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Home > LEU ALL precursor B-cell - UKALL14 with RITUximab [over 40 years] [not for transplant] > LEU - UKALL14 with RITUximab [not for transplant] Maintenance

This regimen is a component of LEU ALL precursor B-cell - UKALL14 with RITUximab [over 40 years] [not for transplant]

UKALL14 with RITUximab [over 40 years] [not for transplant] - Maintenance (LEU ALL precursor B-cell - UKALL14 with RITUximab [over 40 years] [not for transplant])

Treatment Overview

NOT to be used for transplant patients.

Starts after count recovery from Consolidation Cycle 4, with neutrophils greater than 0.75 x 10⁹/L and platelets greater than 75 x 10⁹/L.

Dosing of maintenance therapy should be adjusted to maintain:

Neutrophil count between 0.75 and 1.5 x 10⁹/L.
Platelet count between 75 and 150 x 10⁹/L.

This regimen contains a medicine where one or more biosimilars may exist. Any biosimilars used have been reviewed by the regulator (Medsafe) and relevant specialists were consulted nationally. Where regulators, in consultation with relevant specialists, have agreed that there are no clinically significant differences in either safety or effectiveness between a biosimilar and originator product, these drugs may be used interchangeably.

Cycle 1 - 84 days - Includes RITUximab days 1 and 57

Cycle length:

Intrathecal metHOTREXATe:

May be administered during Maintenance if neutrophils greater than 0.75 x 10⁹/L and platelets greater than 75 x 10⁹/L.
For Ommaya reservoir reduce dose to 6 mg intraventricularly.

mercaptOPURine:

Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L.
Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Oral metHOTREXATe:

Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L.
Avoid trimethoprim + sulfamethoxazole on the days oral metHOTREXATe is administered.

RITUximab, Day 57: Consider administering corticosteroid premedication prior to RITUximab if previous doses not well tolerated or if clinically indicated as per institutional practice.

Cycle 2 - 84 days - Includes RITUximab day 29

Cycle length:

Intrathecal metHOTREXATe:

May be administered during Maintenance if neutrophils greater than 0.75 x 10⁹/L and platelets greater than 75 x 10⁹/L.
For Ommaya reservoir reduce dose to 6 mg intraventricularly.

mercaptOPURine:

Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L.
Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Oral metHOTREXATe:

Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L.
Avoid trimethoprim + sulfamethoxazole on the days oral metHOTREXATe is administered.

RITUximab: Consider administering corticosteroid premedication prior to RITUximab if previous doses not well tolerated or if clinically indicated as per institutional practice.

Cycle 3 - 84 days - Includes RITUximab days 1 and 57

Cycle length:

Intrathecal metHOTREXATe:

May be administered during Maintenance if neutrophils greater than 0.75 x 10⁹/L and platelets greater than 75 x 10⁹/L.
For Ommaya reservoir reduce dose to 6 mg intraventricularly.

mercaptOPURine:

Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L.
Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Oral metHOTREXATe:

Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L.
Avoid trimethoprim + sulfamethoxazole on the days oral metHOTREXATe is administered.

RITUximab, Day 57: Consider administering corticosteroid premedication prior to RITUximab if previous doses not well tolerated or if clinically indicated as per institutional practice.

Cycle 4 - 84 days - Includes RITUximab day 29

Cycle length:

Intrathecal metHOTREXATe:

May be administered during Maintenance if neutrophils greater than 0.75 x 10⁹/L and platelets greater than 75 x 10⁹/L.
For Ommaya reservoir reduce dose to 6 mg intraventricularly.

mercaptOPURine:

Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L.
Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Oral metHOTREXATe:

Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L.
Avoid trimethoprim + sulfamethoxazole on the days oral metHOTREXATe is administered.

RITUximab: Consider administering corticosteroid premedication prior to RITUximab if previous doses not well tolerated or if clinically indicated as per institutional practice.

Cycles 5 to 8 - 84 days

Cycle length:

Intrathecal metHOTREXATe:

May be administered during Maintenance if neutrophils greater than 0.75 x 10⁹/L and platelets greater than 75 x 10⁹/L.
For Ommaya reservoir reduce dose to 6 mg intraventricularly.

mercaptOPURine:

Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L.
Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Oral metHOTREXATe:

Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L.
Avoid trimethoprim + sulfamethoxazole on the days oral metHOTREXATe is administered.

Cycle details

Cycle 1 - 84 days - Includes RITUximab days 1 and 57

Medication	Dose	Route	Days	Max Duration
metHOTREXATe	12 mg flat dosing	intrathecal injection	1
vinCRISTine	1.4 mg/m² Cap dose per administration at: 2 mg	intravenous	1	10 minutes
prEDNISone	60 mg/m² Once daily	oral administration	1 to 5
mercaptOPURine	75 mg/m² Once daily	oral administration	1 to 84
metHOTREXATe	20 mg/m² Once a week	oral administration	1, 8, 15, 22, 29, 36, 43, 50, 57, 64, 71, 78
paracetamol *	1000 mg flat dosing	oral administration	1, 57
loratadine *	10 mg	oral administration	1, 57
RITUximab *	375 mg/m²	intravenous	1, 57	6 hours

Intrathecal metHOTREXATe:

May be administered during Maintenance if neutrophils greater than 0.75 x 10⁹/L and platelets greater than 75 x 10⁹/L.
For Ommaya reservoir reduce dose to 6 mg intraventricularly.

mercaptOPURine:

Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L.
Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Oral metHOTREXATe:

Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L.
Avoid trimethoprim + sulfamethoxazole on the days oral metHOTREXATe is administered.

RITUximab, Day 57: Consider administering corticosteroid premedication prior to RITUximab if previous doses not well tolerated or if clinically indicated as per institutional practice.

Cycle 2 - 84 days - Includes RITUximab day 29

Medication	Dose	Route	Days	Max Duration
metHOTREXATe	12 mg flat dosing	intrathecal injection	1
vinCRISTine	1.4 mg/m² Cap dose per administration at: 2 mg	intravenous	1	10 minutes
prEDNISone	60 mg/m² Once daily	oral administration	1 to 5
mercaptOPURine	75 mg/m² Once daily	oral administration	1 to 84
metHOTREXATe	20 mg/m² Once a week	oral administration	1, 8, 15, 22, 29, 36, 43, 50, 57, 64, 71, 78
paracetamol *	1000 mg flat dosing	oral administration	29
loratadine *	10 mg	oral administration	29
RITUximab *	375 mg/m²	intravenous	29	6 hours

Intrathecal metHOTREXATe:

May be administered during Maintenance if neutrophils greater than 0.75 x 10⁹/L and platelets greater than 75 x 10⁹/L.
For Ommaya reservoir reduce dose to 6 mg intraventricularly.

mercaptOPURine:

Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L.
Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Oral metHOTREXATe:

Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L.
Avoid trimethoprim + sulfamethoxazole on the days oral metHOTREXATe is administered.

RITUximab: Consider administering corticosteroid premedication prior to RITUximab if previous doses not well tolerated or if clinically indicated as per institutional practice.

Cycle 3 - 84 days - Includes RITUximab days 1 and 57

Medication	Dose	Route	Days	Max Duration
metHOTREXATe	12 mg flat dosing	intrathecal injection	1
vinCRISTine	1.4 mg/m² Cap dose per administration at: 2 mg	intravenous	1	10 minutes
prEDNISone	60 mg/m² Once daily	oral administration	1 to 5
mercaptOPURine	75 mg/m² Once daily	oral administration	1 to 84
metHOTREXATe	20 mg/m² Once a week	oral administration	1, 8, 15, 22, 29, 36, 43, 50, 57, 64, 71, 78
paracetamol *	1000 mg flat dosing	oral administration	1, 57
loratadine *	10 mg	oral administration	1, 57
RITUximab *	375 mg/m²	intravenous	1, 57	6 hours

Intrathecal metHOTREXATe:

May be administered during Maintenance if neutrophils greater than 0.75 x 10⁹/L and platelets greater than 75 x 10⁹/L.
For Ommaya reservoir reduce dose to 6 mg intraventricularly.

mercaptOPURine:

Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L.
Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Oral metHOTREXATe:

Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L.
Avoid trimethoprim + sulfamethoxazole on the days oral metHOTREXATe is administered.

RITUximab, Day 57: Consider administering corticosteroid premedication prior to RITUximab if previous doses not well tolerated or if clinically indicated as per institutional practice.

Cycle 4 - 84 days - Includes RITUximab day 29

Medication	Dose	Route	Days	Max Duration
metHOTREXATe	12 mg flat dosing	intrathecal injection	1
vinCRISTine	1.4 mg/m² Cap dose per administration at: 2 mg	intravenous	1	10 minutes
prEDNISone	60 mg/m² Once daily	oral administration	1 to 5
mercaptOPURine	75 mg/m² Once daily	oral administration	1 to 84
metHOTREXATe	20 mg/m² Once a week	oral administration	1, 8, 15, 22, 29, 36, 43, 50, 57, 64, 71, 78
paracetamol *	1000 mg flat dosing	oral administration	29
loratadine *	10 mg	oral administration	29
RITUximab *	375 mg/m²	intravenous	29	6 hours

Intrathecal metHOTREXATe:

May be administered during Maintenance if neutrophils greater than 0.75 x 10⁹/L and platelets greater than 75 x 10⁹/L.
For Ommaya reservoir reduce dose to 6 mg intraventricularly.

mercaptOPURine:

Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L.
Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Oral metHOTREXATe:

Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L.
Avoid trimethoprim + sulfamethoxazole on the days oral metHOTREXATe is administered.

RITUximab: Consider administering corticosteroid premedication prior to RITUximab if previous doses not well tolerated or if clinically indicated as per institutional practice.

Cycles 5 to 8 - 84 days

Medication	Dose	Route	Days	Max Duration
metHOTREXATe	12 mg flat dosing	intrathecal injection	1
vinCRISTine	1.4 mg/m² Cap dose per administration at: 2 mg	intravenous	1	10 minutes
prEDNISone	60 mg/m² Once daily	oral administration	1 to 5
mercaptOPURine	75 mg/m² Once daily	oral administration	1 to 84
metHOTREXATe	20 mg/m² Once a week	oral administration	1, 8, 15, 22, 29, 36, 43, 50, 57, 64, 71, 78

Intrathecal metHOTREXATe:

May be administered during Maintenance if neutrophils greater than 0.75 x 10⁹/L and platelets greater than 75 x 10⁹/L.
For Ommaya reservoir reduce dose to 6 mg intraventricularly.

mercaptOPURine:

Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L.
Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Oral metHOTREXATe:

Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L.
Avoid trimethoprim + sulfamethoxazole on the days oral metHOTREXATe is administered.

Full details

Cycle 1 - 84 days - Includes RITUximab days 1 and 57

Day: 1

Medication	Dose	Route	Max duration	Details
metHOTREXATe	12 mg flat dosing	intrathecal injection		Instructions: May be administered during Maintenance if neutrophils > 0.75 x 10⁹/L and platelets > 75 x 10⁹/L. Adhere to local institution policy for intrathecal administration. For Ommaya reservoir reduce dose to 6 mg intraventricularly.
vinCRISTine	1.4 mg/m² Cap dose per administration at: 2 mg	intravenous	10 minutes	Instructions: Diluted in a minibag. FOR INTRAVENOUS USE ONLY – fatal if given by any other routes. Warning vesicant—ensure vein is patent prior to administration, administer vesicant as per institutional policy and monitor for signs of extravasation throughout administration.
prEDNISone	60 mg/m² Once daily	oral administration		Instructions: Take in the morning with food, at least 30 to 60 minutes prior to RITUximab.
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.
paracetamol *	1000 mg flat dosing	oral administration		Instructions: 30 to 60 minutes prior to RITUximab.
loratadine *	10 mg	oral administration		Instructions: 30 to 60 minutes prior to RITUximab.
RITUximab *	375 mg/m²	intravenous	6 hours	Instructions: Start infusion at 100 mg/hour. If tolerated, rate can be increased by 100 mg/hour every 30 minutes to a maximum rate of 400 mg/hour, or as per institutional practice.

Day: 2

Medication	Dose	Route	Max duration	Details
prEDNISone	60 mg/m² Once daily	oral administration		Instructions: Take in the morning with food.
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 3

Medication	Dose	Route	Max duration	Details
prEDNISone	60 mg/m² Once daily	oral administration		Instructions: Take in the morning with food.
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 4

Medication	Dose	Route	Max duration	Details
prEDNISone	60 mg/m² Once daily	oral administration		Instructions: Take in the morning with food.
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 5

Medication	Dose	Route	Max duration	Details
prEDNISone	60 mg/m² Once daily	oral administration		Instructions: Take in the morning with food.
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 6

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 7

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 8

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 9

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 10

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 11

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 12

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 13

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 14

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 15

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 16

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 17

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 18

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 19

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 20

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 21

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 22

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 23

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 24

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 25

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 26

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 27

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 28

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 29

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 30

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 31

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 32

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 33

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 34

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 35

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 36

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 37

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 38

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 39

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 40

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 41

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 42

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 43

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 44

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 45

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 46

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 47

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 48

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 49

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 50

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 51

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 52

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 53

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 54

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 55

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 56

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 57

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.
paracetamol *	1000 mg flat dosing	oral administration		Instructions: 30 to 60 minutes prior to RITUximab.
loratadine *	10 mg	oral administration		Instructions: 30 to 60 minutes prior to RITUximab.
RITUximab *	375 mg/m²	intravenous	6 hours	Instructions: Consider administering corticosteroid premedication if previous doses not well tolerated or if clinically indicated as per institutional practice. Start infusion at 100 mg/hour. If tolerated, rate can be increased by 100 mg/hour every 30 minutes to a maximum rate of 400 mg/hour, or as per institutional practice.

Day: 58

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 59

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 60

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 61

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 62

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 63

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 64

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 65

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 66

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 67

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 68

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 69

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 70

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 71

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 72

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 73

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 74

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 75

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 76

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 77

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 78

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 79

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 80

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 81

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 82

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 83

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 84

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Cycle 2 - 84 days - Includes RITUximab day 29

Day: 1

Medication	Dose	Route	Max duration	Details
metHOTREXATe	12 mg flat dosing	intrathecal injection		Instructions: May be administered during Maintenance if neutrophils > 0.75 x 10⁹/L and platelets > 75 x 10⁹/L. Adhere to local institution policy for intrathecal administration. For Ommaya reservoir reduce dose to 6 mg intraventricularly.
vinCRISTine	1.4 mg/m² Cap dose per administration at: 2 mg	intravenous	10 minutes	Instructions: Diluted in a minibag. FOR INTRAVENOUS USE ONLY – fatal if given by any other routes. Warning vesicant—ensure vein is patent prior to administration, administer vesicant as per institutional policy and monitor for signs of extravasation throughout administration.
prEDNISone	60 mg/m² Once daily	oral administration		Instructions: Take in the morning with food.
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 2

Medication	Dose	Route	Max duration	Details
prEDNISone	60 mg/m² Once daily	oral administration		Instructions: Take in the morning with food.
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 3

Medication	Dose	Route	Max duration	Details
prEDNISone	60 mg/m² Once daily	oral administration		Instructions: Take in the morning with food.
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 4

Medication	Dose	Route	Max duration	Details
prEDNISone	60 mg/m² Once daily	oral administration		Instructions: Take in the morning with food.
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 5

Medication	Dose	Route	Max duration	Details
prEDNISone	60 mg/m² Once daily	oral administration		Instructions: Take in the morning with food.
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 6

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 7

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 8

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 9

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 10

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 11

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 12

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 13

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 14

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 15

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 16

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 17

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 18

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 19

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 20

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 21

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 22

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 23

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 24

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 25

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 26

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 27

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 28

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 29

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.
paracetamol *	1000 mg flat dosing	oral administration		Instructions: 30 to 60 minutes prior to RITUximab.
loratadine *	10 mg	oral administration		Instructions: 30 to 60 minutes prior to RITUximab.
RITUximab *	375 mg/m²	intravenous	6 hours	Instructions: Consider administering corticosteroid premedication if previous doses not well tolerated or if clinically indicated as per institutional practice. Start infusion at 100 mg/hour. If tolerated, rate can be increased by 100 mg/hour every 30 minutes to a maximum rate of 400 mg/hour, or as per institutional practice.

Day: 30

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 31

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 32

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 33

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 34

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 35

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 36

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 37

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 38

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 39

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 40

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 41

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 42

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 43

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 44

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 45

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 46

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 47

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 48

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 49

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 50

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 51

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 52

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 53

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 54

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 55

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 56

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 57

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 58

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 59

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 60

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 61

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 62

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 63

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 64

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 65

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 66

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 67

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 68

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 69

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 70

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 71

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 72

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 73

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 74

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 75

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 76

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 77

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 78

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 79

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 80

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 81

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 82

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 83

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 84

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Cycle 3 - 84 days - Includes RITUximab days 1 and 57

Day: 1

Medication	Dose	Route	Max duration	Details
metHOTREXATe	12 mg flat dosing	intrathecal injection		Instructions: May be administered during Maintenance if neutrophils > 0.75 x 10⁹/L and platelets > 75 x 10⁹/L. Adhere to local institution policy for intrathecal administration. For Ommaya reservoir reduce dose to 6 mg intraventricularly.
vinCRISTine	1.4 mg/m² Cap dose per administration at: 2 mg	intravenous	10 minutes	Instructions: Diluted in a minibag. FOR INTRAVENOUS USE ONLY – fatal if given by any other routes. Warning vesicant—ensure vein is patent prior to administration, administer vesicant as per institutional policy and monitor for signs of extravasation throughout administration.
prEDNISone	60 mg/m² Once daily	oral administration		Instructions: Take in the morning with food, at least 30 to 60 minutes prior to RITUximab.
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.
paracetamol *	1000 mg flat dosing	oral administration		Instructions: 30 to 60 minutes prior to RITUximab.
loratadine *	10 mg	oral administration		Instructions: 30 to 60 minutes prior to RITUximab.
RITUximab *	375 mg/m²	intravenous	6 hours	Instructions: Start infusion at 100 mg/hour. If tolerated, rate can be increased by 100 mg/hour every 30 minutes to a maximum rate of 400 mg/hour, or as per institutional practice.

Day: 2

Medication	Dose	Route	Max duration	Details
prEDNISone	60 mg/m² Once daily	oral administration		Instructions: Take in the morning with food.
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 3

Medication	Dose	Route	Max duration	Details
prEDNISone	60 mg/m² Once daily	oral administration		Instructions: Take in the morning with food.
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 4

Medication	Dose	Route	Max duration	Details
prEDNISone	60 mg/m² Once daily	oral administration		Instructions: Take in the morning with food.
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 5

Medication	Dose	Route	Max duration	Details
prEDNISone	60 mg/m² Once daily	oral administration		Instructions: Take in the morning with food.
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 6

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 7

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 8

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 9

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 10

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 11

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 12

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 13

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 14

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 15

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 16

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 17

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 18

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 19

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 20

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 21

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 22

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 23

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 24

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 25

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 26

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 27

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 28

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 29

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 30

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 31

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 32

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 33

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 34

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 35

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 36

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 37

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 38

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 39

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 40

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 41

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 42

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 43

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 44

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 45

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 46

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 47

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 48

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 49

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 50

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 51

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 52

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 53

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 54

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 55

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 56

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 57

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.
paracetamol *	1000 mg flat dosing	oral administration		Instructions: 30 to 60 minutes prior to RITUximab.
loratadine *	10 mg	oral administration		Instructions: 30 to 60 minutes prior to RITUximab.
RITUximab *	375 mg/m²	intravenous	6 hours	Instructions: Consider administering corticosteroid premedication before RITUximab if previous doses not well tolerated or if clinically indicated as per institutional practice. Start infusion at 100 mg/hour. If tolerated, rate can be increased by 100 mg/hour every 30 minutes to a maximum rate of 400 mg/hour, or as per institutional practice.

Day: 58

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 59

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 60

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 61

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 62

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 63

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 64

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 65

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 66

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 67

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 68

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 69

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 70

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 71

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 72

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 73

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 74

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 75

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 76

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 77

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 78

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 79

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 80

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 81

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 82

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 83

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 84

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Cycle 4 - 84 days - Includes RITUximab day 29

Day: 1

Medication	Dose	Route	Max duration	Details
metHOTREXATe	12 mg flat dosing	intrathecal injection		Instructions: May be administered during Maintenance if neutrophils > 0.75 x 10⁹/L and platelets > 75 x 10⁹/L. Adhere to local institution policy for intrathecal administration. For Ommaya reservoir reduce dose to 6 mg intraventricularly.
vinCRISTine	1.4 mg/m² Cap dose per administration at: 2 mg	intravenous	10 minutes	Instructions: Diluted in a minibag. FOR INTRAVENOUS USE ONLY – fatal if given by any other routes. Warning vesicant—ensure vein is patent prior to administration, administer vesicant as per institutional policy and monitor for signs of extravasation throughout administration.
prEDNISone	60 mg/m² Once daily	oral administration		Instructions: Take in the morning with food.
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 2

Medication	Dose	Route	Max duration	Details
prEDNISone	60 mg/m² Once daily	oral administration		Instructions: Take in the morning with food.
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 3

Medication	Dose	Route	Max duration	Details
prEDNISone	60 mg/m² Once daily	oral administration		Instructions: Take in the morning with food.
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 4

Medication	Dose	Route	Max duration	Details
prEDNISone	60 mg/m² Once daily	oral administration		Instructions: Take in the morning with food.
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 5

Medication	Dose	Route	Max duration	Details
prEDNISone	60 mg/m² Once daily	oral administration		Instructions: Take in the morning with food.
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 6

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 7

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 8

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 9

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 10

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 11

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 12

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 13

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 14

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 15

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 16

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 17

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 18

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 19

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 20

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 21

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 22

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 23

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 24

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 25

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 26

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 27

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 28

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 29

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.
paracetamol *	1000 mg flat dosing	oral administration		Instructions: 30 to 60 minutes prior to RITUximab.
loratadine *	10 mg	oral administration		Instructions: 30 to 60 minutes prior to RITUximab.
RITUximab *	375 mg/m²	intravenous	6 hours	Instructions: Consider administering corticosteroid premedication if previous doses not well tolerated or if clinically indicated as per institutional practice. Start infusion at 100 mg/hour. If tolerated, rate can be increased by 100 mg/hour every 30 minutes to a maximum rate of 400 mg/hour, or as per institutional practice.

Day: 30

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 31

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 32

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 33

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 34

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 35

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 36

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 37

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 38

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 39

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 40

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 41

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 42

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 43

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 44

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 45

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 46

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 47

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 48

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 49

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 50

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 51

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 52

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 53

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 54

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 55

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 56

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 57

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 58

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 59

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 60

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 61

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 62

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 63

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 64

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 65

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 66

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 67

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 68

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 69

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 70

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 71

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 72

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 73

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 74

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 75

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 76

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 77

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 78

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 79

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 80

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 81

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 82

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 83

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 84

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Cycles 5 to 8 - 84 days

Day: 1

Medication	Dose	Route	Max duration	Details
metHOTREXATe	12 mg flat dosing	intrathecal injection		Instructions: May be administered during Maintenance if neutrophils > 0.75 x 10⁹/L and platelets > 75 x 10⁹/L. Adhere to local institution policy for intrathecal administration. For Ommaya reservoir reduce dose to 6 mg intraventricularly.
vinCRISTine	1.4 mg/m² Cap dose per administration at: 2 mg	intravenous	10 minutes	Instructions: Diluted in a minibag. FOR INTRAVENOUS USE ONLY – fatal if given by any other routes. Warning vesicant—ensure vein is patent prior to administration, administer vesicant as per institutional policy and monitor for signs of extravasation throughout administration.
prEDNISone	60 mg/m² Once daily	oral administration		Instructions: Take in the morning with food.
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 2

Medication	Dose	Route	Max duration	Details
prEDNISone	60 mg/m² Once daily	oral administration		Instructions: Take in the morning with food.
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 3

Medication	Dose	Route	Max duration	Details
prEDNISone	60 mg/m² Once daily	oral administration		Instructions: Take in the morning with food.
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 4

Medication	Dose	Route	Max duration	Details
prEDNISone	60 mg/m² Once daily	oral administration		Instructions: Take in the morning with food.
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 5

Medication	Dose	Route	Max duration	Details
prEDNISone	60 mg/m² Once daily	oral administration		Instructions: Take in the morning with food.
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 6

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 7

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 8

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 9

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 10

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 11

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 12

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 13

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 14

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 15

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 16

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 17

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 18

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 19

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 20

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 21

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 22

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 23

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 24

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 25

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 26

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 27

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 28

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 29

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 30

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 31

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 32

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 33

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 34

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 35

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 36

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 37

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 38

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 39

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 40

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 41

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 42

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 43

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 44

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 45

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 46

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 47

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 48

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 49

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 50

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 51

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 52

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 53

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 54

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 55

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 56

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 57

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 58

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 59

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 60

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 61

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 62

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 63

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 64

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 65

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 66

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 67

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 68

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 69

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 70

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 71

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 72

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 73

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 74

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 75

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 76

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 77

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 78

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.
metHOTREXATe	20 mg/m² Once a week	oral administration		Instructions: Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 2.5 mg tablets. Protect yourself from too much natural or artificial sunlight while being treated with this medicine.

Day: 79

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 80

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 81

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 82

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 83

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Day: 84

Medication	Dose	Route	Max duration	Details
mercaptOPURine	75 mg/m² Once daily	oral administration		Instructions: Take on an empty stomach – one hour before OR three hours after food or milk. Adjust dose to maintain neutrophils between 0.75 and 1.5 x 10⁹/L and platelets between 75 and 150 x 10⁹/L. Round dose to closest multiple of 25 mg. Consider thiopurine methyltransferase (TPMT) testing and NUDT15 screening for specific patients.

Supportive Care Factors

Factor	Value
Antiviral prophylaxis for hepatitis B virus:	Required for anti–HBc positive patients at risk of reactivation
Antiviral prophylaxis for herpes virus:	Routine antiviral prophylaxis recommended
Constipation risk:	Consider prescribing laxatives with this treatment
Emetogenicity:	Minimal to low
Gastroprotection:	Gastroprotection is recommended
Hypersensitivity / Infusion related reaction risk:	High - routine premedication recommended
Pneumocystis jirovecii pneumonia (PJP) prophylaxis:	Routine antibiotic prophylaxis recommended

Gastroprotection: Gastroprotective agents are only intended for short term use while patient is receiving corticosteroid treatment doses.

PJP prophylaxis: Avoid trimethoprim + sulfamethoxazole on the days oral metHOTREXATe is administered.

References

Tabernero J, Vyas M, Giuliani R, Arnold D, Cardoso F, Casali PG, Cervantes A, Eggermont AMM, Eniu A, Jassem J, Pentheroudakis G, Peters S, Rauh S, Zielinski CC, Stahel RA, Voest E, Douillard JY, McGregor K, Ciardiello F. Biosimilars: a position paper of the European Society for Medical Oncology, with particular reference to oncology prescribers. ESMO Open. 2017 Jan 16;1(6):e000142. doi: 10.1136/esmoopen-2016-000142., PMID: 28848668

Lyman GH, Balaban E, Diaz M, Ferris A, Tsao A, Voest E, Zon R, Francisco M, Green S, Sherwood S, Harvey RD, Schilsky RL. American Society of Clinical Oncology Statement: Biosimilars in Oncology. J Clin Oncol. 2018 Apr 20;36(12):1260-1265. doi: 10.1200/JCO.2017.77.4893. Epub 2018 Feb 14., PMID: 29443651

* The medicines, doses, combinations, and schedule in this treatment regimen have been carefully reviewed against international best practice guidelines by specialists in medical oncology around New Zealand and this advice has been accepted for publication by Te Aho o Te Kahu (the Cancer Control Agency). Sometimes medicines that are used in routine clinical practice have not been through a formal review process by the NZ Medicines Regulator Medsafe and are therefore considered unapproved or off-label. These medicines are legally able to be prescribed through sections 25 and 29 of the Medicines Act and by obtaining informed consent from patients. All treatment regimens listed on this website have been through robust peer review and are considered an accepted standard of care, whether prescribed through sections 25 or 29 or carrying formal Medsafe Approval.

s29: This symbol indicates that some formulations of the associated medicine are legally only able to be prescribed under section 29 of the Medicines Act. You can see which formulations are section 29 by hovering over the s29 symbol. You can access full medication details from the New Zealand Formulary by clicking on the medication name. Each clinician retains full responsibility for ensuring they have complied with all relevant obligations and requirements of section 29 including obtaining informed patient consent prior to prescribing the applicable medicine.

Cancer Type —

Systemic Anti-Cancer Therapy Regimen Library

UKALL14 with RITUximab [over 40 years] [not for transplant] - Maintenance (LEU ALL precursor B-cell - UKALL14 with RITUximab [over 40 years] [not for transplant])

Treatment Overview

Cycle 1 - 84 days - Includes RITUximab days 1 and 57

Cycle 2 - 84 days - Includes RITUximab day 29

Cycle 3 - 84 days - Includes RITUximab days 1 and 57

Cycle 4 - 84 days - Includes RITUximab day 29

Cycles 5 to 8 - 84 days

Cycle details

Cycle 1 - 84 days - Includes RITUximab days 1 and 57

Cycle 2 - 84 days - Includes RITUximab day 29

Cycle 3 - 84 days - Includes RITUximab days 1 and 57

Cycle 4 - 84 days - Includes RITUximab day 29

Cycles 5 to 8 - 84 days

Full details

Cycle 1 - 84 days - Includes RITUximab days 1 and 57

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Cancer Type
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