Systemic Anti-Cancer Therapy Regimen Library
LEVEL minus 2 (LYM NHL B-cell - DA-R-EPOCH [Dose-adjusted RITUximab, etoposide, prEDNIsone, vinCRISTine, CYCLOPHOSPHamide and DOXOrubicin] [9 levels])
Treatment Overview
LEVEL minus 2: This may be used as Cycles 3 to 8 depending on neutrophil and platelet count (see Table in Additional details tab above).
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
DOXOrubicin, etoposide (as phosphate) and vinCRISTine:
- May be admixed and administered as a 96 hour infusion.
- Consult latest literature for stability information of an admixed solution.
- Consider accuracy of infusion device, infusion time must not be less than 90 hours or longer than 100 hours (i.e. +/- 5% of total time of 96 hours).
- A central venous access device is required for administration of the 96 hour infusion.
vinCRISTine: Dose capping of vinCRISTine to 2 mg (flat dose) over 96 hours is not included in published DA-R-EPOCH protocol but could be considered for patients over 50 years of age.
filgrastim:
- Give filgrastim 5 microgram/kg subcutaneously ONCE daily from day 6 until neutrophil recovery past nadir, or as per institutional practice.
- The original published data uses daily filgrastim. Small single centre predominantly retrospective publications, support the use of pegFILGRASTIM 6 mg subcutaneously administered 24 to 48 hours after chemotherapy as an alternative to daily filgrastim and this may be considered.
Cycle details
Cycles 1 to 6 - 21 days
Medication | Dose | Route | Days | Max Duration |
---|---|---|---|---|
prEDNISone * | 60 mg/m² Twice 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 |
DOXOrubicin * | 10 mg/m² Once daily | intravenous | 1 to 4 | 24 hours Min: 24 hours |
vinCRISTine * | 0.4 mg/m² Once daily | intravenous | 1 to 4 | 24 hours Min: 24 hours |
etoposide (as phosphate) | 50 mg/m² Once daily | intravenous | 1 to 4 | 24 hours Min: 24 hours |
CYCLOPHOSPHamide | 480 mg/m² | intravenous | 5 | 60 minutes |
filgrastim | 5 microgram/kg Once daily | subcutaneous injection | 6 |
DOXOrubicin, etoposide (as phosphate) and vinCRISTine:
- May be admixed and administered as a 96 hour infusion.
- Consult latest literature for stability information of an admixed solution.
- Consider accuracy of infusion device, infusion time must not be less than 90 hours or longer than 100 hours (i.e. +/- 5% of total time of 96 hours).
- A central venous access device is required for administration of the 96 hour infusion.
vinCRISTine: Dose capping of vinCRISTine to 2 mg (flat dose) over 96 hours is not included in published DA-R-EPOCH protocol but could be considered for patients over 50 years of age.
filgrastim:
- Give filgrastim 5 microgram/kg subcutaneously ONCE daily from day 6 until neutrophil recovery past nadir, or as per institutional practice.
- The original published data uses daily filgrastim. Small single centre predominantly retrospective publications, support the use of pegFILGRASTIM 6 mg subcutaneously administered 24 to 48 hours after chemotherapy as an alternative to daily filgrastim and this may be considered.
Full details
Cycles 1 to 6 - 21 days
Day: 1
Medication | Dose | Route | Max duration | Details |
---|---|---|---|---|
prEDNISone * | 60 mg/m² Twice daily | oral administration |
Instructions:
Give first dose at least ONE hour prior to RITUximab with food. |
|
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 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. |
DOXOrubicin * | 10 mg/m² Once daily | intravenous | 24 hours Min: 24 hours |
Instructions:
|
vinCRISTine * | 0.4 mg/m² Once daily | intravenous | 24 hours Min: 24 hours |
Instructions:
|
etoposide (as phosphate) | 50 mg/m² Once daily | intravenous | 24 hours Min: 24 hours |
Instructions:
|
Day: 2
Medication | Dose | Route | Max duration | Details |
---|---|---|---|---|
prEDNISone * | 60 mg/m² Twice daily | oral administration |
Instructions:
Take with food. |
|
DOXOrubicin * | 10 mg/m² Once daily | intravenous | 24 hours Min: 24 hours |
Instructions:
|
vinCRISTine * | 0.4 mg/m² Once daily | intravenous | 24 hours Min: 24 hours |
Instructions:
|
etoposide (as phosphate) | 50 mg/m² Once daily | intravenous | 24 hours Min: 24 hours |
Instructions:
|
Day: 3
Medication | Dose | Route | Max duration | Details |
---|---|---|---|---|
prEDNISone * | 60 mg/m² Twice daily | oral administration |
Instructions:
Take with food. |
|
DOXOrubicin * | 10 mg/m² Once daily | intravenous | 24 hours Min: 24 hours |
Instructions:
|
vinCRISTine * | 0.4 mg/m² Once daily | intravenous | 24 hours Min: 24 hours |
Instructions:
|
etoposide (as phosphate) | 50 mg/m² Once daily | intravenous | 24 hours Min: 24 hours |
Instructions:
|
Day: 4
Medication | Dose | Route | Max duration | Details |
---|---|---|---|---|
prEDNISone * | 60 mg/m² Twice daily | oral administration |
Instructions:
Take with food. |
|
DOXOrubicin * | 10 mg/m² Once daily | intravenous | 24 hours Min: 24 hours |
Instructions:
|
vinCRISTine * | 0.4 mg/m² Once daily | intravenous | 24 hours Min: 24 hours |
Instructions:
|
etoposide (as phosphate) | 50 mg/m² Once daily | intravenous | 24 hours Min: 24 hours |
Instructions:
|
Day: 5
Medication | Dose | Route | Max duration | Details |
---|---|---|---|---|
prEDNISone * | 60 mg/m² Twice daily | oral administration |
Instructions:
Take with food. |
|
CYCLOPHOSPHamide | 480 mg/m² | intravenous | 60 minutes |
Day: 6
Medication | Dose | Route | Max duration | Details |
---|---|---|---|---|
filgrastim | 5 microgram/kg Once daily | subcutaneous injection |
Instructions:
Give ONCE daily from Day 6 until neutrophil recovery past the nadir, or as per institutional practice. Round dose to nearest prefilled syringe dose of 300 micrograms or 480 micrograms. |
Additional details
Section 1: Subsequent cycle levels determined by neutrophil and platelet counts as per Table:
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: | Medium |
Gastroprotection: | Gastroprotection may be considered |
Growth factor support: | Recommended for primary prophylaxis |
Hypersensitivity / Infusion related reaction risk: | High - routine premedication recommended |
Pneumocystis jirovecii pneumonia (PJP) prophylaxis: | Routine antibiotic prophylaxis recommended |
Tumour lysis syndrome prophylaxis: | Tumour lysis syndrome prophylaxis may be considered |
References
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.