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CHOP+R-DHAP+R

Cancer Type: Hematologic, Lymphoma - Non-Hodgkin's Low Grade  Intent: Palliative
Regimen Category: Evidence-informed
Funding:
New Drug Funding Program
    Rituximab in Combination with Chemotherapy - Indolent B-cell Lymphoma
New Drug Funding Program
    Rituximab (SC) in Combination with Chemotherapy - Indolent B-cell Lymphoma
ODB - General Benefit
    dexamethasone
A - Regimen Name

CHOP+R-DHAP+R Regimen


Disease Site
Hematologic - Lymphoma - Non-Hodgkin's Low Grade

Intent
Palliative

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.


Rationale and Uses

For treatment of mantle cell lymphoma prior to ASCT.


Supplementary Public Funding

riTUXimab
New Drug Funding Program (Rituximab in Combination with Chemotherapy - Indolent B-cell Lymphoma) (NDFP Website)

riTUXimab (subcut)
New Drug Funding Program (Rituximab (SC) in Combination with Chemotherapy - Indolent B-cell Lymphoma)

dexamethasone
ODB - General Benefit (dexamethasone)

 
B - Drug Regimen

Sequential Treatment: CHOP+R for 3 Cycles followed by DHAP+R for 3 cycles

Alternating Treatment: CHOP+R alternating with DHAP+R for a total of 6 cycles

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

 

CHOP+R:

riTUXimab
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)
1400 mg Subcut Day 1


Plus CHOP chemotherapy

prednisone
100 mg PO daily Days 1 to 5*

*(On Day 1 to be given as part of premedication before riTUXimab) 

vinCRIStine
1.4 mg /m² IV (max 2 mg) Day 1
DOXOrubicin
50 mg /m² IV Day 1
cyclophosphamide
750 mg /m² IV Day 1


DHAP+R (adapted for outpatient administration):

Rituximab IV:

riTUXimab
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)
1400 mg Subcut Day 1


Plus DHAP Chemotherapy:

CISplatin
100 mg /m² IV continuous infusion over 8 hours Day 1
cytarabine
2000 mg /m² IV over 2 hours q12h, on Day 2
dexamethasone
40 mg PO Daily, Days 1 to 4*

*(On Day 1 to be given as part of premedication before riTUXimab)

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C - Cycle Frequency

For Sequential Treatment:

CHOP+R:  REPEAT EVERY 21 DAYS

DHAP+R:  REPEAT EVERY 21 to 28 DAYS

For Alternating Treatment:

CHOP+R alternating with DHAP+R: REPEAT EVERY 21 DAYS

 
D - Premedication and Supportive Measures

Antiemetic Regimen:

Moderate (CHOP)
High (DHAP)

Other Supportive Care:

Also refer to CCO Antiemetic Recommendations.

 
J - Administrative Information

Pharmacy Workload (average time per visit)
39.115 minutes
Nursing Workload (average time per visit)
73.375 minutes
 
K - References

Davies A, Merli F, Mihaljević B, et al.  Efficacy and safety of subcutaneous rituximab versus intravenous rituximab for first-line treatment of follicular lymphoma (SABRINA): a randomised, open-label, phase 3 trial.  Lancet Haematol. 2017 Jun;4(6):e272-e282.

Delanue R, Haioun C, Ribrag V et al.  CHOP and DHAP plus rituximab followed by autologous stem cell transplantation in mantle cell lymphoma: a phase 2 study from the Groupe d'Etude des Lymphomes de l'Adulte.  2013 Blood;121(1):48-53.

Hermine O, Hoster E, Walewski J, et al. Addition of high-dose cytarabine to immunochemotherapy before autologous stem-cell transplantation in patients aged 65 years or younger with mantle cell lymphoma (MCL Younger): a randomized, open-label, phase 3 trial of the European Mnatle Cell Lymphoma Network. Lancet. 2016;388:565-75.

Lefrere F, Delmer A, Suzan F, et al. Sequential chemotherapy by CHOP and DHAP regimens followed by high-dose therapy with stem cell transplantation induces a high rate of complete response and improves event-free survival in mantle cell lymphoma: a prospective study. 2002 Leukemia 16:587-593.

 


PEBC Advice Documents or Guidelines

August 2019 Added alternating schedule as an option


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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.