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Home > LEU ALL - HyperCVAD with pegaspargase Part A and B followed by POMP Maintenance [under 40 years] > LEU - HyperCVAD with pegaspargase [under 40 years] Part B with Intrathecal CNS prophylaxis Unknown Risk [default]
This regimen is a component of LEU ALL - HyperCVAD with pegaspargase Part A and B followed by POMP Maintenance [under 40 years]

HyperCVAD with pegaspargase [under 40 years] - Part B with CNS prophylaxis for Unknown Risk [default] (LEU ALL - HyperCVAD with pegaspargase Part A and B followed by POMP Maintenance [under 40 years])

Treatment Overview

Alternates with a cycle of Part A every 21 days, or sooner if counts have recovered.

Intrathecal therapy included in this regimen is for CNS prophylaxis for patients with Unknown Risk [default].


High dose metHOTREXATe

  • metHOTREXATe levels MUST be measured once every 24 hours.
  • Intravenous alkalinized fluids MUST be commenced at least 6 hours before the start of metHOTREXATe infusion and MUST continue until the metHOTREXATe serum level is less than 0.05 µmol/L – 0.1 µmol/L (level as per institutional practice). Additional oral alkalinization can be considered as Ural® 2 sachets orally the night before and 2 sachets the morning of high dose metHOTREXATe infusion.
  • Before commencing the high dose metHOTREXATe infusion, urinary pH MUST be 7.5 or above (pH 7.5 to 8.0).
  • Closely monitor renal function, electrolytes, fluid balance, and weight.
  • foliNIc acid MUST start 36 hours after start of metHOTREXATe infusion and MUST continue to be administered until serum metHOTREXATe level is less than 0.05 µmol/L – 0.1 µmol/L (level as per institutional practice).

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.

Cycles 1 to 2 - 21 days

Cycle length:
21

foliNIc acid: MUST start 36 hours after start of metHOTREXATe infusion and MUST continue to be administered every 6 hours until serum metHOTREXATe level is less than 0.05 µmol/L – 0.1 µmol/L (level as per institutional practice).


cytarabine: Check metHOTREXATe level and renal function post high dose metHOTREXATe prior to administration of cytarabine:

  • If metHOTREXATe level greater than 20 µmol/L post completion of metHOTREXATe infusion, OR
  • Urine output is reduced, OR
  • Serum creatinine has increased, cytarabine dose should be withheld and reviewed by the haematologist, and either:
  • Reduce cytarabine dose to at least 1000 mg/m2.
  • OR delay cytarabine dose until renal recovery is achieved.
  • OR omit cytarabine in the event of severe neurotoxicity.

Intrathecal metHOTREXATe: For Ommaya reservoir reduce dose to 6 mg intraventricularly.


filgrastim: Give filgrastim 5 micrograms/kg subcutaneously ONCE daily from Day 4 until neutrophil recovery past the nadir.


pegaspargase:

  • Consider reducing dose of pegaspargase to 500 international units/m2 for certain patients.
  • Monitor patients for one hour after administration of pegaspargase in a setting with resuscitation equipment and other agents necessary to treat anaphylaxis (e.g. adrenaline, oxygen, intravenous steroids, antihistamines).
  • See also Additional details for Further information on pegaspargase.

Cycles 3 to 4 - 21 days

Cycle length:
21

foliNIc acid: MUST start 36 hours after start of metHOTREXATe infusion and MUST continue to be administered every 6 hours until serum metHOTREXATe level is less than 0.05 µmol/L – 0.1 µmol/L (level as per institutional practice).


cytarabine: Check metHOTREXATe level and renal function post high dose metHOTREXATe prior to administration of cytarabine:

  • If metHOTREXATe level greater than 20 µmol/L post completion of metHOTREXATe infusion, OR
  • Urine output is reduced, OR
  • Serum creatinine has increased, cytarabine dose should be withheld and reviewed by the haematologist, and either:
  • Reduce cytarabine dose to at least 1000 mg/m2.
  • OR delay cytarabine dose until renal recovery is achieved.
  • OR omit cytarabine in the event of severe neurotoxicity.

filgrastim: Give filgrastim 5 micrograms/kg subcutaneously ONCE daily from Day 4 until neutrophil recovery past the nadir.


pegaspargase:

  • Consider reducing dose of pegaspargase to 500 international units/m2 for certain patients.
  • Monitor patients for one hour after administration of pegaspargase in a setting with resuscitation equipment and other agents necessary to treat anaphylaxis (e.g. adrenaline, oxygen, intravenous steroids, antihistamines).
  • See also Additional details for Further information on pegaspargase.

Cycle details

Cycles 1 to 2 - 21 days

Medication Dose Route Days Max Duration
methylprednisolone 50 mg Twice daily intravenous 1, 2, 3 1 minutes
potassium chloride 20mmol/1000mL + sodium chloride 0.18% + glucose 4% 125 mL/m²/hour intravenous 1 to 4
sodium bicarbonate 50 mmol intravenous 1 to 4
acetazolamide * 250 mg Four times daily oral administration 1 to 4
metHOTREXATe 200 mg/m² intravenous 1 120 minutes
metHOTREXATe 800 mg/m² intravenous 1 22 hours
foliNIc acid (as calcium folinate) 50 mg flat dosing intravenous 2 2 minutes
foliNIc acid (as calcium folinate) 30 mg flat dosing Every six hours intravenous 2, 3, 4 2 minutes
cytarabine 3000 mg/m² Twice daily intravenous 2, 3 3 hours
prednisolone acetate 1% (10 mg/mL) eye drops * 1 Drop Every four hours application to the eye 2 to 5
metHOTREXATe 12 mg flat dosing intrathecal injection 2
filgrastim 5 microgram/kg Once daily subcutaneous injection 4
paracetamol * 1000 mg flat dosing oral administration 5
loratadine * 10 mg oral administration 5
famotidine * 20 mg oral administration 5
pegaspargase * 1000 international unit/m² intravenous 5 120 minutes
cytarabine 100 mg flat dosing intrathecal injection 8

foliNIc acid: MUST start 36 hours after start of metHOTREXATe infusion and MUST continue to be administered every 6 hours until serum metHOTREXATe level is less than 0.05 µmol/L – 0.1 µmol/L (level as per institutional practice).


cytarabine: Check metHOTREXATe level and renal function post high dose metHOTREXATe prior to administration of cytarabine:

  • If metHOTREXATe level greater than 20 µmol/L post completion of metHOTREXATe infusion, OR
  • Urine output is reduced, OR
  • Serum creatinine has increased, cytarabine dose should be withheld and reviewed by the haematologist, and either:
  • Reduce cytarabine dose to at least 1000 mg/m2.
  • OR delay cytarabine dose until renal recovery is achieved.
  • OR omit cytarabine in the event of severe neurotoxicity.

Intrathecal metHOTREXATe: For Ommaya reservoir reduce dose to 6 mg intraventricularly.


filgrastim: Give filgrastim 5 micrograms/kg subcutaneously ONCE daily from Day 4 until neutrophil recovery past the nadir.


pegaspargase:

  • Consider reducing dose of pegaspargase to 500 international units/m2 for certain patients.
  • Monitor patients for one hour after administration of pegaspargase in a setting with resuscitation equipment and other agents necessary to treat anaphylaxis (e.g. adrenaline, oxygen, intravenous steroids, antihistamines).
  • See also Additional details for Further information on pegaspargase.

Cycles 3 to 4 - 21 days

Medication Dose Route Days Max Duration
methylprednisolone 50 mg Twice daily intravenous 1, 2, 3 1 minutes
potassium chloride 20mmol/1000mL + sodium chloride 0.18% + glucose 4% 125 mL/m²/hour intravenous 1 to 4
sodium bicarbonate 50 mmol intravenous 1 to 4
acetazolamide * 250 mg Four times daily oral administration 1 to 4
metHOTREXATe 200 mg/m² intravenous 1 120 minutes
metHOTREXATe 800 mg/m² intravenous 1 22 hours
foliNIc acid (as calcium folinate) 50 mg flat dosing intravenous 2 2 minutes
foliNIc acid (as calcium folinate) 30 mg flat dosing Every six hours intravenous 2, 3, 4 2 minutes
cytarabine 3000 mg/m² Twice daily intravenous 2, 3 3 hours
prednisolone acetate 1% (10 mg/mL) eye drops * 1 Drop Every four hours application to the eye 2 to 5
filgrastim 5 microgram/kg Once daily subcutaneous injection 4
paracetamol * 1000 mg flat dosing oral administration 5
loratadine * 10 mg oral administration 5
famotidine * 20 mg oral administration 5
pegaspargase * 1000 international unit/m² intravenous 5 120 minutes

foliNIc acid: MUST start 36 hours after start of metHOTREXATe infusion and MUST continue to be administered every 6 hours until serum metHOTREXATe level is less than 0.05 µmol/L – 0.1 µmol/L (level as per institutional practice).


cytarabine: Check metHOTREXATe level and renal function post high dose metHOTREXATe prior to administration of cytarabine:

  • If metHOTREXATe level greater than 20 µmol/L post completion of metHOTREXATe infusion, OR
  • Urine output is reduced, OR
  • Serum creatinine has increased, cytarabine dose should be withheld and reviewed by the haematologist, and either:
  • Reduce cytarabine dose to at least 1000 mg/m2.
  • OR delay cytarabine dose until renal recovery is achieved.
  • OR omit cytarabine in the event of severe neurotoxicity.

filgrastim: Give filgrastim 5 micrograms/kg subcutaneously ONCE daily from Day 4 until neutrophil recovery past the nadir.


pegaspargase:

  • Consider reducing dose of pegaspargase to 500 international units/m2 for certain patients.
  • Monitor patients for one hour after administration of pegaspargase in a setting with resuscitation equipment and other agents necessary to treat anaphylaxis (e.g. adrenaline, oxygen, intravenous steroids, antihistamines).
  • See also Additional details for Further information on pegaspargase.

Full details

Cycles 1 to 2 - 21 days

Day: 1

Medication Dose Route Max duration Details
methylprednisolone 50 mg Twice daily intravenous 1 minutes
potassium chloride 20mmol/1000mL + sodium chloride 0.18% + glucose 4% 125 mL/m²/hour intravenous
Instructions:
  • To each 1000 mL bag admix 50 mmol sodium bicarbonate.
  • Or an alternative alkalinized intravenous infusion may be used as per institutional practice.
  • Commence at least 6 hours prior to metHOTREXATe infusion and run continuously until serum metHOTREXATe level is less than 0.05 µmol/L – 0.1 µmol/L (level as per institutional practice).
sodium bicarbonate 50 mmol intravenous
Instructions:
  • Admix 50 mmol sodium bicarbonate to each 1000 mL bag of potassium chloride 20 mmol + sodium chloride 0.18% + glucose 4%.
  • Dose of sodium bicarbonate is approximately 6 mmol/m2/hour when admixed bag is infused at 125 mL/m2/hour.
acetazolamide * 250 mg Four times daily oral administration
Instructions:

When required.

  • Administer immediately if urinary pH drops below 7.5 during metHOTREXATe infusion and until serum metHOTREXATe level is less than 0.05 µmol/L – 0.1 µmol/L (level as per institutional practice).
metHOTREXATe 200 mg/m² intravenous 120 minutes
metHOTREXATe 800 mg/m² intravenous 22 hours
Instructions:

Starting immediately after the 120 minute metHOTREXATe infusion.

Day: 2

Medication Dose Route Max duration Details
methylprednisolone 50 mg Twice daily intravenous 1 minutes
potassium chloride 20mmol/1000mL + sodium chloride 0.18% + glucose 4% 125 mL/m²/hour intravenous
Instructions:
  • To each 1000 mL bag admix 50 mmol sodium bicarbonate.
  • Or an alternative alkalinized intravenous infusion may be used as per institutional practice.
  • Run continuously until serum metHOTREXATe level is less than 0.05 µmol/L – 0.1 µmol/L (level as per institutional practice).
sodium bicarbonate 50 mmol intravenous
Instructions:
  • Admix 50 mmol sodium bicarbonate to each 1000 mL bag of potassium chloride 20 mmol + sodium chloride 0.18% + glucose 4%.
  • Dose of sodium bicarbonate is approximately 6 mmol/m2/hour when admixed bag is infused at 125 mL/m2/hour.
acetazolamide * 250 mg Four times daily oral administration
Instructions:

When required.

  • Administer immediately if urinary pH drops below 7.5 during metHOTREXATe infusion and until serum metHOTREXATe level is less than 0.05 µmol/L – 0.1 µmol/L (level as per institutional practice).
foliNIc acid (as calcium folinate) 50 mg flat dosing intravenous 2 minutes
Instructions:

Administer 36 hours after start of metHOTREXATe infusion for 1 dose, follow with 30 mg dosing every 6 hours.
foliNIc acid (as calcium folinate) 30 mg flat dosing Every six hours intravenous 2 minutes
Instructions:
  • Starting 6 hours after foliNIc acid 50 mg dose and continue to administer every 6 hours until serum metHOTREXATe level is less than 0.05 µmol/L – 0.1 µmol/L (level as per institutional practice).
  • If metHOTREXATe elimination is impaired the dose of foliNIc acid will need to be increased. Consult prescribing information.
cytarabine 3000 mg/m² Twice daily intravenous 3 hours
Instructions:

Every 12 hours.

Check metHOTREXATe level and renal function post high dose metHOTREXATe prior to administration of cytarabine:

  • If metHOTREXATe level greater than 20 µmol/L post completion of metHOTREXATe infusion, OR
  • Urine output is reduced, OR
  • Serum creatinine has increased, cytarabine dose should be withheld and reviewed by the haematologist, and either:
  • Reduce cytarabine dose to at least 1000 mg/m2.
  • OR delay dose until renal recovery is achieved.
  • OR omit in the event of severe neurotoxicity.
prednisolone acetate 1% (10 mg/mL) eye drops * 1 Drop Every four hours application to the eye
Instructions:

Instil ONE drop into each eye every FOUR hours on days 2 to 5.
metHOTREXATe 12 mg flat dosing intrathecal injection
Instructions:
  • Adhere to local institution policy for intrathecal administration.
  • For Ommaya reservoir reduce dose to 6 mg intraventricularly.

Day: 3

Medication Dose Route Max duration Details
methylprednisolone 50 mg Twice daily intravenous 1 minutes
potassium chloride 20mmol/1000mL + sodium chloride 0.18% + glucose 4% 125 mL/m²/hour intravenous
Instructions:
  • To each 1000 mL bag admix 50 mmol sodium bicarbonate.
  • Or an alternative alkalinized intravenous infusion may be used as per institutional practice.
  • Run continuously until serum metHOTREXATe level is less than 0.05 µmol/L – 0.1 µmol/L (level as per institutional practice).
sodium bicarbonate 50 mmol intravenous
Instructions:
  • Admix 50 mmol sodium bicarbonate to each 1000 mL bag of potassium chloride 20 mmol + sodium chloride 0.18% + glucose 4%.
  • Dose of sodium bicarbonate is approximately 6 mmol/m2/hour when admixed bag is infused at 125 mL/m2/hour.
acetazolamide * 250 mg Four times daily oral administration
Instructions:

When required.

  • Administer immediately if urinary pH drops below 7.5 during metHOTREXATe infusion and until serum metHOTREXATe level is less than 0.05 µmol/L – 0.1 µmol/L (level as per institutional practice).
foliNIc acid (as calcium folinate) 30 mg flat dosing Every six hours intravenous 2 minutes
Instructions:
  • Administer every 6 hours until serum metHOTREXATe level is less than 0.05 µmol/L – 0.1 µmol/L (level as per institutional practice).
  • If metHOTREXATe elimination is impaired the dose of foliNIc acid will need to be increased. Consult prescribing information.
cytarabine 3000 mg/m² Twice daily intravenous 3 hours
Instructions:

Every 12 hours.
prednisolone acetate 1% (10 mg/mL) eye drops * 1 Drop Every four hours application to the eye
Instructions:

Instil ONE drop into each eye every FOUR hours on days 2 to 5.

Day: 4

Medication Dose Route Max duration Details
potassium chloride 20mmol/1000mL + sodium chloride 0.18% + glucose 4% 125 mL/m²/hour intravenous
Instructions:
  • To each 1000 mL bag admix 50 mmol sodium bicarbonate.
  • Or an alternative alkalinized intravenous infusion may be used as per institutional practice.
  • Run continuously until serum metHOTREXATe level is less than 0.05 µmol/L – 0.1 µmol/L (level as per institutional practice).
  • Administration may continue past Day 4 if metHOTREXATe level is still elevated.
sodium bicarbonate 50 mmol intravenous
Instructions:
  • Admix 50 mmol sodium bicarbonate 8.4% to each 1000 mL bag of potassium chloride 20 mmol + sodium chloride 0.18% + glucose 4%.
  • Dose of sodium bicarbonate is approximately 6 mmol/m2/hour when admixed bag is infused at 125 mL/m2/hour.
  • Administration may continue past Day 4 if metHOTREXATe level is still elevated.
acetazolamide * 250 mg Four times daily oral administration
Instructions:

When required.

  • Administer immediately if urinary pH drops below 7.5 during metHOTREXATe infusion and until serum metHOTREXATe level is less than 0.05 µmol/L – 0.1 µmol/L (level as per institutional practice).
  • Administration may continue past Day 4 if metHOTREXATe level is still elevated.
foliNIc acid (as calcium folinate) 30 mg flat dosing Every six hours intravenous 2 minutes
Instructions:
  • Administer every 6 hours until serum metHOTREXATe level is less than 0.05 µmol/L – 0.1 µmol/L (level as per institutional practice).
  • If metHOTREXATe elimination is impaired the dose of foliNIc acid will need to be increased. Consult prescribing information.
  • Administration may continue past Day 4 if metHOTREXATe level is still elevated.
prednisolone acetate 1% (10 mg/mL) eye drops * 1 Drop Every four hours application to the eye
Instructions:

Instil ONE drop into each eye every FOUR hours on days 2 to 5.
filgrastim 5 microgram/kg Once daily subcutaneous injection
Instructions:

Give ONCE daily from Day 4 until neutrophil recovery past the nadir.

  • Round dose to nearest prefilled syringe dose of 300 micrograms or 480 micrograms.

Day: 5

Medication Dose Route Max duration Details
prednisolone acetate 1% (10 mg/mL) eye drops * 1 Drop Every four hours application to the eye
Instructions:

Instil ONE drop into each eye every FOUR hours on days 2 to 5.
paracetamol * 1000 mg flat dosing oral administration
Instructions:

30 minutes prior to pegaspargase.
loratadine * 10 mg oral administration
Instructions:

30 minutes prior to pegaspargase.
famotidine * 20 mg oral administration
Instructions:

30 minutes prior to pegaspargase.

  • Do not take indigestion remedies, iron or calcium preparations within 2 hours of taking this medicine.
pegaspargase * 1000 international unit/m² intravenous 120 minutes
Instructions:
  • Consider reducing dose of pegaspargase to 500 international units/m2 for certain patients.
  • Monitor patients for one hour after administration of pegaspargase in a setting with resuscitation equipment and other agents necessary to treat anaphylaxis (e.g. adrenaline, oxygen, intravenous steroids, antihistamines).
Additional details:

Day: 8

Medication Dose Route Max duration Details
cytarabine 100 mg flat dosing intrathecal injection
Instructions:

Adhere to local institution policy for intrathecal administration.

Cycles 3 to 4 - 21 days

Day: 1

Medication Dose Route Max duration Details
methylprednisolone 50 mg Twice daily intravenous 1 minutes
potassium chloride 20mmol/1000mL + sodium chloride 0.18% + glucose 4% 125 mL/m²/hour intravenous
Instructions:
  • To each 1000 mL bag admix 50 mmol sodium bicarbonate.
  • Or an alternative alkalinized intravenous infusion may be used as per institutional practice.
  • Commence at least 6 hours prior to metHOTREXATe infusion and run continuously until serum metHOTREXATe level is less than 0.05 µmol/L – 0.1 µmol/L (level as per institutional practice).
sodium bicarbonate 50 mmol intravenous
Instructions:
  • Admix 50 mmol sodium bicarbonate to each 1000 mL bag of potassium chloride 20 mmol + sodium chloride 0.18% + glucose 4%.
  • Dose of sodium bicarbonate is approximately 6 mmol/m2/hour when admixed bag is infused at 125 mL/m2/hour.
acetazolamide * 250 mg Four times daily oral administration
Instructions:

When required.

  • Administer immediately if urinary pH drops below 7.5 during metHOTREXATe infusion and until serum metHOTREXATe level is less than 0.05 µmol/L – 0.1 µmol/L (level as per institutional practice).
metHOTREXATe 200 mg/m² intravenous 120 minutes
metHOTREXATe 800 mg/m² intravenous 22 hours
Instructions:

Starting immediately after the 120 minute metHOTREXATe infusion.

Day: 2

Medication Dose Route Max duration Details
methylprednisolone 50 mg Twice daily intravenous 1 minutes
potassium chloride 20mmol/1000mL + sodium chloride 0.18% + glucose 4% 125 mL/m²/hour intravenous
Instructions:
  • To each 1000 mL bag admix 50 mmol sodium bicarbonate.
  • Or an alternative alkalinized intravenous infusion may be used as per institutional practice.
  • Run continuously until serum metHOTREXATe level is less than 0.05 µmol/L – 0.1 µmol/L (level as per institutional practice).
sodium bicarbonate 50 mmol intravenous
Instructions:
  • Admix 50 mmol sodium bicarbonate to each 1000 mL bag of potassium chloride 20 mmol + sodium chloride 0.18% + glucose 4%.
  • Dose of sodium bicarbonate is approximately 6 mmol/m2/hour when admixed bag is infused at 125 mL/m2/hour.
acetazolamide * 250 mg Four times daily oral administration
Instructions:

When required.

  • Administer immediately if urinary pH drops below 7.5 during metHOTREXATe infusion and until serum metHOTREXATe level is less than 0.05 µmol/L – 0.1 µmol/L (level as per institutional practice).
foliNIc acid (as calcium folinate) 50 mg flat dosing intravenous 2 minutes
Instructions:

Administer 36 hours after start of metHOTREXATe infusion for 1 dose, follow with 30 mg dosing every 6 hours.
foliNIc acid (as calcium folinate) 30 mg flat dosing Every six hours intravenous 2 minutes
Instructions:
  • Starting 6 hours after foliNIC acid 50 mg dose and continue to administer every 6 hours until serum metHOTREXATe level is less than 0.05 µmol/L – 0.1 µmol/L (level as per institutional practice).
  • If metHOTREXATe elimination is impaired the dose of foliNIc acid will need to be increased. Consult prescribing information.
cytarabine 3000 mg/m² Twice daily intravenous 3 hours
Instructions:

Every 12 hours.

Check metHOTREXATe level and renal function post high dose metHOTREXATe prior to administration of cytarabine:

  • If metHOTREXATe level greater than 20 µmol/L post completion of metHOTREXATe infusion, OR
  • Urine output is reduced, OR
  • Serum creatinine has increased, cytarabine dose should be withheld and reviewed by the haematologist, and either:
  • Reduce cytarabine dose to at least 1000 mg/m2.
  • OR delay dose until renal recovery is achieved.
  • OR omit in the event of severe neurotoxicity.
prednisolone acetate 1% (10 mg/mL) eye drops * 1 Drop Every four hours application to the eye
Instructions:

Instil ONE drop into each eye every FOUR hours on days 2 to 5.

Day: 3

Medication Dose Route Max duration Details
methylprednisolone 50 mg Twice daily intravenous 1 minutes
potassium chloride 20mmol/1000mL + sodium chloride 0.18% + glucose 4% 125 mL/m²/hour intravenous
Instructions:
  • To each 1000 mL bag admix 50 mmol sodium bicarbonate.
  • Or an alternative alkalinized intravenous infusion may be used as per institutional practice.
  • Run continuously until serum metHOTREXATe level is less than 0.05 µmol/L – 0.1 µmol/L (level as per institutional practice).
sodium bicarbonate 50 mmol intravenous
Instructions:
  • Admix 50 mmol sodium bicarbonate to each 1000 mL bag of potassium chloride 20 mmol + sodium chloride 0.18% + glucose 4%.
  • Dose of sodium bicarbonate is approximately 6 mmol/m2/hour when admixed bag is infused at 125 mL/m2/hour.
acetazolamide * 250 mg Four times daily oral administration
Instructions:

When required.

  • Administer immediately if urinary pH drops below 7.5 during metHOTREXATe infusion and until serum metHOTREXATe level is less than 0.05 µmol/L – 0.1 µmol/L (level as per institutional practice).
foliNIc acid (as calcium folinate) 30 mg flat dosing Every six hours intravenous 2 minutes
Instructions:
  • Administer every 6 hours until serum metHOTREXATe level is less than 0.05 µmol/L – 0.1 µmol/L (level as per institutional practice).
  • If metHOTREXATe elimination is impaired the dose of foliNIc acid will need to be increased. Consult prescribing information.
cytarabine 3000 mg/m² Twice daily intravenous 3 hours
Instructions:

Every 12 hours.
prednisolone acetate 1% (10 mg/mL) eye drops * 1 Drop Every four hours application to the eye
Instructions:

Instil ONE drop into each eye every FOUR hours on days 2 to 5.

Day: 4

Medication Dose Route Max duration Details
potassium chloride 20mmol/1000mL + sodium chloride 0.18% + glucose 4% 125 mL/m²/hour intravenous
Instructions:
  • To each 1000 mL bag admix 50 mmol sodium bicarbonate.
  • Or an alternative alkalinized intravenous infusion may be used as per institutional practice.
  • Run continuously until serum metHOTREXATe level is less than 0.05 µmol/L – 0.1 µmol/L (level as per institutional practice).
  • Administration may continue past Day 4 if metHOTREXATe level is still elevated.
sodium bicarbonate 50 mmol intravenous
Instructions:
  • Admix 50 mmol sodium bicarbonate 8.4% to each 1000 mL bag of potassium chloride 20 mmol + sodium chloride 0.18% + glucose 4%.
  • Dose of sodium bicarbonate is approximately 6 mmol/m2/hour when admixed bag is infused at 125 mL/m2/hour.
  • Administration may continue past Day 4 if metHOTREXATe level is still elevated.
acetazolamide * 250 mg Four times daily oral administration
Instructions:

When required.

  • Administer immediately if urinary pH drops below 7.5 during metHOTREXATe infusion and until serum metHOTREXATe level is less than 0.05 µmol/L – 0.1 µmol/L (level as per institutional practice).
  • Administration may continue past Day 4 if metHOTREXATe level is still elevated.
foliNIc acid (as calcium folinate) 30 mg flat dosing Every six hours intravenous 2 minutes
Instructions:
  • Administer every 6 hours until serum metHOTREXATe level is less than 0.05 µmol/L – 0.1 µmol/L (level as per institutional practice).
  • If metHOTREXATe elimination is impaired the dose of foliNIc acid will need to be increased. Consult prescribing information.
  • Administration may continue past Day 4 if metHOTREXATe level is still elevated.
prednisolone acetate 1% (10 mg/mL) eye drops * 1 Drop Every four hours application to the eye
Instructions:

Instil ONE drop into each eye every FOUR hours on days 2 to 5.
filgrastim 5 microgram/kg Once daily subcutaneous injection
Instructions:

Give ONCE daily from Day 4 until neutrophil recovery past the nadir.

  • Round dose to nearest prefilled syringe dose of 300 micrograms or 480 micrograms.

Day: 5

Medication Dose Route Max duration Details
prednisolone acetate 1% (10 mg/mL) eye drops * 1 Drop Every four hours application to the eye
Instructions:

Instil ONE drop into each eye every FOUR hours on days 2 to 5.
paracetamol * 1000 mg flat dosing oral administration
Instructions:

30 minutes prior to pegaspargase.
loratadine * 10 mg oral administration
Instructions:

30 minutes prior to pegaspargase.
famotidine * 20 mg oral administration
Instructions:

30 minutes prior to pegaspargase.

  • Do not take indigestion remedies, iron or calcium preparations within 2 hours of taking this medicine.
pegaspargase * 1000 international unit/m² intravenous 120 minutes
Instructions:
  • Consider reducing dose of pegaspargase to 500 international units/m2 for certain patients.
  • Monitor patients for one hour after administration of pegaspargase in a setting with resuscitation equipment and other agents necessary to treat anaphylaxis (e.g. adrenaline, oxygen, intravenous steroids, antihistamines).
Additional details:

Additional details

Section 1: Further information on pegaspargase

  • Pegaspargase (and asparaginase products) should only be administered by centres with appropriate expertise.
  • Prior to using pegaspargase perform a baseline abdominal ultrasound scan is recommended to examine the biliary tract, pancreas and hepatic echotexture. Pegasparagase is contraindicated in those with a history of severe significant hepatic impairment, including alcoholic liver disease, autoimmune or viral hepatitis, and steatohepatitis/NASH.
  • If after pegaspargase there is any evidence of steatosis/liver disease, perform an ultrasound of the liver. 
  • Development of anti-asparaginase antibodies may be associated with low asparaginase activity levels. As a precaution, periodic measurement of the asparaginase activity level in serum or plasma is recommended 
  • Routine monitoring for bone marrow suppression, coagulations abnormalities, pancreatitis, hepatic toxicity, hyperuricaemia, hyperglycaemia, ketoacidosis and hypertriglyceridaemia is required. See Additional information - pegaspargase. 
  • To reduce risk of hypersensitivity to pegaspargase avoid using other pegylated products e.g. pegFILGRASTIM if there is a suitable non-pegylated form.

Supportive Care Factors

Factor Value
Antifungal prophylaxis: Routine antifungal prophylaxis recommended
Antiviral prophylaxis for herpes virus: Routine antiviral prophylaxis recommended
Emetogenicity: Variable
Folinic acid rescue for high dose methotrexate: Mandatory
Gastroprotection: Gastroprotection is recommended
Growth factor support: Recommended for primary prophylaxis
Hydration: Routine hydration recommended
Hypersensitivity / Infusion related reaction risk: High - routine premedication recommended
Ocular toxicity risk: High - administer corticosteroid eyedrops to minimise corneal toxicity
Pneumocystis jirovecii pneumonia (PJP) prophylaxis: Routine antibiotic prophylaxis recommended
Tumour lysis syndrome prophylaxis: Tumour lysis syndrome prophylaxis may be considered

Antiviral prophylaxis for hepatitis B virus: Guidance is limited to high-risk anti-cancer medicines. Clinicians will need to assess individual patient risk for other anti-cancer medicines.


Emetogenicity:

  • MEDIUM day 1 to 3, high dose metHOTREXATe may be highly emetogenic in certain patients.
  • MINIMAL day 5.

Gastroprotection: Use an H2 receptor antagonist as a gastroprotective agent for short term use while patient is receiving corticosteroid treatment doses. Do not use proton pump inhibitors with high dose metHOTREXATe.


PJP prophylaxis: If trimethoprim + sulfamethoxazole is used as prophylaxis, it is recommended to withhold at least 48 hours prior to high dose metHOTREXATe administration and until serum metHOTREXATe level is less than 0.05 µmol/L – 0.1µmol/L (as per institutional practice).


Tumour lysis syndrome prophylaxis: May be considered if not in complete remission.

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.