Chemotherapy Protocol
Central Nervous System
TEMOZOLOMIDE (150)
Regimen
• CNS – Temozolomide (150)
Indication
• First line treatment of newly diagnosed glioblastoma multiforma starting four weeks
after treatment with concomitant radiotherapy and temozolomide
• Recurrent or progressive malignant glioma in patients previously treated with
chemotherapy
• Performance status 0, 1
Toxicity
Drug Adverse Effect
Hepatic injury, thrombocytopenia, nausea and vomiting,
Temozolomide
Pneumocystis jirovecii infection
The adverse effects listed are not exhaustive. Please refer to the relevant Summary of
Product Characteristics for full details.
Monitoring
Drugs
• FBC, LFT’s, U&E’s and glucose on day 22 of the cycle
• Clinical examination including neurological assessment, whole brain imaging and
chest x-ray prior to starting treatment
Dose Modifications
The dose modifications listed are for haematological, liver and renal function and drug
specific toxicities only. Dose adjustments may be necessary for other toxicities as well.
In principle all dose reductions due to adverse drug reactions should not be re-escalated in
subsequent cycles without consultant approval. It is also a general rule for chemotherapy
that if a third dose reduction is necessary treatment should be stopped.
Please discuss all dose reductions / delays with the relevant consultant before prescribing, if
appropriate. The approach may be different depending on the clinical circumstances.
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CNS – Temozolomide (150)
Haematological
Prior to starting treatment the following criteria must be met;
Criteria Eligible Level
Neutrophil equal to or more than 1.5x109/L
Platelets equal to or more than 100x109/L
Consider blood transfusion if patient symptomatic of anaemia or has a haemoglobin of less
than 8g/dL.
During treatment a complete blood count should be obtained on day 22 (21 days after the
first dose of temozolomide). Temozolomide can be restarted, at a reduced dose, provided
the neutrophils have recovered to 1x109/L and platelets 100x109/L within seven days of the
planned administration date, or administration discontinued according to the tables below.
Toxicity Reduce dose by 50mg/m2 Discontinue temozolomide
Neutrophil 0.5 - 1x109/L less than 0.5x109/L
Platelet 10 - 100x109/L less than 10x109/L
Temozolomide is to be discontinued if a dose of 100mg/m2 still results in unacceptable
toxicity or the same NCI CTC grade 3 non-haematological toxicity (except for alopecia,
nausea, vomiting) recurs after dose reduction.
Hepatic Impairment
Toxicity Action
Bilirubin more than 1.5xULN Stop temozolomide
ALT more than 2.5xULN Stop temozolomide
Renal Impairment
Drug Action
Temozolomide No dose reductions are required. Caution in severe renal
impairment
Other
Dose reductions or interruptions in therapy are not necessary for those toxicities that are
considered unlikely to be serious or life threatening. For example, alopecia, altered taste or
nail changes.
For all other non-haematological NCI-CTC grade 2 toxicities delay treatment until the
adverse effect has resolved to NCI-CTC grade 1 or below. For toxicity that is NCI-CTC grade
3 or above discontinue treatment, in some situations it may be appropriate to re-start
treatment with a reduced dose when symptoms have resolved
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CNS – Temozolomide (150)
Regimen
When used following concomitant temozolomide and radiotherapy treatment is started four
weeks after completing the concomitant phase. The dose in cycle 1 (monotherapy) is
150mg/m2 once a day for 5 days followed by 23 days without treatment. At the start of cycle
2, the dose is escalated to 200mg/m2 if the NCI CTC non-haematological toxicity for cycle 1
is less than or equal to grade 2 (except for alopecia, nausea and vomiting) or the absolute
neutrophil count is greater than or equal to 1.5x109/L, and the thrombocyte count is greater
than or equal to 100x109/L. If the dose is not escalated at cycle 2, escalation should not be
done in subsequent cycles. Once escalated, the dose remains at 200mg/m2 per day for the
first 5 days of each subsequent cycle except if toxicity occurs.
28 day cycle for 6 cycles
Cycle One
Drug Dose Days Administration
Temozolomide 150mg/m2 1-5 inclusive Oral
(maximum 300mg)
Cycle Two to Six
Drug Dose Days Administration
Temozolomide 200mg/m2 1-5 inclusive Oral
(maximum 400mg)
Dose
• Temozolomide will be dose banded in accordance with the national dose bands
(temozolomide oral)
• The dose of temozolomide will be capped at 2m2
Administration Information
• Temozolomide should be taken on an empty stomach
• Temozolomide to be taken with plenty of water swallowed whole, not chewed
Additional Therapy
Antiemetics
• As take home medication
- ondansetron 8mg 15 – 30 minutes prior to temozolomide oral
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CNS – Temozolomide (150)
• Co-trimoxazole 960mg once a day on Monday, Wednesday and Friday until
lymphocytes are above 0.8
• Gastric protection with a proton pump inhibitor or a H2 antagonist may be considered
in patients considered at high risk of GI ulceration or bleed.
Additional Information
• The National Patient Safety Alert on oral chemotherapy (NPSA/2008/RRR001) must
be followed in relation to oral temozolomide.
Coding
• Procurement – X70.5, X71.1
• Delivery – X73.1
References
1.National Institute for Health and Clinical Excellence (2007). NICE TA 121. Carmustine implants and temozolomide for the
treatment of newly diagnosed high-grade glioma. DOH: London
2.National Institute for Clinical Excellence (2001). NICE TA 23: Guidance on the use of temozolomide for the treatment of
recurrent malignant glioma (brain cancer). DOH: London
3.Stupp et al. Radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma. N Engl J Med 2005; 352: 987-96
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CNS – Temozolomide (150)
REGIMEN SUMMARY
Temozolomide (150)
Cycle 1
Take Home Medicines
1. Temozolomide 150mg/m2 oral once a day for 5 days oral
Administration Instructions
Take on an empty stomach, swallow whole, do not chew
2. Ondansetron 8mg once a day 15-30 minutes prior to the temozolomide oral
Administration Instructions
An additional 8mg dose may be taken 12 hours later if required for the treatment of nausea and vomiting
Please supply an original pack (10 tablets) or nearest appropriate equivalent
Cycle 2 - 6
Take Home Medicines
3. Temozolomide 200mg/m2 oral once a day for 5 days oral
Administration Instructions
Take on an empty stomach, swallow whole, do not chew
4. Ondansetron 8mg once a day 15-30 minutes prior to the temozolomide oral
Administration Instructions
An additional 8mg dose may be taken 12 hours later if required for the treatment of nausea and vomiting
Please supply an original pack (10 tablets) or nearest appropriate equivalent
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CNS – Temozolomide (150)
DOCUMENT CONTROL
Version Date Amendment Written By Approved By
Lymphocyte dose adjustment
removed Donna Kimber
Dr Deborah Wright
1.1 Feb 2019 Dose rounding changed to dose Pharmacy
Pharmacist
bands Technician
Disclaimer updated
Dr Deborah Wright Dr Omar Al Salihi
1 Oct 2015 None
Pharmacist Consultant Clinical
Oncologist
This chemotherapy protocol has been developed as part of the chemotherapy electronic
prescribing project. This was and remains a collaborative project that originated from the
former CSCCN. These documents have been approved on behalf of the following Trusts;
Hampshire Hospitals NHS Foundation Trust
NHS Isle of Wight
Portsmouth Hospitals NHS Trust
Salisbury Hospital NHS Foundation Trust
University Hospital Southampton NHS Foundation Trust
Western Sussex Hospitals NHS Foundation Trust
All actions have been taken to ensure these protocols are correct. However, no responsibility
can be taken for errors that occur as a result of following these guidelines. These protocols
should be used in conjunction with other references such as the Summary of Product
Characteristics and relevant published papers.
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