Systemic Anti-Cancer Therapy Regimen Library
LUNG NSCLC Metastatic - cARBOplatin, pemetrexed and pembrolizumab
Treatment Overview
Usually up to 4 cycles of cARBOplatin, pemetrexed and pembrolizumab.
Pemetrexed and pembrolizumab may continue until disease progression or unacceptable toxicity.
Cycles 1 to 4 - 21 days - cARBOplatin, pemetrexed and pembrolizumab
folic acid: Starting 7 days before the first cycle, continue ONCE daily until 21 days after the last dose of pemetrexed.
hydroxocobalamin: Starting 7 days before the first cycle and then repeat ONCE every 9 weeks until 21 days after the last dose of pemetrexed.
Cycle 5 (and all further cycles) - 21 days - pemetrexed and pembrolizumab maintenance
folic acid: Take ONCE daily until 21 days after the last dose of pemetrexed.
hydroxocobalamin: Repeat ONCE every 9 weeks (every 3 cycles) until 21 days after the last dose of pemetrexed.
Cycle details
Cycles 1 to 4 - 21 days - cARBOplatin, pemetrexed and pembrolizumab
| Medication | Dose | Route | Days | Max Duration |
|---|---|---|---|---|
| folic acid * | 800 microgram Once daily | oral administration | -7 | |
| hydroxocobalamin | 1 mg | intramuscular injection | -7 | |
| dexamethasone | 4 mg Twice daily | oral administration | 0 to 3 | |
| aprepitant | 125 mg | oral administration | 1 | |
| aprepitant | 80 mg | oral administration | 2, 3 | |
| ondansetron | 8 mg | oral administration | 1 | |
| pembrolizumab | 200 mg flat dosing | intravenous | 1 | 30 minutes |
| pemetrexed * | 500 mg/m² | intravenous | 1 | 10 minutes |
| cARBOplatin * | 5 AUC (area under the curve) | intravenous | 1 | 60 minutes |
| ondansetron | 8 mg | oral administration | 1 | |
| domperidone | 10 mg Three times daily | oral administration | 1 |
folic acid: Starting 7 days before the first cycle, continue ONCE daily until 21 days after the last dose of pemetrexed.
hydroxocobalamin: Starting 7 days before the first cycle and then repeat ONCE every 9 weeks until 21 days after the last dose of pemetrexed.
Cycle 5 (and all further cycles) - 21 days - pemetrexed and pembrolizumab maintenance
| Medication | Dose | Route | Days | Max Duration |
|---|---|---|---|---|
| dexamethasone * | 4 mg Twice daily | oral administration | 0, 1, 2 | |
| folic acid * | 800 microgram Once daily | oral administration | 1 | |
| hydroxocobalamin | 1 mg | intramuscular injection | 1 | |
| pembrolizumab | 200 mg flat dosing | intravenous | 1 | 30 minutes |
| pemetrexed | 500 mg/m² | intravenous | 1 | 10 minutes |
| domperidone | 10 mg Three times daily | oral administration | 1 |
folic acid: Take ONCE daily until 21 days after the last dose of pemetrexed.
hydroxocobalamin: Repeat ONCE every 9 weeks (every 3 cycles) until 21 days after the last dose of pemetrexed.
Full details
Cycles 1 to 4 - 21 days - cARBOplatin, pemetrexed and pembrolizumab
Day: -7
| Medication | Dose | Route | Max duration | Details |
|---|---|---|---|---|
| folic acid * | 800 microgram Once daily | oral administration |
Instructions:
800 microgram = 0.8 mg. Start 7 days before the first cycle, continue until 21 days after the last dose of pemetrexed. |
|
| hydroxocobalamin | 1 mg | intramuscular injection |
Instructions:
1 mg = 1000 microgram. Start 7 days before the first cycle and then repeat ONCE every 9 weeks until 21 days after the last dose of pemetrexed. |
Day: 0
| Medication | Dose | Route | Max duration | Details |
|---|---|---|---|---|
| dexamethasone | 4 mg Twice daily | oral administration |
Instructions:
Take with food. |
Day: 1
| Medication | Dose | Route | Max duration | Details |
|---|---|---|---|---|
| dexamethasone | 4 mg Twice daily | oral administration |
Instructions:
Take with food. |
|
| aprepitant | 125 mg | oral administration |
Instructions:
ONE hour prior to chemotherapy. |
|
| ondansetron | 8 mg | oral administration |
Instructions:
ONE hour prior to chemotherapy. |
|
| pembrolizumab | 200 mg flat dosing | intravenous | 30 minutes |
Instructions:
Administer via a sterile, non-pyrogenic, low protein binding 0.2 to 5 micron in-line or add-on filter. |
| pemetrexed * | 500 mg/m² | intravenous | 10 minutes | |
| cARBOplatin * | 5 AUC (area under the curve) | intravenous | 60 minutes |
Instructions:
To be infused approximately 30 minutes after completion of pemetrexed infusion. Hypersensitivity risk increases with number of cycles of cARBOplatin. |
| ondansetron | 8 mg | oral administration |
Instructions:
EIGHT hours after chemotherapy OR before bed. |
|
| domperidone | 10 mg Three times daily | oral administration |
Instructions:
When required for nausea and/or vomiting. The choice of rescue antiemetic may be substituted to reflect institutional policy or individual patient characteristics. |
Day: 2
| Medication | Dose | Route | Max duration | Details |
|---|---|---|---|---|
| dexamethasone | 4 mg Twice daily | oral administration |
Instructions:
Take with food. |
|
| aprepitant | 80 mg | oral administration |
Instructions:
ONCE daily in the morning. |
Day: 3
| Medication | Dose | Route | Max duration | Details |
|---|---|---|---|---|
| dexamethasone | 4 mg Twice daily | oral administration |
Instructions:
Take with food. |
|
| aprepitant | 80 mg | oral administration |
Instructions:
ONCE daily in the morning. |
Cycle 5 (and all further cycles) - 21 days - pemetrexed and pembrolizumab maintenance
Day: 0
| Medication | Dose | Route | Max duration | Details |
|---|---|---|---|---|
| dexamethasone * | 4 mg Twice daily | oral administration |
Instructions:
Take with food. |
Day: 1
| Medication | Dose | Route | Max duration | Details |
|---|---|---|---|---|
| dexamethasone * | 4 mg Twice daily | oral administration |
Instructions:
Take with food. |
|
| folic acid * | 800 microgram Once daily | oral administration |
Instructions:
800 microgram = 0.8 mg. Take ONCE daily until 21 days after the last dose of pemetrexed. |
|
| hydroxocobalamin | 1 mg | intramuscular injection |
Instructions:
1 mg = 1000 microgram. Administer ONCE every 9 weeks until 21 days after the last dose of pemetrexed. |
|
| pembrolizumab | 200 mg flat dosing | intravenous | 30 minutes |
Instructions:
Administer via a sterile, non-pyrogenic, low protein binding 0.2 to 5 micron in-line or add-on filter. |
| pemetrexed | 500 mg/m² | intravenous | 10 minutes | |
| domperidone | 10 mg Three times daily | oral administration |
Instructions:
When required for nausea and/or vomiting. The choice of rescue antiemetic may be substituted to reflect institutional policy or individual patient characteristics. |
Day: 2
| Medication | Dose | Route | Max duration | Details |
|---|---|---|---|---|
| dexamethasone * | 4 mg Twice daily | oral administration |
Instructions:
Take with food. |
Supportive Care Factors
| Factor | Value |
|---|---|
| Emetogenicity: | Variable |
Emetogenicity: HIGH (cARBOplatin AUC≥4, pemetrexed and pembrolizumab) cycles 1 to 4; LOW pemetrexed maintenance
References
3. 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).
4. Juno Pharmaceuticals NZ Ltd. (2021, May 18). Pemetrexed Juno Medsafe Datasheet 17 August 2017. Retrieved from Medsafe: https://www.medsafe.govt.nz/profs/Datasheet/p/PemetrexedJunoinf.pdf
* 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.