Printed by Isobel Webster on 10/27/2021 4:16:03 PM. For personal use only. Not approved for distribution.
Copyright © 2021 National Comprehensive Cancer Network, Inc., All Rights Reserved.
Chemotherapy Order Template DBL40
Page 1 of 3
Diffuse Large B-Cell Lymphoma
Mini-CHOP (Cyclophosphamide/DOXOrubicin/ VinCRIStine/PredniSONE) + RiTUXimab
INDICATION: REFERENCES: NCCN SUPPORTIVE CARE:
First-line: Very frail patients and patients >80 1. NCCN Guidelines® for B-Cell Lymphomas 1. Emetic risk: Day 1 High
years of age with comorbidities V.3.2021. 2. Febrile Neutropenia Risk: Intermediate
2. Peyrade F, et al. Lancet Oncol.
2011;12(5):460-8.a
CHEMOTHERAPY REGIMEN
21-day cycle for 6 cycles
Cyclophosphamide 400 mg/m² IV over 30 minutes on Day 1
Oral hydration is strongly encouraged with cyclophosphamide; poorly hydrated patients may need supplemental IV hydration. Patients
should attain combined oral and IV hydration of 2,000 – 3,000 mL/day on day of chemotherapy.
See Other Supportive Therapy for example of IV hydration.
DOXOrubicin 25 mg/m² IV push on Day 1
See Safety Parameters and Special Instructions for information on slow IV Push administration.
VinCRIStine 1 mg IV over 5 – 10 minutes on Day 1
PredniSONE 40 mg/m² PO daily on Days 1 – 5
RiTUXimab 375 mg/m² IV on Day 1
See Safety Parameters and Special Instructions for recommended infusion rate.
See Safety Parameters and Special Instructions for alternative dosing information.
RiTUXimab and hyaluronidase human for subcutaneous injection may be substituted for riTUXimab in patients who have received one
full dose of a riTUXimab product by intravenous route without experiencing severe adverse reactions. Please see order template
DBL56 for riTUXimab and hyaluronidase human dosing.
A biosimilar agent may be substituted if clinically appropriate. For more information on the use of biosimilars, please refer to disease-
specific guideline.
There may be an increased risk of CNS events in selected cases (4 – 6 factors according to prognostic model to assess risk of CNS
disease, HIV-associated lymphoma, testicular lymphoma, high-grade B-cell lymphomas (HGBLs) with translocations of MYC and BCL2
and/or BCL6 (Double/Triple Hit Lymphoma), HGBLs not otherwise specified, Primary cutaneous DLBCL, leg type, stage IE DLBCL of the
breast, or kidney or adrenal involvement). See NCCN Guidelines for B-Cell Lymphomas for additional information.
CNS prophylaxis can be considered (4 – 8 doses of intrathecal methotrexate and/or cytarabine, or high-dose systemic methotrexate)
during or after the course of treatment.
Please see Order Template DBL32 (Intrathecal Cytarabine), DBL34 (Intrathecal Methotrexate), DBL55 (Intrathecal
Cytarabine/Methotrexate/Hydrocortisone), or DBL39 (High-Dose Methotrexate) for examples of CNS prophylaxis courses.
SUPPORTIVE CARE
Premedications
For riTUXimab: Premedication for infusion reactions is required. The recommended dosing is:
DiphenhydrAMINE 12.5 – 50 mg IV/PO 30 – 60 minutes pre-riTUXimab
AND
Acetaminophen 650 mg PO 30 – 60 minutes pre-riTUXimab
Antiemetic Therapy
Scheduled prophylactic antiemetic therapy should be given for prevention of acute and delayed nausea and vomiting based on the emetic risk of
the chemotherapy regimen. This may include antiemetic therapy given on the days following chemotherapy. For more information on emetic
prophylaxis, refer to the NCCN Guidelines for Antiemesis and Appendix D to the NCCN Chemotherapy Order Templates.
PRN for breakthrough: All patients should be provided with at least one medication for breakthrough emesis. Please consult the NCCN
Guidelines for Antiemesis for appropriate antiemetic therapy.
Dexamethasone dose may be modified or omitted based on steroids within the chemotherapy regimen.
Myeloid Growth Factor Therapy
CSFs may be considered for primary prophylaxis based on the febrile neutropenia (FN) risk of the chemotherapy regimen. For more
information on prophylaxis of FN and a list of appropriate agents, refer to the Myeloid Growth Factors algorithms in the NCCN Guidelines for
Hematopoietic Growth Factors and Appendix C to the NCCN Templates.
Template continued on page 2
NCCN Chemotherapy Order Templates (NCCN Templates®) are peer-reviewed statements of the consensus of its authors derived from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®)
regarding their views of currently accepted approaches to treatment. An NCCN Template does not constitute an order. Any clinician seeking to treat a patient using the NCCN Templates® is expected to use
independent medical judgment in the context of individual clinical circumstances of a specific patient's care or treatment. NCCN disclaims all warranties, express or implied including, without limitation, the
implied warranties of merchantability and fitness for a particular purpose. NCCN does not warrant the accuracy, currency, or completeness of the NCCN Templates or make any representation regarding the
use or the results of the use of the NCCN Templates in treatment. In no event shall NCCN or its members be liable for any damages including, without limitation, incidental, indirect, special, punitive, or
consequential damages arising out of or in connection with the use of the NCCN Templates including, without limitation, loss of life, loss of data, loss of income or profit, losses sustained as a result of any
injury to any person, or loss or damage to property or claims of third parties.
National Comprehensive Cancer Network, Inc. © 2021. All rights reserved. 06/03/2021
Printed by Isobel Webster on 10/27/2021 4:16:03 PM. For personal use only. Not approved for distribution. Copyright © 2021 National Comprehensive Cancer Network, Inc., All Rights Reserved.
Chemotherapy Order Template DBL40
Page 2 of 3
Diffuse Large B-Cell Lymphoma
Mini-CHOP (Cyclophosphamide/DOXOrubicin/ VinCRIStine/PredniSONE) + RiTUXimab
Other Supportive Therapy
This regimen may be associated with a risk of tumor lysis syndrome with the first cycle. Tumor lysis prophylaxis and/or treatment may be
indicated. Review NCCN Guidelines for B-cell Lymphomas for additional information.
For cyclophosphamide: Example of recommended hydration: Sodium chloride 0.9% infused IV at a rate of 1.5 – 3 mL/kg/hour for a total of
500 mL on day of chemotherapy.
For vinCRIStine: This agent may cause constipation. Evaluate risk prior to initiation of therapy, then monitor for symptoms as clinically
indicated for potential dose modification or discontinuation. Patients often require prophylaxis with a bowel regimen (eg, docusate sodium
and senna) to maintain normal bowel function.
For predniSONE: Risk of stress ulcers may occur with treatment. Consider use of a H2 blocker or proton pump inhibitor.
For riTUXimab:
Risk of hepatitis B reactivation exists with therapy. Review drug package insert and NCCN Guidelines for Prevention and Treatment of
Cancer-Related Infections for monitoring and antiviral therapy recommendations.
Risk of serious bacterial, viral, and fungal infections exists during treatment. Refer to drug package insert, individual NCCN disease
guideline, NCCN Guidelines for Prevention and Treatment of Cancer-Related Infections for monitoring, prophylaxis and/or preemptive
therapy recommendations.
MONITORING AND HOLD PARAMETERS
CBC with differential should be monitored as clinically indicated for potential dose modification.
This regimen may be associated with a risk of tumor lysis syndrome in some patients. Patients at risk should be monitored for clinical
presentation of tumor lysis, including electrolytes, uric acid, and renal function at least daily until risk of tumor lysis has passed.
For cyclophosphamide: Renal function should be monitored as clinically indicated for potential dose modification or discontinuation.
For DOXOrubicin:
This agent is an anthracycline. Cumulative anthracycline dosage should be monitored.
Ejection fraction should be monitored prior to initiation of treatment and as clinically indicated.
Liver function should be monitored prior to each cycle and as clinically indicated for potential dose modification or discontinuation.
For vinCRIStine:
Signs and symptoms of neurotoxicity should be monitored prior to each cycle for potential dose modification or discontinuation.
This agent may cause peripheral neuropathy. Monitor patients as clinically indicated for persistent issues with altered sensation
including pain or discomfort and/or regional motor weakness that may interfere with activities of daily living. Dose modification or
discontinuation of therapy may be warranted.
Liver function should be monitored prior to each cycle and as clinically indicated for potential dose modification or discontinuation.
For predniSONE:
Serum glucose should be monitored as clinically indicated.
Hypertension may occur with therapy. Blood pressure should be monitored as clinically indicated for potential dose modification.
For riTUXimab:
Infusion reactions may occur with administration. Monitor for and treat infusion reactions (e.g. fever, chills, flushing, itching and/or
muscle pain) per institutional standard. Initiation and/or adjustment of premedications should be considered. Infusion rate changes may
be warranted. Refer to the "Management of Drug Reactions" algorithm in the NCCN Guidelines for Ovarian Cancer for additional
information and recommendations.
This agent may cause severe mucocutaneous reactions. Monitor for signs and symptoms as clinically indicated including painful sores
or ulcers on the lips or mouth, blisters, peeling skin, rash, and pustules for discontinuation.
SAFETY PARAMETERS AND SPECIAL INSTRUCTIONS
For cyclophosphamide: Secondary malignancies have been associated with this drug. Review drug package insert for additional information.
For DOXOrubicin:
This agent is a vesicant.
This agent is administered IV push. The preferred IV push method for a vesicant is administration through the side port of a freely
flowing IV.
Central venous access is recommended for administration of this agent.
Secondary malignancies have been associated with this drug. Review drug package insert for additional information.
For vinCRIStine:
This agent is a vesicant.
VinCRIStine is for IV use only and usually results in death or serious neurological damage if given via other routes.
VinCRIStine should be administered via a minibag (eg, 25 mL – 50 mL).
VinCRIStine can be safely administered in a minibag via a peripheral vein by allowing the infusion to flow via gravity. Use of infusion
pumps are not recommended for peripheral administration.
Central venous access is recommended for administration of this agent.
For predniSONE: Take with food.
Template continued on page 3
NCCN Chemotherapy Order Templates (NCCN Templates®) are peer-reviewed statements of the consensus of its authors derived from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®)
regarding their views of currently accepted approaches to treatment. An NCCN Template does not constitute an order. Any clinician seeking to treat a patient using the NCCN Templates® is expected to use
independent medical judgment in the context of individual clinical circumstances of a specific patient's care or treatment. NCCN disclaims all warranties, express or implied including, without limitation, the
implied warranties of merchantability and fitness for a particular purpose. NCCN does not warrant the accuracy, currency, or completeness of the NCCN Templates or make any representation regarding the
use or the results of the use of the NCCN Templates in treatment. In no event shall NCCN or its members be liable for any damages including, without limitation, incidental, indirect, special, punitive, or
consequential damages arising out of or in connection with the use of the NCCN Templates including, without limitation, loss of life, loss of data, loss of income or profit, losses sustained as a result of any
injury to any person, or loss or damage to property or claims of third parties.
National Comprehensive Cancer Network, Inc. © 2021. All rights reserved. 06/03/2021
Printed by Isobel Webster on 10/27/2021 4:16:03 PM. For personal use only. Not approved for distribution. Copyright © 2021 National Comprehensive Cancer Network, Inc., All Rights Reserved.
Chemotherapy Order Template DBL40
Page 3 of 3
Diffuse Large B-Cell Lymphoma
Mini-CHOP (Cyclophosphamide/DOXOrubicin/ VinCRIStine/PredniSONE) + RiTUXimab
For riTUXimab:
The recommended infusion rate of riTUXimab for the first dose is 50 mg/hr, increased by 50 mg/hr every 30 minutes until a maximum
infusion rate of 400 mg/hr is reached.
For subsequent doses, rapid-infusion riTUXimab may be administered to patients meeting the following specific criteria:
no severe infusion-related event during the first dose
no clinically significant cardiovascular disease
lymphocyte count <5000/mm3
Rapid-infusion riTUXimab consists of a 90-minute infusion given as:
20% of the total dose administered in the first 30 minutes, followed by
80% of the total dose administered over the next 60 minutes
For patients not meeting criteria for rapid-infusion riTUXimab, the recommended infusion rate for subsequent doses is 100 mg/hr
increased by 100 mg/hr every 30 minutes until a maximum infusion rate of 400 mg/hr is reached.
Infusion rates are adjusted based on patient tolerance and may be decreased in the setting of infusion-related reactions.
Consider modification of riTUXimab in first cycle. Evidence exists for split-dose riTUXimab or delayed administration in patients with high
tumor burden.
NCCN Chemotherapy Order Templates (NCCN Templates®) are peer-reviewed statements of the consensus of its authors derived from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®)
regarding their views of currently accepted approaches to treatment. An NCCN Template does not constitute an order. Any clinician seeking to treat a patient using the NCCN Templates® is expected to use
independent medical judgment in the context of individual clinical circumstances of a specific patient's care or treatment. NCCN disclaims all warranties, express or implied including, without limitation, the
implied warranties of merchantability and fitness for a particular purpose. NCCN does not warrant the accuracy, currency, or completeness of the NCCN Templates or make any representation regarding the
use or the results of the use of the NCCN Templates in treatment. In no event shall NCCN or its members be liable for any damages including, without limitation, incidental, indirect, special, punitive, or
consequential damages arising out of or in connection with the use of the NCCN Templates including, without limitation, loss of life, loss of data, loss of income or profit, losses sustained as a result of any
injury to any person, or loss or damage to property or claims of third parties.
National Comprehensive Cancer Network, Inc. © 2021. All rights reserved. 06/03/2021
