Canterbury DHB

Context

CHOP + Rituximab (R-CHOP21)

CHOP, with the addition of rituximab for B cell lymphomas, remains the standard chemotherapy for many non-Hodgkin lymphomas.

R-CHOP is given 3 weekly for 6-8 cycles, with an initial reassessment after 3-4 cycles.

Day

Medication

Dose

Administration

Day 1

Rituximab

375 mg/m2

IV infusion

Day 1

Cyclophosphamide

750 mg/m2

IV infusion in 100 mL 0.9S over ½ hour

Day 1

Doxorubicin*

50 mg/m2

IV push into fast running 0.9S

Day 1

Vincristine (Oncovin)

1.4 mg/m2

(max 2 mg)

IV push into fast running 0.9S

Days 1-5

Prednisone

100 mg

PO

*(Doxorubicin = Adriamycin®)

Rituximab - Infusional adverse effects are common during the first dose but uncommon thereafter. The first infusion is started slowly and increased according to tolerability (Rituximab 375 protocol). The second and subsequent infusion is given more quickly (as per Rituximab Rapid protocol) if the first infusion was not complicated by a severe reaction.

Note: A prescription sheet for the R-CHOP protocol is available. You must print it out and use it for the prescriptions to be faxed to Baxter's via Pharmacy. If Rituximab is given, then this precedes chemotherapy.

Antiemetics - see Cytotoxic Schedules and Choice of Antiemetics.

Cardiac toxicity - see Anthracyclines and cardio-toxicity in drug chapter, for full information. Doxorubicin may occasionally (about 1 in 200 risk) cause cardio-toxicity at any dose level, especially if pre-existing cardiac disease is present. For “normal” patients, cardio-toxicity becomes a significant risk when a total dose of 450 mg/m2 has been reached. The figure is lower at 350 mg/m2 for patients with cardiac disease, hypertension, age > 70, and those who have had mediastinal irradiation. A pre-treatment echo is essential. See Salz, T., et al. (2017). "Preexisting Cardiovascular Risk and Subsequent Heart Failure Among Non-Hogkin Lymphoma Survivors." Journal of Clinical Oncology 35(34):3837-3843.

Haematological toxicity - neutropenia is most marked at day 10-12 and is grade 3/4 (ANC <1.0) in a third. Severe anaemia or thrombocytopenia occurs in <5%.

Neutropenic sepsis - Patients are at approximately 20% risk of neutropenic sepsis from R-CHOP21. Where the risk is increased due to patient specific factors (e.g. patient > 65 years), prescribe pegylated G-CSF, 6 mg once on day 4. A special authority number should be obtained which is lifelong. Secondary prophylaxis should be administered in any patient who has had a prior neutropenic sepsis. Special authority criteria for use of G-CSF to prevent neutropenic sepsis are according to Aapro, M. S., J. Bohlius, et al. (2011). "2010 update of EORTC guidelines for the use of granulocyte-colony stimulating factor to reduce the incidence of chemotherapy-induced febrile neutropenia in adult patients with lymphoproliferative disorders and solid tumours." Eur J Cancer 47(1): 8-32.

For all the salvage and alternative protocols described below, the risk of neutropenic sepsis is at least as high as in R-CHOP21, and these protocols require routine primary prophylaxis with G-CSF support for all patients, irrespective of age or other risk factors.

Other toxicity - alopecia occurs in two thirds of patients. Neurotoxicity (due to vincristine) occurs in 3-4%.

About this Canterbury DHB document (5976):

Document Owner:

Peter Ganly (see Who's Who)

Issue Date:

November 2018

Next Review:

November 2021

Keywords:

Note: Only the electronic version is controlled. Once printed, this is no longer a controlled document. Disclaimer

Topic Code: 5976