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Systemic Anti-Cancer Therapy Regimen Library

Home > LYM NHL B-cell Diffuse large - R-CEOP [RITUximab, CYCLOPHOSPHamide, etoposide, vinCRISTine and prEDNIsone] [IV/oral etoposide]

LYM NHL B-cell Diffuse large - R-CEOP [RITUximab, CYCLOPHOSPHamide, etoposide, vinCRISTine and prEDNIsone] [IV/oral etoposide]

Treatment Overview

Usually 3 to 6 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.

Cycles 1 to 6 - 21 days

Cycle length:
21

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.

Cycle details

Cycles 1 to 6 - 21 days

Medication Dose Route Days Max Duration
prEDNISone 100 mg flat dosing Once daily oral administration 1 to 5
paracetamol * 1000 mg flat dosing oral administration 1
loratadine * 10 mg oral administration 1
RITUximab * 375 mg/m² intravenous 1 6 hours
vinCRISTine 1.4 mg/m² Cap dose per administration at: 2 mg intravenous 1 10 minutes
etoposide (as phosphate) 50 mg/m² intravenous 1 60 minutes
etoposide 100 mg/m² Once daily oral administration 2, 3
CYCLOPHOSPHamide 750 mg/m² intravenous 1 60 minutes

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.

Full details

Cycles 1 to 6 - 21 days

Day: 1

Medication Dose Route Max duration Details
prEDNISone 100 mg flat dosing Once daily oral administration
Instructions:

Take in the morning with food, at least ONE hour prior to RITUximab.
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:

First administration: 

  • 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.
  • Start infusion at 50 mg/hour. If tolerated, rate can be increased by 50 mg/hour every 30 minutes to a maximum rate of 400 mg/hour.

Further administrations: 

  • 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.
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.
etoposide (as phosphate) 50 mg/m² intravenous 60 minutes
CYCLOPHOSPHamide 750 mg/m² intravenous 60 minutes

Day: 2

Medication Dose Route Max duration Details
prEDNISone 100 mg flat dosing Once daily oral administration
Instructions:

Take in the morning with food.
etoposide 100 mg/m² Once daily oral administration
Instructions:

Take each dose on an empty stomach - one hour before food OR two hours after food. Grapefruit or grapefruit juice may interact with this medicine, discuss with your pharmacist.

Round dose to closest multiple of 50 mg and/or 100 mg capsules.

Day: 3

Medication Dose Route Max duration Details
prEDNISone 100 mg flat dosing Once daily oral administration
Instructions:

Take in the morning with food.
etoposide 100 mg/m² Once daily oral administration
Instructions:

Take each dose on an empty stomach - one hour before food OR two hours after food. Grapefruit or grapefruit juice may interact with this medicine, discuss with your pharmacist.

Round dose to closest multiple of 50 mg and/or 100 mg capsules.

Day: 4

Medication Dose Route Max duration Details
prEDNISone 100 mg flat dosing Once daily oral administration
Instructions:

Take in the morning with food.

Day: 5

Medication Dose Route Max duration Details
prEDNISone 100 mg flat dosing Once daily oral administration
Instructions:

Take in the morning with food.

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
Constipation risk: laxatives are usually prescribed
Emetogenicity: Variable
Gastroprotection: Gastroprotection may be considered
Growth factor support: Variable
Hypersensitivity / Infusion related reaction risk: High - routine premedication recommended
Tumour lysis syndrome prophylaxis: Tumour lysis syndrome prophylaxis is recommended

Emetogenicity: MEDIUM day 1, MEDIUM to HIGH days 2 and 3.

Growth factor support: Consider primary prophylaxis for patients over 64 years of age or other high-risk patients.

Tumour lysis syndrome prophylaxis: Recommended for cycle 1 and consider for subsequent cycles.

References

Moccia AA, Schall K, Hoskins P, et al. R-CHOP with Etoposide Substituted for Doxorubicin (R-CEOP): Excellent Outcome in Diffuse Large B Cell Lymphoma for Patients with a Contraindication to Anthracyclines (abstract). ASH 2009; abstract 408.

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

Doyle J, Raggatt M, Slavin M, McLachlan SA, Strasser SI, Sasadeusz JJ, Howell J, Hajkowicz K, Nandurkar H, Johnston A, Bak N, Thompson AJ. Hepatitis B management during immunosuppression for haematological and solid organ malignancies: an Australian consensus statement. Med J Aust. 2019 Jun;210(10):462-468. doi: 10.5694/mja2.50160. Epub 2019 May 19. , PMID: 31104328

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.