Monitoring and Supportive Care

See below for dosage modifications, assessment of response, adverse effects, and supportive care needed.

Dose Modifications

Neutropenia and thrombocytopenia may be due to the disease. However, if the fall in counts is due to treatment, the following guidelines should be followed for the next treatment course:

Neutrophils 0.5-1x10⁹/L or platelets 50-75x10⁹/L. Delay next treatment for 1 week.

If after 2 weeks' delay the values have not changed, treatment could proceed at 50% of the dose at the discretion of the specialist.

If neutrophils are below 0.5x10⁹/L or platelets below 50x10⁹/L by the time a new course is due, delay treatment until the counts rise to at least these levels, with dose modification at the discretion of the specialist.

Adverse Effects

Chlorambucil - Grade 3/4 neutropenia and thrombocytopenia is seen in around 15-20%. Gastro-intestinal effects are less common. Rare side effects are allergy, skin reactions and pulmonary toxicity.

Fludarabine - This drug is more myelosuppressive and immunosuppressive than chlorambucil and can also cause severe CD4 lymphopenia. It may be associated with infections, in particular pneumocystis pneumonia, and may precipitate autoimmune complications. Mucositis is rare. Myelosuppression with neutropenia, thrombocytopenia and lymphopenia may occur. Other possible side effects are fever, chills, nausea, emesis, malaise, fatigue, anorexia, weakness, hearing loss, numbness, pneumonia, cough, shortness of breath, diarrhoea, stomatitis, gastrointestinal bleeding, rashes, and rarely peripheral neuropathy.

Fludarabine plus cyclophosphamide - Nausea/vomiting; fatigue, infections, including pneumonia. This combination is more toxic than either drug given alone. In view of the increased risk of myelosuppression check blood counts should be done at 7 days and 14 days at least during the initial treatment course. Subsequent dose modification may be needed if severely cytopenic. G-CSF may need to be considered.


About this Canterbury DHB document (5513):
Document Owner:	Blake Hsu (see Who's Who)
Last Reviewed:	September 2018
Next Review:	September 2021
Keywords:
Note: Only the electronic version is controlled. Once printed, this is no longer a controlled document. Disclaimer The Haematology Department Protocols and Guidelines (the Red Book) are intended as a guide for registered health professionals to communicate guidelines and share best practices with supporting health professionals within New Zealand district health boards. They are not intended to be provided to or used as a reference for patients or non-registered health professionals. All health professionals must exercise their own clinical judgement and use pertinent clinical data when treating patients. The authors and editors of this publication have checked with sources believed to be reliable in their effort to provide information that is complete and in accord with the standards accepted at the time of publication. However, in view of the possibility of human error or changes in medical science, neither the authors, editors, publisher, nor any other party who has been involved in preparing or publishing this work warrants that the information contained in it is accurate or complete in every respect. They therefore have no liability (whether in tort (including negligence) or otherwise) for any loss or damage arising out of any reliance on this information. This publication has been compiled by the staff and contractors of Canterbury District Health Board (CDHB) and as such CDHB has copyright for this book. Amendments must be authorised in accordance with the documented process. No release of part of, or all of, this publication to any other party or organisation is permissible without the prior approval of the designated document owner.
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