ABSTRACT
Vincristine 2 mg IV days 1,8,15,22 Daunorubicin 25 mg/M2 IV days 1,8,15,22 Prednisone 60 mg/M2 PO days 1-28 L-asparaginase 5,000 units/M2 IV days 1-14
INDUCTION-PHASE II | Cyclophosphamide 650 mg/M2 IV days 29,43,57
-maximum dose 1000 mg Ara-C 75 mg/M2 IV days 31-34,38-41,-
45-48,52-55 6-Mercaptopurine 60 mg/M2 PO days 29-57
CNS PROPHYLAXIS-weeks 5 through 8 Methotrexate 10 mg/M2 IT days 31,38,45,52
-maximum dose is 15 mg Cranial 1800-2400 cGy given with phase II radiotherapy induction
CONSOLIDATION-PHASE l-begins week 20 | Vincristine 2 mg IV days 1,8,15,22. Doxorubicin 25 mg/M2 IV days 1,8,15,22 Dexamethasone 10 mg/M2 PO days 1-28
CONSOLIDATION-PHASE II Cyclophosphamide 650 mg/M2 IV day 29
- maximum dose is 1000 mg Ara-C 75 mg/M2 IV days 31-34,38-41 6-Thioguanine 60 mg/M2 PO days 29-42
MAINTENANCE 1 6-Mercaptopurine 60 mg/M2 PO daily
weeks 10-18,29-130 Methotrexate 20 mg/M2 PO/IV weekly
weeks 10-18,29-130
REF: Hoelzer etal. Blood 1988; 71:123-131 PREMEDICATIONS 1. Kytril 1 mg PO/IV 30 minutes before and 12 hours after:
daunorubicin, doxorubicin, and cyclophosphamide 2. Compazine 10 mg PO/IV 30 minutes before: cytarabine
and L-asparaginase
toxicity; vesicant-avoid extravasation
Methotrexate-use 75% dose for CrCI < 50; 50% dose if CrCI < 25; do not give if patient has an effusion (“reservoir effect”)
Vincristine-vesicant-avoid extravasation; cumulative neurotoxic ity-may produce severe constipation; maximum 2 mg per administration
6-Mercaptopurine-reduce dose by 75% when used in conjunc tion with allopurinol
L-asparaginase-be prepared to treat anaphylaxis at each administration; giving with or immediately before Vincristine may increase Vincristine toxicity
Hyper CVAD Regimen HYPER CVAD ALTERNATING WITH HIGH DOSE METHOTREXATE/ARA-C
-alternate above for a total of 8 cycles
-subsequent cycles given when WBC recovers to > 3.0 and platelet count is > 60,000
HYPER CVAD-cycles 1 ,3 , 5, and 7 Cyclophosphamide 300 mg/M2 IVQ12H days 1-3
(over 3 h) Mesna 600 mg/M2/d CIV days 1-3
-start at same time as cyclophosphamide and finish 6 hours after completion of cyclophosphamide
Vincristine 2 mg IV days 4,11 Doxorubicin 50 mg/M2 IV day 4 Dexamethasone 40 mg PO days 1-4,
11-14
PREMEDICATIONS 1. Kytril 1 mg PO/IV 30 minutes before and 12 hours after
chemotherapy on days 1-4
OTHER MEDICATIONS 1. Levofloxacin 500 mg PO QD 2. Fluconazole 200 mg PO QD 3. Valacyclovir 500 mg PO QD 4. Neupogen 10 mcg/kg/d SQ divided BID starting day 5
HIGH DOSE METHOTREXATE AND CYTARABINE (ARA-C)-cycles 2, 4, 6, 8 Methotrexate 200 mg/M2 IV (over 2 h) day 1
-followed by Methotrexate 800 mg/M2 CIV (over 24 h) day 1
-increase Leucovorin to 50 mg PO Q6H if methotrexate level is:
> 20 pmol/L at end of infusion
> 1 pmol/L 24 hr later
> 0.1 pmol/L 48 hr after the end of the methotrexate infusion
- continue until methotrexate level is < 0.1 nmol/L Ara-C 3 gm/M2 IV days 2-3
over 2 hr Q12Hfor4 doses
Methylprednisolone 50 mg IV BID days 1-3
PREMEDICATIONS 1. Kytril 1 mg PO/IV 30 minutes before and 12 hours after
chemotherapy on days 1-3
OTHER MEDICATIONS 1. Levofloxacin 500mg POOD 2. Fluconazole 200 mg PO QD 3. Valacyclovir 500 mg PO QD 4. Neupogen 10 mcg/kg/dSQ divided BID starting day 5 5. Dexamethasone eye drops 2 drops each eye Q3H during
and for 48-72 hours after completion of cytarabine CNS TREATMEN1'/PROPHYLAXIS
High Risk-LDH > 600 and/or high proliferative index; mature B-cell ALL
Low Risk-neither of above
Methotrexate 12 mg IT day 2 Ara-C 100 mg IT day 8
Known CNS disease-IT therapy twice weekly until CNS negative, then per prophylaxis protocol
High risk-above is repeated for each of the 8 cycles of chemo therapy
Low risk-above is repeated only during the first 2 cycles of ; chemotherapy
Unknown risk-above is repeated during the first 4 cycles of chemotherapy
MAINTENANCE PHASE A. Mature B-cell ALL-no maintenance B. Ph+ ALL-allogeneic transplant if donor available; other
wise, IFN and Ara-C as below
-therapy is continued for 2 years | Continued
Ara-C 10 mg
SQ QD SQ QD
C. All other patients
-therapy is continued for 2 years
6-Mercaptopurine 50 mg Methotrexate 20 mg/M2 Vincristine 2 mg Prednisone 200 mg
POTID QD PO weekly IV monthly PO days 1-5
monthly
OTHER MEDICATIONS 1. Trimethoprim/sulfamethoxazole DS1
weekend 2. Valacyclovir 500 mg PO QD or TIW
tab PO BID each
-above medications are continued for first 6 months of maintenance phase
REF: Kantarjian et al. J Clin Oncol 2000; 18:547-561
Methotrexate-25% dose reduction for creatinine 1.5-2 and 50% reduction for creatinine > 2; do not give if patient has an effusion (“reservoir effect”)
Vincristine-vesicant-avoid extravasation; cumulative neurotoxic ity-may produce severe constipation; maximum 2 mg per administration; dose reduced to 1 mg for bilirubin > 2
6-Mercaptopurine-reduce dose by 75% when used in conjunc tion with allopurinol
Doxorubicin-monitor cumulative dose for cardiac toxicity (not to exceed 550 mg/M2 or 450 mg/M2 with prior chest Radio therapy); vesicant-avoid extravasation; dose reduced by 25% if bilirubin 2-3,50% if bilirubin 3-4, and 75% if bilirubin > 4
Ara-C-high doses can cause CNS toxicity (cerebellar dysfunc tion); neurotoxicity increases as infusion time increases; dose reduced to 1 gm/M2 if age > 60, creatinine > 2, or if Methotrex ate level at end of infusion is > 20 pmol/L
Larson Regimen COURSE 1: INDUCTION (4 WEEK) WEEKS 1-4 Cyclophosphamide 1200 mg/M2 IV
Daunorubicin 45 mg/M2 IV Vincristine 2 mg IV
Prednisone 60 mg/M2 PO L-asparaginase 6000 IU/M2 SQ
day 1 days 1-3 days 1,8,
15,22 days 1-21 days 5,8,
11,15,18,22
Cyclophosphamide 800 mg/M2 Daunorubicin 30 mg/M2 Prednisone 60 mg/M2
on day 1 on days 1-3 on days 1-7
COURSE II: EARLY INTENSIFICATION (4 WEEK; REPEAT ONCE) WEEKS 5-12 Methotrexate 15 mg IT day 1
Cyclophosphamide 1000 mg/M2 IV day 1 6-Mercaptopurine 60 mg/M2 PO days 1-14 Ara-C 75 mg/M2 SQ days 1-4,
8-11 Vincristine 2 mg IV days 15,22 L-asparaginase 6,000 IU/M2 SQ days 15,18,
22,25 COURSE III: CNS PROPHYLAXIS AND INTERIM MAINTENANCE (12 WEEK) WEEKS 13-25 Cranial Radiotherapy 2400 cGy over days 1-12
Methotrexate 15 mg IT days 1,8,15, 22,29
6-Mercaptopurine 60 mg/M2 PO days 1-70 Methotrexate 20 mg/M2 PO days 36,43,
50,57,64 COURSE IV: LATE INTENSIFICATION (8 WEEK) WEEKS 26-33 ! Doxorubicin 30 mg/M2 IV days 1,8,15
Vincristine 2 mg IV days 1,8,15 Dexamethasone 10 mg/M2 PO days 1-14 Cyclophosphamide 1000 mg/M2 IV day 29 6-Thioguanine 60 mg/M2 PO days 29-42 Ara-C 75 mg/M2 SQ days 29,32,
36-39 COURSE V: PROLONGED MAINTENANCE UNTIL 24 MONTHS FROM DIAGNOSIS
Vincristine 2 mg IV day 1 every 4 wks
Prednisone 60 mg/M2 PO days 1-5 every 4 wks
Methotrexate
every 4 wks 6-Mercaptopurine
CNJEoCO PO days 1-28 every 4 wks
REF: Larson et al. Blood 1995; 85:2025-2037
PREMEDICATIONS 1. Kytril 1 mg PO/IV 30 minutes before and 12 hours after:
daunorubicin, doxorubicin, and cyclophosphamide 2. Compazine 10 mg PO/IV 30 minutes before: cytarabine
and L-asparaginase
toxicity; vesicant-avoid extravasation
Methotrexate-use 75% dose for CrCI < 50; 50% dose if CrCI < 25; do not give if patient has an effusion (“reservoir effect”)
Vincristine-vesicant-avoid extravasation; cumulative neurotoxicity-may produce severe constipation; maximum 2 mg per administration
6-Mercaptopurine-reduce dose by 75% when used in conjunc tion with allopurinol
L-asparaginase-be prepared to treat anaphylaxis at each administration; giving with or immediately before Vincristine may increase Vincristine toxicity
Linker Regimen INDUCTION
Daunorubicin 50 mg/M2 IV days 1-3 Vincristine 2 mg IV days 1,8,15,22 Prednisone 60 mg/M2 PO days 1-28
divided TID L-asparaginase 6,000 IU/M2 IM days 17-28
-if day 14 bone marrow shows residual leukemia Daunorubicin 50 mg/M2 IV day 15
-if day 28 bone marrow shows residual leukemia Daunorubicin 50 mg/M2 IV days 29,30 Vincristine 2 mg IV days 29,36 Prednisone 60 mg/M2 PO days 29-42
divided TID L-asparaginase 6,000 IU/M2 IM days 29-35
CNS PROPHYLAXIS -initiate within 1 week of achieving complete remission Cranial XRT 1800 cGy in 10 fractions Methotrexate 12 mg IT weekly X 6
-if CNS is positive at time of diagnosis -begin weekly intrathecal MTX during induction
-MTX12 mg IT weekly X 10
-Cranial XRT to 2800 cGy CONSOLIDATION-TREATMENT A-CYCLES 1, 3, 5, 7
Daunorubicin 50 mg/M2 IV days 1,2 Vincristine 2 mg IV days 1,8 Prednisone 60 mg/M2 PO days 1-14
divided TID L-asparaginase 12,000 IU IM days 2,4,7,
9,11,14 Continued
Teniposide 165 mg/M2 IV days 1,4,8,11 Ara-C 300 mg/M2 IV days 1,4,8,11
CONSOLIDATION-TREATMENT C-COURSE 9 Methotrexate 690 mg/M2 IV (over 42 h) day 1 Leucovorin 15 mg/M2 IV Q6H for 12 doses-
start at hour 42 MAINTENANCE THERAPY
-continued for 30 months of CR Methotrexate 20 mg/M2 PO weekly 6-MP 75 mg/M2 PO daily
REF: Linker et al. Blood 1991; 78:2814-2822
PREMEDICATIONS 1. Kytril 1 mg PO/IV 30 minutes before and 12 hours after
daunorubicin 2. Compazine 10 mg PO/IV 30 minutes before Ara-C,
L-asparaginase, and teniposide
Daunorubicin-monitor cumulative dose for possible cardiac toxicity; vesicant-avoid extravasation
Methotrexate-use 75% dose for CrCI < 50; 50% dose if CrCI < 25; do not give if patient has an effusion (“reservoir effect”)
: Vincristine-vesicant-avoid extravasation; cumulative neurotoxic ity-may produce severe constipation; maximum 2 mg per
j administration
6-Mercaptopurine-reduce dose by 75% when used in conjunc-; tion with allopurinol L-asparaginase-be prepared to treat anaphylaxis at each
administration; giving with or immediately before Vincristine may increase Vincristine toxicity
INDUCTION CHEMOTHERAPY
Agent Dosage 7+3 cytarabine (ara-c)/ daunorubicin
Ara-C 100 mg/M2/d CIV days 1-7 Daunorubicin 45 mg/M2 IV days 1-3
REF: Yates et al. Blood 1982; 60:454-462
PREMEDICATIONS 1. Kytril 1 mg PO/IV 30 minutes before and Q12 hours during
chemotherapy on days 1-7 2. Dexamethasone 20 mg IV 30 minutes before chemo
therapy on days 1-3 Daunorubicin-monitor cumulative dose for possible cardiac
toxicity; vesicant-avoid extravasation
CONSOLIDATION-repeat the above drugs for 5 and 2 days respectively
7+3+7 cytarabine (ara-c)/ daunorubicin/ etoposide (VP-16)
Ara-C 100mg/M2/d CIV days 1-7 Daunorubicin 50 mg/M2 IV days 1-3
j VP-16 75 mg/M2 IV (over 1 h)days 1 -7
I REF: Bishop etal. Blood 1990; 75:27-32
PREMEDICATIONS 1. Kytril 1 mg PO/IV 30 minutes before and Q12 hours during
chemotherapy on days 1 -7 i 2. Dexamethasone 20 mg IV 30 minutes before chemo
therapy on days 1-3 I Daunorubicin-monitor cumulative dose for possible cardiac ! toxicity; vesicant-avoid extravasation
CONSOLIDATION-repeat the cytarabine for 5 days and the daunorubicin for 2 days (and optional 5 days of etoposide)
Idarubicin/ cytarabine (ara-c)
Ara-C 100 mg/M2/d CIV days 1-7 Idarubicin 13 mg/M2 IV days 1-3
; REF: Wiernick et al. Blood 1992; 79:313-319
I PREMEDICATIONS 1. Kytril 1 mg PO/IV 30 minutes before and 012 hours during
chemotherapy on days 1-7 2. Dexamethasone 20 mg IV 30 minutes before chemo
therapy on days 1-3
Idarubicin-monitor cumulative dose for possible cardiac
toxicity; vesicant-avoid extravasation
CONSOLIDATION-repeat the above drugs for 5 and 2 days respectively
Mitoxantrone/ cytarabine (ara-c)
Ara-C 100 mg/M2/d CIV days 1-7 Mitoxantrone 12 mg/M2 IV days 1-3
REF: Arlin et al. Leukemia 1990; 4:177-183
PREMEDICATIONS 1. Kytril 1 mg PO/IV 30 minutes before and Q12 hours during
chemotherapy on days 1-5 2. Dexamethasone 20 mg IV 30 minutes before chemo
therapy on days 1 and 2
Mitoxantrone-watch cumulative dose-do not exceed 140 mg/ M2; possible cardiac toxicity
CONSOLIDATION-repeat the above drugs for 5 and 2 days respectively
TAD 9 daunorubicin/ cytarabine (ara-c)/ 6-thioguanine (6-TG)
Ara-C 100 mg/M2/d CIV days 1-2 -followed by Ara-C 100 mg/M2 IV Q12H days 3-8
(over 30 min) Daunorubicin 60 mg/M2 IV days 3-5 6-TG 100 mg/M2 POQ12H days 3-9
REF: Buchner et al. J Clin Oncol 1985; 3:1583-1589
-there are several variations of the DAT/TAD regimen
PREMEDICATIONS 1. Kytril 1 mg PO/IV 30 minutes before and Q12 hours during
chemotherapy on days 1-8 2. Dexamethasone 20 mg IV 30 minutes before chemo
therapy on days 1-5 j Daunorubicin-monitor cumulative dose for possible cardiac j toxicity; vesicant-avoid extravasation
CONSOLIDATION CHEMOTHERAPY HiDAC high-dose cytarabine (ara-c)
-has been used as consolidation chemotherapy or for recurrent disease Ara-C 3000 mg/M2 IVQ12H days 1,3,5
(over 3 h) -note that this is given with an anthracycline, as in the above
regimens
REF: Mayer et al. NEJM 1994; 331:896-903
-there are several variations of the HiDAC regimen
PREMEDICATIONS 1. Kytril 1 mg PO/IV 30 minutes before and 12 hours after
chemotherapy on days 1,3, and 5 2. Dexamethasone 20 mg IV 30 minutes before chemo
therapy on days 1,3, and 5 3. Dexamethasone eye drops 2 drops each eye Q3H during
and for 48-72 hours after completion of cytarabine
Repeat every 28 days (as consolidation) for 2 or 3 courses
Ara-C-high doses can cause CNS toxicity (cerebellar dysfunc tion); neurotoxicity increases as infusion time increases
RELAPSED/REFRACTORY DISEASE
HAM high-dose cytarabine (ara-c)/ mitoxantrone
Ara-C 3000 mg/M2 IVQ12H(over3h) days 1-4 Mitoxantrone 10 mg/M2 IV(over 30 min) days 2-5 or 6
REF: Hiddemann et al. Blood 1987; 69:744-749
PREMEDICATIONS 1. Kytril 1 mg PO/IV 30 minutes before and Q12 hours during
chemotherapy on days 1 -5 2. Dexamethasone 20 mg IV 30 minutes before chemo
therapy on days 1-4 3. Dexamethasone eye drops 2 drops each eye Q3H during
and for 48-72 hours after completion of cytarabine
Ara-C-high doses can cause CNS toxicity (cerebellar dysfunc tion); neurotoxicity increases as infusion time increases
Mitoxantrone-watch cumulative dose-do not exceed 140 mg/M2; possible cardiac toxicity
High-dose cytarabine (ara-c)/ fludarabine
Fludarabine 30 mg/M2 IV(over 30 min) days 2-6 -followed 31/2 hours later by Ara-C 1000 mg/M2 IV(over2h) days 1-6
j REF: Estey et al. Leuk Lymphoma 1993; 9:343-350
PREMEDICATIONS 1. Kytril 1 mg PO/IV 30 minutes before and 012 hours during
chemotherapy on days 1-5 2. Dexamethasone 20 mg IV 30 minutes before chemo
therapy on days 1-5 3. Dexamethasone eye drops 2 drops each eye Q3H during
and for 48-72 hours after completion of cytarabine Ara-C-high doses can cause CNS toxicity (cerebellar dysfunc
tion); neurotoxicity increases as infusion time increases Continued
Mitoxantrone/ etoposide (VP-16)
INDUCTION VP-16 100 mg/M2 IV Mitoxantrone 10 mg/M2 IV
days 1-5 days 1-5
CONSOLIDATION VP-16 75 mg/M2 IV Mitoxantrone 8 mg/M2 IV Ara-C 75 mg/M2 IVQ12H
days 1-5 days 1-5 days 1-5
REF: Ho et al. J Clin Oncol 1988; 6:213-217
PREMEDICATIONS 1. Kytril 1 mg PO/IV 30 minutes before and 012 hours during
chemotherapy on days 1-5 2. Dexamethasone 20 mg IV 30 minutes before chemo
therapy on days 1-5
Mitoxantrone-watch cumulative dose-do not exceed 140 mg/M2; possible cardiac toxicity
Gemtuzumab zogamicin (Mylotarg)
-also called CMA-676 Mylotarg 9mg/M2 IV days 1,15
i REF: Sievers et al. Blood 1999; 94 (Suppl 1):abstract 3079
PREMEDICATIONS : 1. Benadryl 25-50 mg PO/IV 30 minutes before
2. Tylenol 650 mg PO 30 minutes before Day 15 dose is given regardless of blood counts
ACUTE PROMYELOCYTIC LEUKEMIA ATRA/ daunorubicin/ cytarabine (ara-c)
INDUCTION ATRA 45 mg/M2 PO
(divided BID) Daunorubicin 60 mg/M2 IV Ara-C 200 mg/M2 IV
daily until CR or 90 days
days 3-5 days 3-9
CONSOLIDATION 1 Daunorubicin 60 mg/M2 IV Ara-C 200 mg/M2 IV
days 1-3 days 1-7
CONSOLIDATION 2 Daunorubicin 45 mg/M2 IV Ara-C 1000 mg/M2 IVQ12H
days 1-3 days 1-4
MAINTENANCE -continued to complete 2 years of therapy ATRA 45 mg/M2 PO
every 3 mos
6-MP 90 mg/M2/d PO daily Methotrexate 15 mg/M2 PO weekly
REF: Fenaux et al. Blood 1999; 94:1192-1200
PREMEDICATIONS 1. Kytril 1 mg PO/IV 30m minutes before and Q12 hours
during daunorubicin and ara-c 2. Dexamethasone 20 mg IV 30 minutes before chemo
therapy during daunorubicin and ara-c
6-Mercaptopurine-reduce dose by 75% when used in conjunc tion with allopurinol
Daunorubicin-monitor cumulative dose for possible cardiac toxicity; vesicant-avoid extravasation
Ara-C-high doses can cause CNS toxicity (cerebellar dysfunc tion); neurotoxicity increases as infusion time increases
Methotrexate-use 75% dose for CrCI < 50; 50% dose if CrCI < 25; do not give if patient has an effusion (“reservoir effect”)
AIDA ATRA/idarubicin
INDUCTION ATRA 45 mg/M2 PO (divided bid) daily until
CR or 90 days Idarubicin 12 mg/M2 IV days 2,4,6,8
CONSOLIDATION 1 Idarubicin 5 mg/M2 IV days 1-4
CONSOLIDATION 2 Mitoxantrone 10 mg/M2 IV days 1-5
CONSOLIDATION 3 Idarubicin 12 mg/M2 IV day 1
MAINTENANCE -continued to complete 2 years of therapy
ATRA 45 mg/M2 PO (divided BID every 3 mos fori 5 days)
6-MP 90 mg/M2/d PO daily Methotrexate 15 mg/M2 IM weekly
REF: Sanz et al. Blood 1999; 94:3015-3021
PREMEDICATIONS 1. Kytril 1 mg PO/IV 30m minutes before and Q12 hours
during anthracycline therapy 2. Dexamethasone 20 mg IV 30 minutes before chemo
therapy during anthracycline therapy
6-Mercaptopurine-reduce dose by 75% when used in conjunc tion with allopurinol
Idarubicin-monitor cumulative dose for possible cardiac toxicity; vesicant - avoid extravasation
Mitoxantrone-watch cumulative dose-do not exceed 140 mg/ M2; possible cardiac toxicity
Methotrexate-use 75% dose for CrCI < 50; 50% dose if CrCI < 25; do not give if patient has an effusion (“reservoir effect”)
Arsenic trioxide Arsenic trioxide 0.1 mg/kg/d IV days 1-28 (over 1-2 h)
REF: Westervelt et al. Blood 1999; 94 (Suppl 1):abstract 2268
Repeat every 42 days for a maximum of 3 cycles (or until cytogenetic remission, followed by 1 consolidation course)
Chronic L] Agent COP
miphocytic Leukemia Dosage Cyclophosphamide 400 mg/M2 PO days 1-5
cyclophos phamide/ vincristine/ prednisone
Vincristine 1.4 mg/M2 IV day 1 Prednisone 80 mg PO days 1-5
REF: Raphael et al. J Clin Oncol 1991; 9:770-776
PREMEDICATIONS 1. Kytril 1 mg PO/IV 30 minutes before and 12 hours after
chemotherapy on days 1-5 Repeat every 21 days Vincristine-vesicant-avoid extravasation; cumulative neurotoxic
FCR - cyclophos phamide/
ity; may produce severe constipation; maximum 2 mg per administration
Cyclophosphamide 250 mg/M2 IV days 1-3 Fludarabine 25 mg/M2 IV days 1-3 Rituximab 375 mg/M2 IV day 1
fludarabine/ rituximab -fo r cycles 2-6, dose is increased to 500 mg/M2
-infusion is started at 50 mg/hr (25 mg/hr in patients with circulating tumor cells) and slowly increased to a maximum of 400 mg/hr (300 mg/hr during initial infusion)
REF: Keating et al. Proc Am Soc Clin Oncol 2000; abstract 2214
PREMEDICATIONS 1. Kytril 1 mg PO/IV 30 minutes before and 12 hours after
chemotherapy 2. Tylenol 650 mg PO 30 minutes before rituximab 3. Benadryl 25 mg PO/IV 30 minutes before rituximab
Trimethoprim-sulfamethoxazole DS BID for 2 days each week for patients who require any corticosteroids
Chlorambucil daily
Repeat every 28 days Chlorambucil 0.1 mg/kg PO QD
REF: Dighiero et al. NEJM1998; 338:1506-1514 Given daily -adjust dose based on CBC
Chlorambucil pulse
Chlorambucil 0.3 mg/kg PO days 1-5 Prednisone 40 mg/M2 PO days 1-5 REF: Dighiero etal. NEJM 1998; 338:1506-1514
Brain C
ancer BreastCancer
Carcinom a
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ary
Endocrine Cancer
Gastrointestinal Cancer
Genitourinary Cancer
G ynecologic
Cancer Head
and Neck
Cancer
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OR Chlorambucil 30 mg/M2 PO day 1 Prednisone 100 mg/M2 PO days 1-5 REF: Raphael et al. J Clin Oncol 1991; 9:770-776 Repeat every 28 days -adjust dose based on CBC
Cyclophos phamide-oral
Cyclophosphamide 1-2 mg/kg P0 daily
REF: Huguley et al. Cancer Treat Rev 1977; 4:261-273 -there are multiple variations of this regimen Cyclophosphamide-precautions against hemorrhagic cystitis
Cyclophosphamide-IV
Cyclophosphamide 20 mg/kg IV day 1 REF: Huguley et al. Cancer Treat Rev 1977; 4:261-273 -there are multiple variations of this regimen PREMEDICATIONS 1. Kytril 1 mg PO/IV 30 minutes before and 12 hours after
chemotherapy 2. Dexamethasone 20 mg IV 30 minutes before chemo
therapy Repeat every 14-21 days Cyclophosphamide-precautions against hemorrhagic cystitis
Fludarabine Consider prophylactic use of trimethoprin-sulfamethoxazole Fludarabine 25 mg/M2 IV days 1-5
REF: Keating et al. J Clin Oncol 1991; 9:44-49
Repeat every 28 days
Br ain
Ca
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Chronic Myelogenous Leukemia Agent Dosage Interferon-alfa 2a (IFN)/ cytarabine (Ara-C)
IFN 5 X106 units/M2 SQ Ara-C 10 mg SQ
REF: Kantarjian et al. J Clin Oncol 1999; 17:284-292
daily daily
PREMEDICATIONS 1. Tylenol 650 mg PO before IFN 2. Compazine 10 mg PO before prn
Busulfan Busulfan 4-8 mg PO daily REF: Bolin et al. Cancer 1982; 50:1683-1686 Hold for WBC count < 20,000; resume for WBC > 50,000
Hydroxyurea Hydroxyurea 500-2000 mg PO daily REF: Bolin et al. Cancer 1982; 50:1683-1686
Interferon-alfa IFN 5 X106 units/M2 SQ daily 2a (IFN)
REF: Alimena et al. Blood 1988; 72:642-647 PREMEDICATIONS 1. Tylenol 650 mg PO before IFN prn Interferon-adjust dose as tolerated to maintain WBC count
3000-5000 Thiotepa -this agent can be used for persistent thrombocythemia in
CML patients who have adequate WBC count Thiotepa 75 mg/M2 IV day 1
REF: Rodriquez-Monge et al. Cancer 1997; 80:396-400 PREMEDICATIONS 1. Compazine 10 mg PO/IV 30 minutes before chemotherapy
Repeat every 14-21 days
Brain Cancer
BreastCancer Carcinom
a ofUnknown
Prim ary
Endocrine Cancer
Gastrointestinal Cancer
Genitourinary Cancer
Gynecologic Head
and Neck
Cancer Cancer
Hairy Cell Leukemia Agent Dosage Cladribine (2-chlorodeoxyadenosine, 2-CdA)
2-CdA 0.1 mg/kg/d CIV
REF: Piro et al. NEJM 1990; 322:1117-1121
Single 7 day infusion
days 1-7
Interferon alfa-2a (IFN)
IFN 2 MIU/M2 SQ TIW for 1 year
REF: Rai et al. Leukemia 1995; 9:1116-1120 PREMEDICATIONS 1. Acetaminophen as needed to alleviate fever or “flu-like”
symptoms Pentostatin (2-deoxycoformycin)
Pentostatin 4 mg/M2 IV
REF: Grever et al. J Clin Oncol 1995; 13:974-982
Repeat every 14 days for at least 3 months
day 1
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Hodgkin’s Disease Agent Dosage ABVD Doxorubicin 25 mg/M2 IV days 1,15 doxorubicin/ Bleomycin 10 mg/M2 IV days 1,15 bleomycin/ Vinblastine 6 mg/M2 IV days 1,15 vinblastine/ DTIC 375 mg/M2 IV days 1,15 dacarbazine (DTIC) REF: Bonadonna et al. Cancer 1975; 36:252-259
PREMEDICATIONS 1. Kytril 1 mg PO/IV 30 minutes before and 12 hours after
chemotherapy on days 1 and 15 2. Dexamethasone 20 mg IV 30 minutes before chemo
therapy on days 1 and 15 Repeat every 28 days Doxorubicin-monitor cumulative dose for cardiac toxicity (not to
exceed 550 mg/M2 or 450 mg/M2 with prior chest radiotherapy); vesicant-avoid extravasation; use 50% for bilirubin 1.5-3.0; use 25% for bilirubin > 3.0
Vinblastine-use 50% of dose for bilirubin > 3.0; vesicant-avoid extravasation; watch for neurotoxicity
Bleomycin-give test dose of 1-2 units because of possible acute pulmonary, anaphylactoid, or severe febrile reactions; must dose adjust for renal insufficiency; total lifetime dose should not exceed 400 units; avoid high Fi02 as it can exacerbate pulmo nary toxicity
Dacarbazine-vesicant-avoid extravasation ASHAP Doxorubicin 10mg/M2/d CIV days 1-4 doxorubicin/ (for 96 h) methyl-Methylprednisolone 500 mg IV days 1-4 prednisolone/ (over 15 min) cytarabine/ Cytarabine 1500 mg/M2 IV day 5 cisplatin (over 2 h)
REF: Rodriguez et al. Blood 1999; 93:3632-3636 PREMEDICATIONS 1. Kytril 1 mg PO/IV Q12H for 10 doses, starting 30 minutes
before chemotherapy on day 1 OTHER MEDICATIONS 1. Give cisplatin delayed-emesis prophylaxis Repeat every 21-28 days
Brain Cancer
BreastCancer Carcinoma
Endocrine Gastrointestinal
Genitourinary G
ic Head
and Neck
ofUnknown Cancer
Cancer Cancer
Cancer Cancer
Prim ary
Agent Dosage Doxorubicin-monitor cumulative dose for cardiac toxicity (not to
exceed 550 mg/M2 or 450 mg/M2 with prior chest radiotherapy); vesicant-avoid extravasation; use 50% for bilirubin 1.5-3.0; use 25% for bilirubin > 3.0
Cisplatin-vigorous hydration is required; can be nephrotoxic and ototoxic; can cause peripheral neuropathy; hold or reduce for creatinine > 1.5
Cytarabine-high doses can cause CNS toxicity (cerebellar dysfunction); neurotoxicity increases as infusion time increases
BEACOPP Cyclophosphamide 650 mg/M2 IV day 1 cyclophos Vincristine 1.4 mg/M2 IV day 1 phamide/ VP-16 100 mg/M2 IV days 1-3 vincristine/ Procarbazine 100 mg/M2 PO days 1-7 etoposide Prednisone 40 mg/M2 PO days 1-14 (VP-16)/ Doxorubicin 25 mg/M2 IV day 1 procarbazine/ prednisone/ doxorubicin/ bleomycin
Bleomycin 10 mg/M2 IV day 8
REF: Tesch et al. Blood 1998; 92:4560-4567
PREMEDICATIONS 1. Kytril 1 mg PO/IV 30 minutes before and 12 hours after
chemotherapy on day 1 2. Dexamethasone 20 mg IV 30 minutes before chemo
therapy on day 1 3. Compazine 10 mg PO/IV 30 minutes before chemotherapy
on day 8 Repeat every 28 days Vincristine-vesicant-avoid extravasation; cumulative
neurotoxicity-may produce severe constipation; maximum 2 mg per administration
Doxorubicin-monitor cumulative dose for cardiac toxicity (not to exceed 550 mg/M2 or 450 mg/M2 with prior chest radiotherapy); vesicant-avoid extravasation; use 50% for bilirubin 1.5-3.0; use 25% for bilirubin > 3.0
Bleomycin-give test dose of 1-2 units because of possible acute pulmonary, anaphylactoid, or severe febrile reactions; must dose adjust for renal insufficiency; total lifetime dose should not exceed 400 units; avoid high Fi02 as it can exacerbate pulmo nary toxicity Hea
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Dexa-BEAM Dexamethasone 8 mg PO Q8H days 1-10 dexamethasone/ BCNU 60 mg/M2 IV day 2 carmustine VP-16 75 mg/M2 IV days 4-7 (BCNU)/ Ara-C 100 mg/M2 IVQ12H days 4-7 etoposide Melphalan 20 mg/M2 IV day 3 (VP-16)/ cytarabine REF: Pfreundschuh et al. J Clin Oncol 1994; 12:580-586 (Ara-C)/ melphalan PREMEDICATIONS
1. Kytril 1 mg PO/IV 30 minutes before and 12 hours after chemotherapy on days 2 and 3 2. Compazine 10 mg PO/IV 30 minutes before chemotherapy on
days 4-7 OTHER MEDICATIONS 1. Give non-cisplatin delayed emesis prophylaxis Repeat every 28 days Carmustine-maximum total dose is 1440 mg/M2; causes
delayed myelosuppression Mini-BEAM BCNU 60 mg/M2 IV day 1 carmustine VP-16 75 mg/M2 IV days 2-5 (BCNU)/ Ara-C 100 mg/M2 IVQ12H days 2-5 etoposide Melphalan 20 mg/M2 IV day 6 (VP-16)/ cytarabine REF: Colwill et al. J Clin Oncol 1995; 13:396-402 (Ara-C)/ melphalan PREMEDICATIONS
1. Kytril 1 mg PO/IV 30 minutes before and 12 hours after chemotherapy on days 1 and 6
2. Dexamethasone 20 mg IV 30 minutes before chemo therapy on days 1 and 6
3. Compazine 10 mg PO/IV 30 minutes before chemotherapy on days 2-5
OTHER MEDICATIONS 1. Give non-cisplatin delayed emesis prophylaxis Repeat every 28-42 days Carmustine-maximum total dose is 1440 mg/M2; causes
delayed myelosuppression ChlVPP Chlorambucil 6 mg/M2 PO days 1-14 chlorambucil/ Vinblastine 6 mg/M2 IV days 1,8 vinblastine/ -maximum dose is 10 mg procarbazine/ Procarbazine 100 mg/M2 PO days 1-14 prednisone Prednisone 40 mg/M2 PO days 1-14
Cancer BreastCancer
Carcinoma Endocrine
Gastrointestinal Genitourinary
Head and
Neck ofUnknown
Cancer Cancer
Cancer Cancer
Cancer Prim
ary
REF: Selby et al. Br J Cancer 1990; 62:279-285 PREMEDICATIONS 1. Compazine 10 mg PO/IV 30 minutes before chemotherapy
on days 1 and 8 Repeat every 28 days for 6 cycles Vinblastine-use 50% of dose for bilirubin > 3.0; vesicant-avoid
extravasation; watch for neurotoxicity DHAP Cisplatin 100 mg/M2 CIV (X 24 h) dayl dexamethasone/ Ara-C 2000 mg/M2 IVQ12H day 2 cytarabine X 2 doses, (Ara-C )/cisp I ati n each over 3 h
-start at completion of cisplatin infusion Dexamethasone 40 mg PO/IV days 1-4 REF: Velasquez et al. Blood 1988; 71:117-122 PREMEDICATIONS 1. Kytril 1 mg PO/IV 30 minutes before and 12 hours after_ 1__ _ I J I Achemo on days 1 and 2 OTHER MEDICATIONS 1. Give cisplatin delayed-emesis prophylaxis Repeat every 21-28 days Cisplatin-vigorous hydration is required; can be nephrotoxic and
ototoxic; can cause peripheral neuropathy; hold or reduce for creatinine >1.5
Cytarabine-high doses can cause CNS toxicity (cerebellar dysfunction); neurotoxicity increases as infusion time increases
EVA VP-16 100 mg/M2 IV days 1-3 etoposide Vinblastine 6 mg/M2 IV day 1 (VP-16)/ Doxorubicin 50 mg/M2 IV day 1 vinblastine/ doxorubicin REF: Canellos et al. J Clin Oncol 1995; 13:2005-2011
PREMEDICATIONS 1. Kytril 1 mg PO/IV 30 minutes before and 12 hours after
chemotherapy on day 1 2. Dexamethasone 20 mg IV 30 minutes before chemo
therapy on day 1 3. Compazine 10 mg PO/IV 30 minutes before etoposide on
days 2 and 3 Repeat every 28 days
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Doxorubicin-monitor cumulative dose for cardiac toxicity (not to
exceed 550 mg/M2 or 450 mg/M2 with prior chest radiotherapy); vesicant-avoid extravasation; use 50% for bilirubin 1.5-3.0; use 25% for bilirubin > 3.0
Vinblastine-use 50% of dose for bilirubin > 3.0; vesicant-avoid extravasation; watch for neurotoxicity
MOPP nitrogen
-this regimen is rarely utilized today, and is listed primarily for historical interest Nitrogen mustard 6 mg/M2 IV days 1,8 Vincristine 1.4 mg/M2 IV days 1,8 Procarbazine 100 mg/M2 P0 days 1-14 Prednisone 40 mg/M2 P0 days 1-14
REF: DeVita et al. Ann Intern Med 1970; 73:881-895 PREMEDICATIONS 1. Kytril 1 mg PO/IV 30 minutes before and 12 hours after
chemotherapy on days 1 and 8 2. Dexamethasone 20 mg IV 30 minutes before chemo
therapy on days 1 and 8 Repeat every 28 days Vincristine-vesicant-avoid extravasation; cumulative
neurotoxicity-may produce severe constipation; maximum 2 mg per administration
Nitrogen mustard-potent vesicant-avoid extravasation; decomposes rapidly after mixing; must not be mixed in same syringe with any other drug
mustard/ vincristine/ procarbazine/ prednisone
MOPP-ABV Hybrid
Nitrogen mustard 6 mg/M2 IV day 1 Vincristine 1.4 mg/M2 IV day 1 Procarbazine 100 mg/M2 P0 days 1-7 Prednisone 40 mg/M2 P0 days 1-14 Doxorubicin 35 mg/M2 IV day 8 Bleomycin 10 mg/M2 IV day 8
: Vinblastine 6 mg/M2 IV day 8
REF: Klimo et al. J Clin Oncol 1985; 3:1174-1182
PREMEDICATIONS 1. Kytril 1 mg PO/IV 30 minutes before and 12 hours after
chemotherapy on days 1 and 8 2. Dexamethasone 20 mg IV 30 minutes before chemo
therapy on days 1 and 8 Repeat every 28 days
nitrogen mustard/ vincristine/ procarbazine/ prednisone/ doxorubicin/ bleomycin/ vinblastine
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