East Midlands Cancer Network
Leicestershire, Northamptonshire & Rutland
Regimen Name:
INDICATION:
ICE +/- R
Relapsed/refractory Lymphoma
Consider Rituximab for CD20+ve Lymphoma. Funding approval
is required for each case.
DRUG REGIMEN:
100mg/m2
Day:1
Etoposide
IV infusion over 1 hour
Day 2:
Etoposide
100mg/m2
IV infusion over 1 hour
Carboplatin AUC 5 (max 800mg)
IV infusion over 1 hour
2
Ifosfamide 5000mg/m IV infusion over 24 hours
Mesna5000mg/m2 IV infusion over 24 hours
Day 3:
Etoposide
100mg/m2
IV infusion over 1 hour
2
Mesna3000mg/m over 22 hrs
Cycle frequency: Repeat every 21 days from Day 1 if counts recovered
Number of cycles: 2 to 3. Where stem cell harvesting is planned discuss the date
of day 1 with the transplant team.
ANTI EMETIC GUIDELINES: High
CONCURRENT MEDICATION:
Consider allopurinol to prevent tumour lysis
Discuss GCSF with transplant team for patients undergoing stem cell harvest
Mesna is given to prevent haemorrhagic cystitis.
Paracetamol 1000mg Oral pre Rituximab
Chlorphenamine 10mg IV Bolus pre Rituximab
DOSE MODIFICATIONS:
Haematological:
Unless Bone marrow involvement:
Counts
Give Discuss
Neutrophils x 109/L
1
<1
9
Platelets x 10 /L
100
<100
Renal:
Creatinine Clearance
Dose modification
40 -60ml/min
70% dose ifosfamide, 80% dose etoposide
<40ml/min
Clinical decision
Document Code: LNRCN-0039-09 Date of Issue: July 2009
Written By: C Loughran/F Miall
Authorised By: M Dyer Haem NSSG chair
Issue Number: 1
Review Date: July 2011
Page Number: 1/2
Website: Check www.eastmidlandscancernetwork.nhs.uk for latest
version
East Midlands Cancer Network
Leicestershire, Northamptonshire & Rutland
Hepatic:
Consider dose reduction of etoposide and ifosfamide in patients with significant
hepatic dysfunction.
Other side effects:
Ifosfamide: 10-15% of patients treated with ifosfamide develop encephalopathy, which
usually manifests as a decreased rousability and disorientation often leading to
somnolence. In severe cases this can progress to irreversible encephalopathy
and death. Patients with low albumin or renal impairment are at increased risk.
Consider methylene blue injection to treat.
Dip stick urine for blood, consider increasing hydration or mesna dose if results are
repeatedly positive. If frank haematuria occurs consider stopping ifosfamide and
contact urology for advice.
Rituximab infusion-related reactions & cytokine release syndrome –
Rituximab can cause allergic type reactions during the IV infusion such as
hypotension, wheezing, rash, flushing, alarm, pruritus, sneezing, cough, fever or
faintness.
If an allergic reaction occurs, stop the infusion and after recovery of symptoms,
restart the infusion at one infusion rate below the rate at which the reaction occurred
and continue with escalation of infusion rates on the appropriate schedule above. If
the infusion must be stopped a second time, restart after clearance of symptoms, at
one infusion rate lower and continue at that rate without further escalation. Patients
with a high tumour burden or high number (≥ 25 x 10 9 /L) of circulating malignant
cells may be at risk of severe cytokine release syndrome.
INVESTIGATIONS:
FBC, U&E, LFTs
24 hour urine creatinine clearance
Screen for Igs, Hep prior to first cycle rituximab.
SIDE EFFECTS:
Reduced immunity with possible life-threatening infection
Anaemia
Bruising/bleeding
Confusion
Impaired fertility
Flu-like symptoms
Hair loss
Gritty sore eyes
Irritation of the
bladder
Loss of appetite
Sore mouth
Taste changes
Pins & needles
Numbness & foot
Skin changes
drop
Steroid effects:
Sleep disturbance,
Stomach irritation,
Sleepiness
Lethargy
Loss of balance
Allergic reaction
Diarrhoea
Kidney changes
Liver changes
Nausea & vomiting
Onset of diabetes.
REFERENCES:
1. Guidelines for the use of Methylene Blue for the Treatment and Prophylaxis of
Ifosfamide-induced Encephalitis www.nlcn.nhs.uk
Document Code: LNRCN-0039-09 Date of Issue: July 2009
Written By: C Loughran/F Miall
Authorised By: M Dyer Haem NSSG chair
Issue Number: 1
Review Date: July 2011
Page Number: 2/2
Website: Check www.eastmidlandscancernetwork.nhs.uk for latest
version