Example orders for High-dose (HD) IL-2 in renal cancer

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High-dose (HD) IL-2

Original references may be found at High-dose (HD) IL-2

Example regimen #1

• IL-2 - Aldesleukin (Proleukin) 600,000 units/kg IV every 8 hours (at 00:00, 08:00, 16:00) x up to 14 doses per week, on days 1-5
  • After a 6-9 day rest period, another 14 doses per week given over 5 days is given as described above

6-12 weeks per cycle x up to 5 cycles

Supportive medications:

• Acetaminophen (Tylenol) 975 mg PO Q6H, to begin prior to IL-2. Total acetaminophen dosage not to exceed 3900 mg/day
• Naproxen 375 mg PO Q12H
• Ranitidine (Zantac) 150 mg PO BID
• Lorazepam (Ativan) 1-2 mg PO/IV Q4H prn nausea/vomiting
• Meperidine (Demerol) 25-50 mg in 50 mL D5W IV over 15 minutes Q2H prn severe chills/rigors
• Diphenhydramine (Benadryl) 25-50 mg PO/IV Q6H prn pruritis
• Prochlorperazine (Compazine) 10 mg PO/IV Q6H prn nausea/vomiting
• Cephalexin (Keflex) 500 mg PO BID
• Diphenoxylate-Atropine (Lomotil) 1-2 tabs PO prn each loose stool, maximum of 8 tabs per day

• Dopamine 4 mcg/kg/min IV drip, titrate to keep SBP at least 80, prn hypotension refractory to fluid boluses. Cardiac monitor while on medication.
• Phenylephrine 1 mcg/kg/min IV drip, titrate to keep SBP at least 80, prn if target SBP not met while patient is on on maximum dopamine dose. Cardiac monitor while on medication.
• Potassium chloride PO/IV sliding scale repletion; for K 3.8-3.6: 40 mEq; for K 3.5-3.3: 60 mEq; for K 3.2-3.0: 80 mEq; for K <3.0: contact NP/MD
• Calcium gluconate IV sliding scale repletion; for corrected Ca 7.5-7.1: 2 g IV; for corrected Ca <7: 3 g and contact NP/MD
• Magnesium sulfate IV sliding scale repletion; for Mg 1.6-2: 2 g IV; for Mg 1.2-1.5: 2-4 g IV; for Mg <1.2: 4 g IV and call NP/MD
• Potassium phosphate 15 mmol in 250 mL NS IV over 5 hours prn serum phosphate 1.5-2.3; if serum phosphate <1.5, call NP/MD
• Hydrocerin (Eucerin) apply topically QID prn dry skin
• Sarna lotion apply topically QID prn pruritis
• Gelclair 15 mL PO TID prn mucositis
• Maalox/Diphenhydramine/Lidocaine 5 mL PO QID prn mucositis
• Ondansetron (Zofran) ODT 8 mg PO/NG Q8H prn nausea
• Loperamide (Imodium) 2 mg PO QID prn diarrhea

Hydration:

• Standing IV fluids: 1 liter NS, continous at 75 mL/H
• For hypotension: 250 ml NS bolus over 15 minutes prn SBP <90, may repeat X2 (total 3 boluses). This order to be discontinued for weight gain >5% of baseline.
• Sodium bicarbonate-containing fluids to be used as follows:
  • If serum bicarbonate is 18-19, change IV fluids to 1 liter D5 1/2 NS with 50 mEq sodium bicarbonate, continuous at 75 mL/H. Once bicarbonate is at least 20, resume standing IV fluids above.
  • If serum bicarbonate is 16-17, administer 100 mL D5W with 100 mEq sodium bicarbonate over 1 hour and hold IL-2.
  • If bicarbonate is <16, give 100 mEq sodium bicarbonate as above and contact NP/MD and recheck bicarbonate 1 hour after infusion.

Monitoring:

• Check daily CBC with differential, comprehensive metabolic panel including sodium, potassium, chloride, bicarbonate, BUN, creatinine, glucose, calcium, magnesium, phosphate, alkaline phosphatase, AST, ALT, total bilirubin; once every 2 day monitoring of PT/PTT

Clinical scenario & comments:

• 43 year-old gentleman with metastatic clear cell renal carcinoma, who was treated first-line with Sunitinib (Sutent), and then had progression of disease. Experiences in my institution have been that HD IL-2 is not as likely to succeed as second-line therapy after progression on Sunitinib (Sutent) as compared to HD IL-2 in the first-line setting, but the patient chose to proceed with IL-2 treatment.