08) Thalidomide 100mg/day (cycle 2), 150mg/day (cycle 3) & 200mg/day (cycle 4 onward). Bortezomib+MP (VMP) Bortezomib 1.3mg/m 2 SC (or IV) D1, 4, 8 & 11, 22,25,29 & 32 (reduced to D1,8,22 & 29 in cycles 5 to 9). Melphalan 9mg/m 2 PO OD D1-4 Prednisolone 60mg/m 2 PO OD D1-4 Bortezomib Bortezomib 1.3mg/m 2 SC (or IV) D1, 4, 8 & 11 Dexamethasone 40*mg PO D1, 2, 4, 5, 8, 9, 11 & 12 *Dex dose reduced to 20mg in elderly or poor PS. BortezomibWeekly Bortezomib 1.3mg/m 2 SC (or IV) D1, 8, 15 & 22 Dexamethasone 40*mg PO D1, 2, 8, 9, 15, 16, 22 & 23 *Dex dose reduced to 20mg in elderly or poor PS. LenDex Lenalidomide 25mg PO OD D1-21 Dexamethasone 40mg PO OD D HIGH DOSE THERAPY Melphalan mg/m 2 IV D1 BEAM Carmustine 300mg/m 2 IV D-6 Etoposide 200mg/m 2 IV D -5, -4, -3 & -2 Cytarabine 200mg/m 2 IV BD D -5, -4, -3 & - 2 Melphalan 140mg/m 2 IV on D -1 Etoposide Mobilisation Etoposide g/m 2 IV D1 GCSF 10mcg/kg daily IV/SC until harvest 6/52 for up to 9 cycles. 3/52 5/52 4/52 First line use in patients not suitable for SCT and in whom thalidomide is contraindicated. IV route only to be used in patients unable to tolerate SC. regimen for second or subsequent line. Cases must be agreed at MDT. IV route only to be used in patients unable to tolerate SC. Alternative regimen for second or subsequent line. Unlicensed but better tolerated vs standard regimen. Cases must be agreed at MDT. IV route only to be used in patients unable to tolerate SC. Third or subsequent line. Cases must be agreed at MDT. One Cycle One Cycle Lymphoma One Cycle Stem Cell Mobilisation July 2011 / approved Sept SC route approved by Nov NICE approved. SC route approved by Nov approved variant on regimen Nov Page 7 of 8

8 Cyclophosphamide Mobilisation Cyclophosphamide g/m 2 GCSF 5mcg/kg (to nearest whole vial) daily IV/SC until harvest INTRATHECAL CHEMOTHERAPY IT Methotrexate Methotrexate mg IT +/- Hydrocortisone mg IT IT Cytarabine Cytarabine 50mg IT IT Triple Therapy Hydrocortisone mg IT Cytarabine 50mg IT Methotrexate mg IT Up to thrice weekly Up to thrice weekly Up to thrice weekly Stem Cell Mobilisation High grade lymphoma, ALL, AML prophylaxis. Burkitts Lymphoma prophylaxis. High grade lymphoma in patients unsuitable for methotrexate. For proven CNS disease in high grade lymphoma, Burkitts, ALL, AML or myeloma. Page 8 of 8

Emetogenicity level 1. Emetogenicity level 2

Emetogenicity level 1. Emetogenicity level 2 Emetogenicity level 1 15 mins Pre-Chemo Maxalon 10mg po During chemo and Post Chemo 3 days Maxalon10mg po 8 hourly Increase Maxalon 20mg po 8 hourly Change to Cyclizine 50mg po 8 hourly 3 days If nausea