Example orders for High-dose Methotrexate (MTX) & Ifosfamide in lymphoma

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High-dose Methotrexate (MTX) & Ifosfamide

Original references may be found at High-dose Methotrexate (MTX) & Ifosfamide

Example regimen #1

• Methotrexate (MTX) 4000 mg/m2 IV over 4 hours on day 1
  • Do not start methotrexate until urine pH is at least 8 or higher. Admix with sodium bicarbonate.
• Sodium bicarbonate 25 mEq IV once on day 1, admix with methotrexate
• Ifosfamide (Ifex) 2000 mg/m2 IV over 3 hours on days 3-5
• Mesna (Mesnex) 500 mg/m2 IV every 3 hours x 4 doses per day on days 3-5 with ifosfamide
  • Times for mesna in relation to start of ifosfamide; Dose 1 of mesna is at time at 0, dose 2 is 3 hours after start of ifosfamide, dose 3: 6 hours after start of ifosfamide, dose 4: 9 hours post ifosfamide.
• Folinic acid (Leucovorin) 50 mg IV every 6 hours, starting on day 2
  • To begin 24 hours after the start of day 1's methotrexate infusion and continue for at least 8 doses. Discuss changes such as potential transition to PO leucovorin with MD according to MTX levels.

Supportive medications:

• Ondansetron (Zofran) 8 mg IV on days 1-5, 30 minutes prior to chemotherapy
• Dexamethasone (Decadron) 8 mg IV BID on days 1-5
• Ondansetron (Zofran) 4-8 mg IV Q8H prn nausea
• Prochlorperazine (Compazine) 10 mg PO Q6H prn nausea

Hydration:

• 150 mEq sodium bicarbonate in 1000 mL D5W, continuous at 125 mL/H, start on day 1 hours before methotrexate infusion for urine alkalinization. Continue fluids unless discussed otherwise with MD.

Monitoring:

• Check methotrexate levels 24, 48, and 72 hours after completion of methotrexate infusion.
• Check urine pH every 4 hours and notify physician if urine pH <8

Clinical scenario & comments:

• 54 year-old gentleman with stage IV diffuse large B-cell lymphoma with extranodal disease (primary testicular lymphoma), with progression after 6 cycles of R-CHOP. He only received treatment with high-dose methotrexate & ifosfamide for one cycle; treatment was complicated by acute kidney injury, with subsequent improvement back to baseline. This was followed with R-ICE therapy, with disease remission achieved and subsequent allogeneic stem cell transplant.