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EPOCH+RITU

Cancer Type: Hematologic, Lymphoma - Non-Hodgkin's High Grade, Lymphoma - Non-Hodgkin's Intermediate Grade  Intent: Curative
Regimen Category: Evidence-informed
Funding:
New Drug Funding Program
    Rituximab - Aggressive Histology Lymphoma
New Drug Funding Program
    Rituximab - HIV-Related, Aggressive Histology, B-cell Lymphoma
ODB - General Benefit
    prednisone
New Drug Funding Program
    Rituximab (SC) - Aggressive Histology Lymphoma
New Drug Funding Program
    Rituximab (SC) - HIV-Related - Aggressive Histology - B-cell Lymphoma
Regimen Monograph
A - Regimen Name

EPOCH+RITU Regimen
Etoposide-Prednisone-Vincristine-Cyclophosphamide-Doxorubicin-Rituximab


Disease Site
Hematologic - Lymphoma - Non-Hodgkin's High Grade
Hematologic - Lymphoma - Non-Hodgkin's Intermediate Grade

Burkitt Lymphoma


Intent
Curative

Regimen Category
Evidence-informed :

Regimen is considered appropriate as part of the standard care of patients; meaningfully  improves outcomes (survival, quality of life), tolerability or costs compared to alternatives (recommended by the Disease Site Team and national consensus body e.g. pan-Canadian Oncology Drug Review, pCODR).  Recommendation is based on an appropriately conducted phase III clinical trial relevant to the Canadian context OR (where phase III trials are not feasible) an appropriately sized phase II trial. Regimens where one or more drugs are not approved by Health Canada for any indication will be identified under Rationale and Use.

This Regimen Abstract is an abbreviated version of a Regimen Monograph and contains only top level information on usage, dosing, schedule, cycle length and special notes (if available). Information in regimen abstracts is accurate to the extent of the ST-QBP regimen master listings, and has not undergone the full review process of a regimen monograph. Full regimen monographs will be published for each ST-QBP regimen as they are developed.


Supplementary Public Funding

riTUXimab
New Drug Funding Program (Rituximab - Aggressive Histology Lymphoma) (NDFP Website )

riTUXimab
New Drug Funding Program (Rituximab - HIV-Related, Aggressive Histology, B-cell Lymphoma)

prednisone
ODB - General Benefit (prednisone)

riTUXimab (subcut)
New Drug Funding Program (Rituximab (SC) - Aggressive Histology Lymphoma)

riTUXimab (subcut)
New Drug Funding Program (Rituximab (SC) - HIV-Related - Aggressive Histology - B-cell Lymphoma)

 
B - Drug Regimen

Note: This is dose-adjusted EPOCH.
The following are doses for the first cycle. Doses are adjusted based on nadir ANC or platelet counts (refer to references).

Cycle 1:  All patients must receive their first dose of rituximab by IV infusion.

riTUXimab

1

375 mg /m² IV Day 1
etoposide
50 mg /m²/day IV continuous IV Days 1 to 4
vinCRIStine
0.4 mg /m²/day IV continuous IV Days 1 to 4
DOXOrubicin
10 mg /m²/day IV continuous IV Days 1 to 4
prednisone

2

60 mg /m² PO Daily OR BID on Days 1 to 5
cyclophosphamide
750 mg /m² IV Day 5


Cycle 2 and onwards (For a usual total of 6-8 cycles including initial IV rituximab cycle(s))

Rituximab IV:

riTUXimab

1

375 mg /m² IV Day 1

 

OR

Rituximab (subcut):  
The subcutaneous formulation must only be given at the second or subsequent cycles, if the patient has previously received at least one full rituximab IV dose.

riTUXimab (subcut)

1

1400 mg Subcut Day 1


Plus EPOCH Chemotherapy:  Doses are adjusted based on nadir ANC or platelet counts (refer to references).

(1) Give rituximab before EPOCH
(2) On Day 1 to be given as part of premedication before riTUXimab

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C - Cycle Frequency

REPEAT EVERY 21 DAYS

For a usual total of 6-8 cycles unless disease progression or unacceptable toxicity occurs

 
K - References

Dunleavy K, Pittaluga S, Maeda LS, et al. Dose-Adjusted EPOCH-Rituximab Therapy in Primary Mediastinal B-Cell Lymphoma. N Engl J Med 2013;368:1408-16.

Jermann M, Jost LM, Taverna Ch, et al. Rituximab-EPOCH, an effective salvage therapy for relapsed, refractory or transformed B-cell lymphomas: results of a phase II study. Ann Oncol. 2004 Mar;15(3):511-6.

Wilson WH, Grossbard ML, Pittaluga S, et al. Dose-adjusted EPOCH chemotherapy for untreated large B-cell lymphomas: a pharmacodynamic approach with high efficacy. Blood 2002 Apr 15;99(8):2685-93.

Lugtenburg P, Avivi I, Berenschot H et al. Efficacy and safety of subcutaneous and intravenous rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone in first-line diffuse large B-cell lymphoma: the randomized MabEase study. Haematologica. 2017;102(11):1913-1922.

Rummel M, Kim TM, Aversa F et al. Preference for subcutaneous or intravenous administration of rituximab among patients with untreated CD20+ diffuse large B-cell lymphoma or follicular lymphoma: results from a prospective, randomized, open-label, crossover study (PrefMab). Ann Oncol. 2017;28(4):836-842.


PEBC Advice Documents or Guidelines

July 2018 Added rituximab subcut option and NDFP forms


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M - Disclaimer

Regimen Abstracts
A Regimen Abstract is an abbreviated version of a Regimen Monograph and contains only top level information on usage, dosing, schedule, cycle length and special notes (if available). It is intended for healthcare providers and is to be used for informational purposes only. It is not intended to constitute or be a substitute for medical advice, and all uses of the Regimen Abstract are subject to clinical judgment. Such information is provided on an “as-is” basis, without any representation, warranty, or condition, whether express, or implied, statutory or otherwise, as to the information’s quality, accuracy, currency, completeness, or reliability, and Cancer Care Ontario disclaims all liability for the use of this information, and for any claims, actions, demands or suits that arise from such use.
Information in regimen abstracts is accurate to the extent of the ST-QBP regimen master listings, and has not undergone the full review process of a regimen monograph.  Full regimen monographs will be published for each ST-QBP regimen as they are developed.
Regimen Monographs
Refer to the New Drug Funding Program or Ontario Public Drug Programs websites for the most up-to-date public funding information.
The information set out in the drug monographs, regimen monographs, appendices and symptom management information (for health professionals) contained in the Drug Formulary (the "Formulary") is intended for healthcare providers and is to be used for informational purposes only. The information is not intended to cover all possible uses, directions, precautions, drug interactions or adverse effects of a particular drug, nor should it be construed to indicate that use of a particular drug is safe, appropriate or effective for a given condition. The information in the Formulary is not intended to constitute or be a substitute for medical advice and should not be relied upon in any such regard. All uses of the Formulary are subject to clinical judgment and actual prescribing patterns may not follow the information provided in the Formulary.
The format and content of the drug monographs, regimen monographs, appendices and symptom management information contained in the Formulary will change as they are reviewed and revised on a periodic basis. The date of last revision will be visible on each page of the monograph and regimen. Since standards of usage are constantly evolving, it is advised that the Formulary not be used as the sole source of information. It is strongly recommended that original references or product monograph be consulted prior to using a chemotherapy regimen for the first time.
Some Formulary documents, such as the medication information sheets, regimen information sheets and symptom management information (for patients), are intended for patients. Patients should always consult with their healthcare provider if they have questions regarding any information set out in the Formulary documents.
While care has been taken in the preparation of the information contained in the Formulary, such information is provided on an “as-is” basis, without any representation, warranty, or condition, whether express, or implied, statutory or otherwise, as to the information’s quality, accuracy, currency, completeness, or reliability.
CCO and the Formulary’s content providers shall have no liability, whether direct, indirect, consequential, contingent, special, or incidental, related to or arising from the information in the Formulary or its use thereof, whether based on breach of contract or tort (including negligence), and even if advised of the possibility thereof. Anyone using the information in the Formulary does so at his or her own risk, and by using such information, agrees to indemnify CCO and its content providers from any and all liability, loss, damages, costs and expenses (including legal fees and expenses) arising from such person’s use of the information in the Formulary.