Example orders for R-CHOP in lymphoma

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.

R-CHOP

R-CHOP: Rituximab, Cyclophosphamide, Hydroxydaunorubicin, Oncovin, Prednisone

Original references may be found at R-CHOP (Non-Hodgkin lymphoma)

Example regimen #1

• Cyclophosphamide (Cytoxan) 750 mg/m² IV on day 1
  • Infuse over 30 to 45 minutes.
• Doxorubicin (Adriamycin) 50 mg/m² IV on day 1
  • Administer IV push through running IV.
• Vincristine (Oncovin) 1.4 mg/m² (maximum dose of 2mg per cycle) IV on day 1
  • Administer IV push through running IV. Make sure to address patient's bowel status.
• Prednisone (Sterapred) 100 mg PO once per day on days 1 to 5
• Rituximab (Rituxan) 375 mg/m² IV on day 1
  • Infusion rate per hospital policy.

21-day cycles x 6 cycles

Supportive therapy

• Pegfilgrastim (Neulasta) 6 mg SC x1 on day 3
• Acetaminophen (Tylenol) 650 mg PO 30 to 60 minutes prior to rituximab
• Diphenhydramine (Benadryl) 25 to 50 mg IV or PO 30 to 60 minutes prior to rituximab. 50 mg to be used for the first dose of Rituximab (Rituxan). Dose may be reduced to 25 mg on subsequent Rituximab (Rituxan) treatments if tolerated.
• Ondansetron (Zofran) 8 mg IV 30 minutes prior to CHOP
• Hydrocortisone (Cortef) 50 mg IV prn Rituximab (Rituxan) infusion reaction, may repeat x1

Hydration:

• Prehydration with 500 ml NS at 500 mL/hour, to start 60 minutes before chemotherapy
• 500 ml NS at KVO rate to be used as running IV for chemotherapy infusion. Give up to 500 ml NS.

Monitoring:

• On day 1 of each cycle: CBC with differential, absolute neutrophil count (ANC), BUN/Cr as part of a comprehensive metabolic panel, alk phos, AST, ALT, total bilirubin, albumin, LDH
  • Physician to be notified if liver function tests or bilirubin are not within normal limits
• On day 8, check nadir CBC with differential, absolute neutrophil count (ANC). Need for further nadir count checks to be determined by degree of cytopenias.
• Check hepatitis B status prior to therapy with rituximab

Outpatient medications:

• Prednisone (Sterapred) as described above
• Ondansetron (Zofran) 8 mg PO every 8 hours prn nausea
• Acyclovir (Zovirax) 400 mg PO every 8 hours
• Allopurinol (Zyloprim) 100 to 300 mg PO once per day, adjusted for renal function

Clinical scenario & comments:

• 74 year-old gentleman with diffuse large B-cell lymphoma (DLBCL), using R-CHOP as first-line therapy. This patient had a creatinine of 1.4, with calculated creatinine clearance by Cockcroft-Gault of 55, but the team chose to be more conservative with allopurinol dosing and used 100 mg PO daily.