Example orders for CVD, IL-2, IFN alfa-2b - sequential biochemotherapy in melanoma

Use of this site is subject to you reading and agreeing with the terms set forth in the disclaimer.

CVD, IL-2, IFN alfa-2b - sequential biochemotherapy

CVD: Cisplatin, Vinblastine, Dacarbazine
Original reference may be found at CVD, IL-2, IFN alfa-2b - sequential biochemotherapy

Example regimen #1

• Cisplatin (Platinol) 20 mg/m2 IV in 250 mL NS over 30 minutes on days 1-4, given first
• Vinblastine (Velban) 1.2 mg/m2 IV push on days 1-4, given second
  • Give via IV push immediately after cisplatin.
• Dacarbazine (DTIC) 800 mg/m2 IV in 250 mL D5W over 1 hour on day 1, given third
• IL-2 - Aldesleukin (Proleukin) 9,000,000 units/m2/day IV continuous infusion over 96 hours on days 1-4
  • Continuous Infusion. Infuse each dose over 24 hours. Total of 4 doses. Mix in 250 mL D5W with 0.1% albumin. Begin at 3PM on day 1. Hold dose if bicarbonate of <18 and call house officer.
• Interferon alfa-2b (Intron-A) 5,000,000 units/m2 SC on days 1-5, 8, 10, 12; days 8, 10, 12 given as outpatient doses
  • Give at start of Aldesleukin each day and at the completion of Aldesleukin on Day 5. To be given on days 8, 10, 12 as an outpatient.

21-day cycles x up to 4 cycles

Supportive medications:

• Pegfilgrastim (Neulasta) 6 mg SC on day 6
• All antihypertensive therapy discontinued at least 24 hours before each cycle
• Naproxen 375 mg PO Q12H
• Acetaminophen 975 mg PO/PR Q6H, to begin prior to IL-2. Total acetaminophen dosage not to exceed 3900 mg/day
• Ranitidine (Zantac) 150 mg PO BID
• Cephalexin (Keflex) 500 mg PO BID on days 1-15
• Diphenhydramine (Benadryl) 25-50 mg PO/IV Q6H prn pruritis
• Prochlorperazine (Compazine) 10 mg PO/IV Q6H prn nausea
• Diphenoxylate-Atropine (Lomotil) 1 tab PO prn each loose stool, maximum of 8 tabs per day
• Lorazepam (Ativan) 1-2 mg PO/IV Q6H prn nausea, vomiting, anxiety, insomnnia
• 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
• Furosemide (Lasix) 20 mg IV prn urine output <100 ml/H for at least 3 hours before cisplatin is due. Call NP/MD before administering
• Meperidine (Demerol) 25-50 mg in 50 mL D5W IV over 15 minutes Q2H prn severe chills/rigors. May repeat x2; then call NP/MD
• Ondansetron (Zofran) 24 mg IV daily, 30 minutes before cisplatin on days 1-4
• Ondansetron (Zofran) 24 mg IV daily prn nausea/vomiting on days 5-7
• 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.
• In case of anaphylaxis:
  • Methylprednisolone (Solu-Medrol) 125 mg IV x1 prn anaphylaxis
  • Diphendyramine (Benadryl) 50 mg IV push prn anaphylaxis
  • Famotidine (Pepcid) 20 mg IV over 15 minutes
  • Epinephrine (EpiPen) 0.3 mg IM x1 prn anaphylaxis

Hydration:

• Standing IV fluids: 1 liter D5 1/2 NS with 20 mEq potassium chloride, continous at 100 mL/H on days 1-4. Hold during cisplatin hydration (see below).
• For hypotension: 250 ml NS bolus over 15 minutes prn SBP <90, may repeat X1 (total 2 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
• If urine output <500 mL in an 8-hour period, give 500 mL NS bolus over 30 minutes. If urine output <250 mL over next 4 hours, call NP/MD.
• If urine output <100 mL/H for at least 3 hours before cisplatin is due, give 1000 mL NS over 1 hr prior to proceeding with cisplatin. Call NP/MD prior to administration.
• If creatinine >1.6, give 500 mL NS bolus over 60 minutes. Recheck creatinine 4 hours later, and if still >1.6, hold that day's dose of chemotherapy & call NP/MD.

Monitoring:

• As an inpatient, 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:

• 47 year-old gentleman with initially stage IIIC (T4b N1b M0) and now metastatic melanoma, s/p wide local excision, lymph node dissection, adjuvant interferon alfa-2B, with metastatic recurrence. At the time of treatment with this regimen, ipilimumab (which he later received) was not yet available outside of a clinical trial.