Systemic Anti-Cancer Therapy Regimen Library
LYM NHL B-cell Relapsed - R-DHAC [RITUximab, dexamethasone, high dose cytarabine and cARBOplatin]
Treatment Overview
Number of cycles: 2 to 6 cycles depending on response.
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
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.
cARBOplatin: Some centres may choose to cap the dose of cARBOplatin at 800 mg.
cytarabine: Consider dose reduction of cytarabine to 1000 mg/m2 in patients over 70 years.
If for stem cell harvest, mobilise as per institutional practice.
Cycle details
Cycles 1 to 6 - 21 days
| Medication | Dose | Route | Days | Max Duration |
|---|---|---|---|---|
| dexamethasone * | 40 mg flat dosing Once daily | oral administration | 1 to 4 | |
| paracetamol * | 1000 mg flat dosing | oral administration | 1 | |
| loratadine * | 10 mg | oral administration | 1 | |
| RITUximab | 375 mg/m² | intravenous | 1 | 6 hours |
| cARBOplatin * | 5 AUC (area under the curve) | intravenous | 1 | 60 minutes |
| cytarabine * | 2000 mg/m² Once daily | intravenous | 1, 2 | 3 hours |
| prednisolone acetate 1% (10 mg/mL) eye drops * | 1 Drop Every four hours | application to the eye | 1 to 4 | |
| pegFILGRASTIM | 6 mg | subcutaneous injection | 4 |
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.
cARBOplatin: Some centres may choose to cap the dose of cARBOplatin at 800 mg.
cytarabine: Consider dose reduction of cytarabine to 1000 mg/m2 in patients over 70 years.
If for stem cell harvest, mobilise as per institutional practice.
Full details
Cycles 1 to 6 - 21 days
Day: 1
| Medication | Dose | Route | Max duration | Details |
|---|---|---|---|---|
| dexamethasone * | 40 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:
Further administrations:
|
| cARBOplatin * | 5 AUC (area under the curve) | intravenous | 60 minutes |
Instructions:
Some centres may choose to cap dose at 800 mg. Hypersensitivity risk increases with number of cycles of cARBOplatin. |
| cytarabine * | 2000 mg/m² Once daily | intravenous | 3 hours |
Instructions:
Consider dose reduction to 1000 mg/m2 in patients over 70 years. |
| 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 1 to 4. |
Day: 2
| Medication | Dose | Route | Max duration | Details |
|---|---|---|---|---|
| dexamethasone * | 40 mg flat dosing Once daily | oral administration |
Instructions:
Take in the morning with food. |
|
| cytarabine * | 2000 mg/m² Once daily | intravenous | 3 hours |
Instructions:
Consider dose reduction to 1000 mg/m2 in patients over 70 years. |
| 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 1 to 4. |
Day: 3
| Medication | Dose | Route | Max duration | Details |
|---|---|---|---|---|
| dexamethasone * | 40 mg flat dosing Once daily | oral administration |
Instructions:
Take in the morning with food. |
|
| 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 1 to 4. |
Day: 4
| Medication | Dose | Route | Max duration | Details |
|---|---|---|---|---|
| dexamethasone * | 40 mg flat dosing Once daily | oral administration |
Instructions:
Take in the morning with food. |
|
| 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 1 to 4. |
|
| pegFILGRASTIM | 6 mg | subcutaneous injection |
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 |
| Gastroprotection: | Gastroprotection may be considered |
| Growth factor support: | Recommended for primary prophylaxis |
| 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 is recommended |
Emetogenicity: HIGH (cARBOplatin) day 1; MEDIUM day 2.
Tumour lysis syndrome prophylaxis: Recommended for cycle 1 and consider for subsequent cycles.
References
Cruz R, Czuczman S, Hernandez F et al (2006). Dexamethasone (D), High Dose Ara-C (HA) and Carboplatin (DHAC) with or without Rituximab (R) Is an Effective Salvage Regimen for Patients with Relapsed/Refractory B-Cell Lymphoma in Preparation for Autologous Stem Cell Transplantation. Blood (ASH Annual Meeting Abstracts), Nov 2006; 108: 4730.
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.