Systemic Anti-Cancer Therapy Regimen Library
LYM NHL B-cell Relapsed - R-ICE [RITUximab, fractionated IFOSFamide, cARBOplatin and etoposide]
Treatment Overview
Usually 2 or 3 cycles.
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 - 21 days
RITUximab, first dose:
- Consider withholding routine anti-hypertensives for 12 hours prior to first RITUximab dose.
- For patients at high risk of infusion-related reaction, consider additional pre-medications such as an extra antihistamine dose the day before, an H2 receptor antagonist and montelukast.
If for stem cell harvest, mobilise as per institutional practice.
Mesna dosing, as per Hertzberg 2003 (see Reference below) plus pre- and post-IFOSFamide dosing added.
Cycles 2 to 3 - 21 days
RITUximab: Consider administering corticosteroid premedication prior to RITUximab if previous doses not well tolerated or if clinically indicated as per institutional practice.
If for stem cell harvest, mobilise as per institutional practice.
Mesna dosing, as per Hertzberg 2003 (see Reference below) plus pre- and post-IFOSFamide dosing added.
Cycle details
Cycle 1 - 21 days
| Medication | Dose | Route | Days | Max Duration |
|---|---|---|---|---|
| paracetamol * | 1000 mg flat dosing | oral administration | 1 | |
| loratadine * | 10 mg | oral administration | 1 | |
| dexamethasone * | 12 mg flat dosing | intravenous | 1 | 15 minutes |
| RITUximab | 375 mg/m² | intravenous | 1 | 6 hours |
| etoposide (as phosphate) | 100 mg/m² Once daily | intravenous | 1, 2, 3 | 60 minutes |
| cARBOplatin * | 5 AUC (area under the curve) Cap dose per administration at: 800 mg | intravenous | 1 | 60 minutes |
| sodium chloride | 0.9 % Once daily | intravenous | 1, 2, 3 | 120 minutes |
| mesna | 340 mg/m² Once daily | intravenous | 1, 2, 3 | 15 minutes |
| IFOSFamide * | 1666 mg/m² Once daily | intravenous | 1, 2, 3 | 120 minutes |
| mesna | 1666 mg/m² Once daily | intravenous | 1, 2, 3 | 120 minutes |
| sodium chloride | 0.9 % Once daily | intravenous | 1, 2, 3 | 120 minutes |
| mesna | 680 mg/m² Twice daily | oral administration | 1, 2, 3 | |
| filgrastim | 5 microgram/kg Once daily | subcutaneous injection | 4 to 9 |
RITUximab, first dose:
- Consider withholding routine anti-hypertensives for 12 hours prior to first RITUximab dose.
- For patients at high risk of infusion-related reaction, consider additional pre-medications such as an extra antihistamine dose the day before, an H2 receptor antagonist and montelukast.
If for stem cell harvest, mobilise as per institutional practice.
Mesna dosing, as per Hertzberg 2003 (see Reference below) plus pre- and post-IFOSFamide dosing added.
Cycles 2 to 3 - 21 days
| Medication | Dose | Route | Days | Max Duration |
|---|---|---|---|---|
| paracetamol * | 1000 mg flat dosing | oral administration | 1 | |
| loratadine * | 10 mg | oral administration | 1 | |
| RITUximab | 375 mg/m² | intravenous | 1 | 6 hours |
| etoposide (as phosphate) | 100 mg/m² Once daily | intravenous | 1, 2, 3 | 60 minutes |
| cARBOplatin * | 5 AUC (area under the curve) Cap dose per administration at: 800 mg | intravenous | 1 | 60 minutes |
| sodium chloride | 0.9 % Once daily | intravenous | 1, 2, 3 | 120 minutes |
| mesna | 340 mg/m² Once daily | intravenous | 1, 2, 3 | 15 minutes |
| IFOSFamide * | 1666 mg/m² Once daily | intravenous | 1, 2, 3 | 120 minutes |
| mesna | 1666 mg/m² Once daily | intravenous | 1, 2, 3 | 120 minutes |
| sodium chloride | 0.9 % Once daily | intravenous | 1, 2, 3 | 120 minutes |
| mesna | 680 mg/m² Twice daily | oral administration | 1, 2, 3 | |
| filgrastim | 5 microgram/kg Once daily | subcutaneous injection | 4 to 9 |
RITUximab: Consider administering corticosteroid premedication prior to RITUximab if previous doses not well tolerated or if clinically indicated as per institutional practice.
If for stem cell harvest, mobilise as per institutional practice.
Mesna dosing, as per Hertzberg 2003 (see Reference below) plus pre- and post-IFOSFamide dosing added.
Full details
Cycle 1 - 21 days
Day: 1
| Medication | Dose | Route | Max duration | Details |
|---|---|---|---|---|
| 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. |
|
| dexamethasone * | 12 mg flat dosing | intravenous | 15 minutes |
Instructions:
30 to 60 minutes prior to RITUximab, or as per institutional practice. |
| RITUximab | 375 mg/m² | intravenous | 6 hours |
Instructions:
|
| etoposide (as phosphate) | 100 mg/m² Once daily | intravenous | 60 minutes | |
| cARBOplatin * | 5 AUC (area under the curve) Cap dose per administration at: 800 mg | intravenous | 60 minutes |
Instructions:
Hypersensitivity risk increases with number of cycles of cARBOplatin. |
| sodium chloride | 0.9 % Once daily | intravenous | 120 minutes |
Quantity:1000 mL
Instructions:
Prior to iFOSFamide infusion. Recommended daily hydration is 3000 ml per day as oral or IV fluid on day(s) of IFOSFamide and for 24 hours after, or as per institutional practice. |
| mesna | 340 mg/m² Once daily | intravenous | 15 minutes |
Instructions:
Immediately prior to IFOSFamide infusion over 15 minutes, or as per institutional practice. |
| IFOSFamide * | 1666 mg/m² Once daily | intravenous | 120 minutes |
Instructions:
Admixed with mesna 1666mg/m2. |
| mesna | 1666 mg/m² Once daily | intravenous | 120 minutes |
Instructions:
Admixed with IFOSFamide. Mesna dosing as described, or as per institutional practice. |
| sodium chloride | 0.9 % Once daily | intravenous | 120 minutes |
Quantity:1000 mL
Instructions:
After IFOSFamide infusion. Recommended daily hydration is 3000 ml per day as oral or IV fluid on day(s) of IFOSFamide and for 24 hours after, or as per institutional practice. |
| mesna | 680 mg/m² Twice daily | oral administration |
Instructions:
Give at 2 and 6 hours post iFOSFamide infusion, or as per institutional practice. Round dose to closest multiple of 400 mg or 600 mg tablets. |
Day: 2
| Medication | Dose | Route | Max duration | Details |
|---|---|---|---|---|
| etoposide (as phosphate) | 100 mg/m² Once daily | intravenous | 60 minutes | |
| sodium chloride | 0.9 % Once daily | intravenous | 120 minutes |
Quantity:1000 mL
Instructions:
Prior to iFOSFamide infusion. Recommended daily hydration is 3000 ml per day as oral or IV fluid on day(s) of IFOSFamide and for 24 hours after, or as per institutional practice. |
| mesna | 340 mg/m² Once daily | intravenous | 15 minutes |
Instructions:
Immediately prior to IFOSFamide infusion over 15 minutes, or as per institutional practice. |
| IFOSFamide * | 1666 mg/m² Once daily | intravenous | 120 minutes |
Instructions:
Admixed with mesna 1666mg/m2. |
| mesna | 1666 mg/m² Once daily | intravenous | 120 minutes |
Instructions:
Admixed with IFOSFamide. Mesna dosing as described, or as per institutional practice. |
| sodium chloride | 0.9 % Once daily | intravenous | 120 minutes |
Quantity:1000 mL
Instructions:
After IFOSFamide infusion. Recommended daily hydration is 3000 ml per day as oral or IV fluid on day(s) of IFOSFamide and for 24 hours after, or as per institutional practice. |
| mesna | 680 mg/m² Twice daily | oral administration |
Instructions:
Give at 2 and 6 hours post iFOSFamide infusion, or as per institutional practice. Round dose to closest multiple of 400 mg or 600 mg tablets. |
Day: 3
| Medication | Dose | Route | Max duration | Details |
|---|---|---|---|---|
| etoposide (as phosphate) | 100 mg/m² Once daily | intravenous | 60 minutes | |
| sodium chloride | 0.9 % Once daily | intravenous | 120 minutes |
Quantity:1000 mL
Instructions:
Prior to iFOSFamide infusion. Recommended daily hydration is 3000 ml per day as oral or IV fluid on day(s) of IFOSFamide and for 24 hours after, or as per institutional practice. |
| mesna | 340 mg/m² Once daily | intravenous | 15 minutes |
Instructions:
Immediately prior to IFOSFamide infusion over 15 minutes, or as per institutional practice. |
| IFOSFamide * | 1666 mg/m² Once daily | intravenous | 120 minutes |
Instructions:
Admixed with mesna 1666mg/m2. |
| mesna | 1666 mg/m² Once daily | intravenous | 120 minutes |
Instructions:
Admixed with IFOSFamide. Mesna dosing as described, or as per institutional practice. |
| sodium chloride | 0.9 % Once daily | intravenous | 120 minutes |
Quantity:1000 mL
Instructions:
After IFOSFamide infusion. Recommended daily hydration is 3000 ml per day as oral or IV fluid on day(s) of IFOSFamide and for 24 hours after, or as per institutional practice. |
| mesna | 680 mg/m² Twice daily | oral administration |
Instructions:
Give at 2 and 6 hours post iFOSFamide infusion, or as per institutional practice. Round dose to closest multiple of 400 mg or 600 mg tablets. |
Day: 4
| Medication | Dose | Route | Max duration | Details |
|---|---|---|---|---|
| filgrastim | 5 microgram/kg Once daily | subcutaneous injection |
Instructions:
Round dose to nearest prefilled syringe dose of 300 micrograms or 480 micrograms. |
Day: 5
| Medication | Dose | Route | Max duration | Details |
|---|---|---|---|---|
| filgrastim | 5 microgram/kg Once daily | subcutaneous injection |
Instructions:
Round dose to nearest prefilled syringe dose of 300 micrograms or 480 micrograms. |
Day: 6
| Medication | Dose | Route | Max duration | Details |
|---|---|---|---|---|
| filgrastim | 5 microgram/kg Once daily | subcutaneous injection |
Instructions:
Round dose to nearest prefilled syringe dose of 300 micrograms or 480 micrograms. |
Day: 7
| Medication | Dose | Route | Max duration | Details |
|---|---|---|---|---|
| filgrastim | 5 microgram/kg Once daily | subcutaneous injection |
Instructions:
Round dose to nearest prefilled syringe dose of 300 micrograms or 480 micrograms. |
Day: 8
| Medication | Dose | Route | Max duration | Details |
|---|---|---|---|---|
| filgrastim | 5 microgram/kg Once daily | subcutaneous injection |
Instructions:
Round dose to nearest prefilled syringe dose of 300 micrograms or 480 micrograms. |
Day: 9
| Medication | Dose | Route | Max duration | Details |
|---|---|---|---|---|
| filgrastim | 5 microgram/kg Once daily | subcutaneous injection |
Instructions:
Round dose to nearest prefilled syringe dose of 300 micrograms or 480 micrograms. |
Cycles 2 to 3 - 21 days
Day: 1
| Medication | Dose | Route | Max duration | Details |
|---|---|---|---|---|
| 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. |
| etoposide (as phosphate) | 100 mg/m² Once daily | intravenous | 60 minutes | |
| cARBOplatin * | 5 AUC (area under the curve) Cap dose per administration at: 800 mg | intravenous | 60 minutes |
Instructions:
Hypersensitivity risk increases with number of cycles of cARBOplatin. |
| sodium chloride | 0.9 % Once daily | intravenous | 120 minutes |
Quantity:1000 mL
Instructions:
Prior to iFOSFamide infusion. Recommended daily hydration is 3000 ml per day as oral or IV fluid on day(s) of IFOSFamide and for 24 hours after, or as per institutional practice. |
| mesna | 340 mg/m² Once daily | intravenous | 15 minutes |
Instructions:
Immediately prior to IFOSFamide infusion over 15 minutes, or as per institutional practice. |
| IFOSFamide * | 1666 mg/m² Once daily | intravenous | 120 minutes |
Instructions:
Admixed with mesna 1666mg/m2. |
| mesna | 1666 mg/m² Once daily | intravenous | 120 minutes |
Instructions:
Admixed with IFOSFamide. Mesna dosing as described, or as per institutional practice. |
| sodium chloride | 0.9 % Once daily | intravenous | 120 minutes |
Quantity:1000 mL
Instructions:
After IFOSFamide infusion. Recommended daily hydration is 3000 ml per day as oral or IV fluid on day(s) of IFOSFamide and for 24 hours after, or as per institutional practice. |
| mesna | 680 mg/m² Twice daily | oral administration |
Instructions:
Give at 2 and 6 hours post iFOSFamide infusion, or as per institutional practice. Round dose to closest multiple of 400 mg or 600 mg tablets. |
Day: 2
| Medication | Dose | Route | Max duration | Details |
|---|---|---|---|---|
| etoposide (as phosphate) | 100 mg/m² Once daily | intravenous | 60 minutes | |
| sodium chloride | 0.9 % Once daily | intravenous | 120 minutes |
Quantity:1000 mL
Instructions:
Prior to iFOSFamide infusion. Recommended daily hydration is 3000 ml per day as oral or IV fluid on day(s) of IFOSFamide and for 24 hours after, or as per institutional practice. |
| mesna | 340 mg/m² Once daily | intravenous | 15 minutes |
Instructions:
Immediately prior to IFOSFamide infusion over 15 minutes, or as per institutional practice. |
| IFOSFamide * | 1666 mg/m² Once daily | intravenous | 120 minutes |
Instructions:
Admixed with mesna 1666mg/m2. |
| mesna | 1666 mg/m² Once daily | intravenous | 120 minutes |
Instructions:
Admixed with IFOSFamide. Mesna dosing as described, or as per institutional practice. |
| sodium chloride | 0.9 % Once daily | intravenous | 120 minutes |
Quantity:1000 mL
Instructions:
After IFOSFamide infusion. Recommended daily hydration is 3000 ml per day as oral or IV fluid on day(s) of IFOSFamide and for 24 hours after, or as per institutional practice. |
| mesna | 680 mg/m² Twice daily | oral administration |
Instructions:
Give at 2 and 6 hours post iFOSFamide infusion, or as per institutional practice. Round dose to closest multiple of 400 mg or 600 mg tablets. |
Day: 3
| Medication | Dose | Route | Max duration | Details |
|---|---|---|---|---|
| etoposide (as phosphate) | 100 mg/m² Once daily | intravenous | 60 minutes | |
| sodium chloride | 0.9 % Once daily | intravenous | 120 minutes |
Quantity:1000 mL
Instructions:
Prior to iFOSFamide infusion. Recommended daily hydration is 3000 ml per day as oral or IV fluid on day(s) of IFOSFamide and for 24 hours after, or as per institutional practice. |
| mesna | 340 mg/m² Once daily | intravenous | 15 minutes |
Instructions:
Immediately prior to IFOSFamide infusion over 15 minutes, or as per institutional practice. |
| IFOSFamide * | 1666 mg/m² Once daily | intravenous | 120 minutes |
Instructions:
Admixed with mesna 1666mg/m2. |
| mesna | 1666 mg/m² Once daily | intravenous | 120 minutes |
Instructions:
Admixed with IFOSFamide. Mesna dosing as described, or as per institutional practice. |
| sodium chloride | 0.9 % Once daily | intravenous | 120 minutes |
Quantity:1000 mL
Instructions:
After IFOSFamide infusion. Recommended daily hydration is 3000 ml per day as oral or IV fluid on day(s) of IFOSFamide and for 24 hours after, or as per institutional practice. |
| mesna | 680 mg/m² Twice daily | oral administration |
Instructions:
Give at 2 and 6 hours post iFOSFamide infusion, or as per institutional practice. Round dose to closest multiple of 400 mg or 600 mg tablets. |
Day: 4
| Medication | Dose | Route | Max duration | Details |
|---|---|---|---|---|
| filgrastim | 5 microgram/kg Once daily | subcutaneous injection |
Instructions:
Round dose to nearest prefilled syringe dose of 300 micrograms or 480 micrograms. |
Day: 5
| Medication | Dose | Route | Max duration | Details |
|---|---|---|---|---|
| filgrastim | 5 microgram/kg Once daily | subcutaneous injection |
Instructions:
Round dose to nearest prefilled syringe dose of 300 micrograms or 480 micrograms. |
Day: 6
| Medication | Dose | Route | Max duration | Details |
|---|---|---|---|---|
| filgrastim | 5 microgram/kg Once daily | subcutaneous injection |
Instructions:
Round dose to nearest prefilled syringe dose of 300 micrograms or 480 micrograms. |
Day: 7
| Medication | Dose | Route | Max duration | Details |
|---|---|---|---|---|
| filgrastim | 5 microgram/kg Once daily | subcutaneous injection |
Instructions:
Round dose to nearest prefilled syringe dose of 300 micrograms or 480 micrograms. |
Day: 8
| Medication | Dose | Route | Max duration | Details |
|---|---|---|---|---|
| filgrastim | 5 microgram/kg Once daily | subcutaneous injection |
Instructions:
Round dose to nearest prefilled syringe dose of 300 micrograms or 480 micrograms. |
Day: 9
| Medication | Dose | Route | Max duration | Details |
|---|---|---|---|---|
| filgrastim | 5 microgram/kg Once daily | subcutaneous injection |
Instructions:
Round dose to nearest prefilled syringe dose of 300 micrograms or 480 micrograms. |
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 may be considered |
| Emetogenicity: | Variable |
| Growth factor support: | Recommended for primary prophylaxis |
| Hydration: | Routine hydration recommended |
| Hypersensitivity / Infusion related reaction risk: | High - routine premedication recommended |
| Mesna uroprotection: | Routine mesna uroprotection recommended |
| Tumour lysis syndrome prophylaxis: | Tumour lysis syndrome prophylaxis may be considered |
Emetogenicity: HIGH day 1; MEDIUM days 2 and 3.
References
Castells, M.C., Matulonis, U.A., and Horton, TM. Infusion reactions to systemic chemotherapy. Savarese DMF and Feldweg AM, ed. UpToDate. Waltham, MA: UpToDate Inc. https://www.uptodate.com/contents/infusion-reactions-to-systemic-chemotherapy (Accessed 26 March 2021).
Medicines and Hepatitis B Reactivation Prescriber Update 38(1): 2-3 March 2017 https://medsafe.govt.nz/profs/PUArticles/March2017/MedicinesAndHepatitisB.htm
Rituximab and Hepatitis B Reactivation Prescriber Update 34(3):27 September 2013 https://www.medsafe.govt.nz/profs/PUArticles/Sept2013RituximabHepB.htm
* 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.