Canterbury DHB

Chemotherapy Schedules for Indolent NHL

Bendamustine + Rituximab

1. Rituximab 375 mg/m2 day 1, Bendamustine 90 mg/m2 day 1 and 2, repeat at intervals of 4 weeks for up to 6 cycles.
2. Obtain a special authority for bendamustine use.

CVP + Rituximab (R-CVP)

Cyclophosphamide may also be given IV in a dose of 750 mg/m². There is a prescription chart for a CVP protocol when IV cyclophosphamide is used. See below. If oral cyclophosphamide is given, then cyclophosphamide and prednisone are prescribed on an OP prescription form. There is a prescription chart for IV vincristine.

Repeat every 28 days. Courses may be repeated at 21 days if not cytopenic or with aggressive disease. In general, treatment is delayed if patient is cytopenic. If no benefit has been seen, consider the advisability of more intensive treatment such as CHOP.

Note: Copies of the prescription sheets for the CVP IV protocol, Rituximab 375, and Rituximab Rapid are available. You must print these out and use them for the prescriptions to be sent to Pharmacy. If Rituximab is given, this precedes chemotherapy.

Chlorambucil

Chlorambucil may very rarely now be used as a single agent or possibly in combination with rituximab for very frail patients with NHL. It may be used in various ways, e.g:

1. 4–6 mg daily and continue until a satisfactory response has been seen.
2. 10 mg daily for 6 weeks, none for 2 weeks, then 3 further 2-week courses, each separated by 2 weeks without treatment.
3. 14–20 mg daily for 5 days and repeat every 3–4 weeks, with or without prednisone (MRC UK protocol).

See the Chlorambucil Data Sheets on Medsafe.

Metoclopramide 10 mg TDS may be required.

Maintenance therapy in indolent lymphoma

Rituximab, a monoclonal anti-CD20 antibody, in combination with chemotherapy improves overall survival compared to chemotherapy alone when used for induction therapy for patients with newly diagnosed or relapsed indolent lymphoma. Five trials of rituximab maintenance therapy including 1056 adult patients were analysed in a Cochrane review (see Vidal, L., A. Gafter-Gvili, et al. 2009, Cochrane Database Syst Rev(2): CD006552).

Four trials (895 patients) were included in the analysis of overall survival. Patients treated with rituximab as maintenance therapy had a significantly better overall survival compared to observation alone (HR 0.53, 95% CI 0.38 to 0.73). The review concluded that rituximab maintenance therapy should be added to standard therapy of patients with relapsed or refractory follicular lymphoma following a successful induction treatment. The drug should be given either as four weekly infusions every six months or as a single infusion every two to three months.

Maintenance therapy with rituximab has an established place in the treatment of mantle cell lymphoma. See Le Gouill, S., et al. (2017). "Rituximab after Autologous Stem-Cell Transplantation in Mantle-Cell Lymphoma." New England Journal of Medicine 377(13): 1250-1260.

Rituximab is funded for maintenance treatment (12 doses over 2 years) following primary treatment of indolent lymphoma.

Note: Rituximab is not currently funded by PHARMAC for maintenance therapy. Patients may choose to purchase it privately and be treated with rituximab maintenance at St George's Hospital.

Topic Code: 5951