Example orders for Carboplatin (Paraplatin) and Pemetrexed (Alimta) in non-small cell lung cancer

Carboplatin & Paclitaxel (CP)

CP: Carboplatin & Paclitaxel

Regimen

Study	Dates of enrollment	Evidence	Comparator	Comparative Efficacy
Forde et al. 2022 (CheckMate 816)	2017-2019	Phase 3 (C)	1a. CP & Nivolumab 1b. CVb & Nivolumab 1c. DC & Nivolumab	Inferior EFS

Note: there were additional comparator options depending on histology; see the respective histology-specific pages for more details. This study was conducted in the United States. The reason for the study was that an unanswered question at the time was whether adding an immune checkpoint inhibitor would improve outcomes.

Biomarker eligibility criteria

• CheckMate 816: No sensitizing EGFR or ALK mutations

Chemotherapy

• Carboplatin (Paraplatin) AUC 5 or 6 IV once on day 1
• Paclitaxel (Taxol) 175 or 200 mg/m² IV once on day 1

21-day cycle for 3 cycles

Subsequent treatment

• Complete resection

References

1. CheckMate 816: Forde PM, Spicer J, Lu S, Provencio M, Mitsudomi T, Awad MM, Felip E, Broderick SR, Brahmer JR, Swanson SJ, Kerr K, Wang C, Ciuleanu TE, Saylors GB, Tanaka F, Ito H, Chen KN, Liberman M, Vokes EE, Taube JM, Dorange C, Cai J, Fiore J, Jarkowski A, Balli D, Sausen M, Pandya D, Calvet CY, Girard N; CheckMate 816 Investigators. Neoadjuvant Nivolumab plus Chemotherapy in Resectable Lung Cancer. N Engl J Med. 2022 May 26;386(21):1973-1985. Epub 2022 Apr 11. link to original article contains dosing details in manuscript PubMed NCT02998528

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Remember that example order sets that may contain additional information about supportive medications, suggestions for monitoring, hydration, and pre-treatment screening information for chemotherapy regimens are purely anecdotal, provided only as examples of what some other providers may be using, and are typically not based on references in the primary literature.

Carboplatin (Paraplatin) & Pemetrexed (Alimta)

Original references may be found at Carboplatin (Paraplatin) & Pemetrexed (Alimta)

Example regimen #1

• Carboplatin (Paraplatin) AUC 5 IV on day 1
  • Infuse over 30-60 minutes.
• Pemetrexed (Alimta) 500 mg/m² IV on day 1
  • Administer over 10 minutes. Administer after carboplatin.

21-day cycles x 6 cycles

Supportive medications

• Ondansetron (Zofran) 8 mg IV 30 minutes prior to chemotherapy
• Lorazepam (Ativan) 0.5-1 mg PO/IV x 1 prn nausea/anxiety
• Prochlorperazine (Compazine) 10 mg PO x 1 prn nausea
• Dexamethasone (Decadron) 4 mg PO BID the day before, day of, and day after chemotherapy
• Cyanocobalamin (Vitamin B12) 1000 mcg IM every 9 weeks, the first dose given at least 1 week prior to start of pemetrexed therapy
• Folic acid 1000 mcg PO daily, to start at least 1 week prior to start of pemetrexed therapy, to continue throughout therapy with pemetrexed

Hydration:

• 500 ml NS and/or D5W at KVO rate as running IV for chemotherapy infusion. Give up to 500 ml NS and/or D5W as needed for IV compatibility.

Monitoring:

• On day 1 of each cycle: CBC with differential, absolute neutrophil count (ANC), BUN/Cr as part of a basic metabolic panel, alk phos, AST, ALT, total bilirubin, albumin, carcinoembryonic antigen
  • Depending on provider preference and patient's tolerance, may simplify to CBC with differential, absolute neutrophil count (ANC), BUN/Cr
• On cycle 1 day 10, check nadir CBC with differential, absolute neutrophil count (ANC). Need for further nadir count checks to be determined by degree of cytopenias.
• Assess for response with CT scan after cycle 3

Outpatient medications:

• Dexamethasone (Decadron) as described above
• Lorazepam (Ativan) 0.5 mg PO Q6H prn anxiety, insomnia, nausea
• Ondansetron (Zofran) 4 mg PO Q6H prn nausea
• Prochlorperazine (Compazine) 10 mg PO Q6H prn nausea
• Folic acid 1000 mcg PO daily as described above
• Due to refractory nausea, in later cycles, we eventually added Aprepitant (Emend) 125 mg PO on day 1, 80 mg PO on days 2 to 3, and Dexamethasone (Decadron) use was extended to include day -1 through day 4

Clinical scenario & comments:

• 60 year-old lady with stage IV adenocarcinoma of the lung, treated with first-line therapy for metastatic disease. Our institution's standard order set uses Carboplatin (Paraplatin) at AUC 5. This is reasonable in my view; the patient also had a history of pelvic radiation and chemotherapy for an unrelated malignancy many years ago. This was subsequently followed by Pemetrexed (Alimta) maintenance therapy.