| Cycle length: 21 days |
| Drug | Dose and route | Administration | Given on days |
| Cyclophosphamide | 750 mg/m2 IV | Dilute in 250 mL NS or D5W* and administer over 30 minutes. | Day 1 |
| Doxorubicin | 50 mg/m2 IV | Dilute in 50 mL NS or D5W* and administer over 3 to 5 minutes. | Day 1 |
| Vincristine | 1.4 mg/m2 IV (max dose 2 mg) | Dilute in 50 mL NS or D5W* and administer over 15 to 20 minutes. | Day 1 |
| Prednisone¶ | 100 mg orally | Administer 30 minutes prior to chemotherapy on day 1, then every 24 hours on days 2 to 5. | Days 1 to 5 |
| Pretreatment considerations: |
| Emesis risk | - MODERATE.
- Refer to UpToDate topics on prevention of chemotherapy-induced nausea and vomiting in adults.
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| Prophylaxis for infusion reactions | - No premedication to prevent infusion reactions.
- Refer to UpToDate topics on infusion-related reactions to therapeutic monoclonal antibodies used for cancer therapy.
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| Vesicant/irritant properties | - Doxorubicin and vincristine are vesicants; avoid extravasation.
- Refer to UpToDate topics on extravasation injury from chemotherapy and other non-antineoplastic vesicants.
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| Infection prophylaxis | - The risk of febrile neutropenia with this regimen is 10 to 20%;[1] primary prophylaxis with hematopoietic growth factors should be considered on an individual basis, particularly for high-risk patients such as those with pre-existing neutropenia, advanced disease, poor performance status, or patients over age 65 years.
- Refer to UpToDate topics on use of granulocyte colony-stimulating factors in adult patients with chemotherapy-induced neutropenia and conditions other than acute leukemia, myelodysplastic syndrome, and hematopoietic cell transplantation.
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| Dose adjustment for baseline liver or renal dysfunction | - Adjustment of initial cyclophosphamide, doxorubicin, and vincristine doses may be needed for pre-existing liver dysfunction.[2-4] In addition, dose adjustment of cyclophosphamide may be required for renal dysfunction.
- Refer to UpToDate topics on chemotherapy hepatotoxicity and dose modification in patients with liver disease, conventional cytotoxic agents; chemotherapy hepatotoxicity and dose modification in patients with liver disease, molecularly targeted agents; and chemotherapy nephrotoxicity and dose modification in patients with renal insufficiency, conventional cytotoxic agents.
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| Cardiac screening | - LVEF should be evaluated prior to initiation of therapy. Dose alterations should be considered for LVEF <50%, and doxorubicin therapy is contraindicated in patients with LVEF <30% at initiation. Infusion times and schedule may be adjusted to decrease the risk of cardiotoxicity in individuals at high risk for its development.
- Refer to UpToDate topics on clinical manifestations, monitoring, and diagnosis of anthracycline-induced cardiotoxicity and prevention and management of anthracycline cardiotoxicity.
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| Neurotoxicity | - Vincristine may cause constipation and in severe cases, paralytic ileus. A routine prophylactic regimen against constipation is recommended in all patients receiving vincristine.
- Refer to UpToDate topics on overview of neurologic complications of conventional nonplatinum cancer chemotherapy.
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| Monitoring parameters: |
- CBC with differential and platelet count weekly during treatment.
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- Assess basic metabolic panel (creatinine and electrolytes) and liver function prior to each subsequent treatment cycle.
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- LVEF should be evaluated periodically based on LVEF at initiation of therapy and cumulative dose of doxorubicin.
- Refer to UpToDate topics on clinical manifestations, monitoring, and diagnosis of anthracycline-induced cardiotoxicity and prevention and management of anthracycline cardiotoxicity.
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| Suggested dose modifications for toxicity: |
| Myelosuppression | - Treatment should be delayed until ANC is >1000/microL and platelet count is >100,000/microL. If a patient develops grade 4 (ANC <500) neutropenia or febrile neutropenia with any cycle, HGF support is added to the regimen for subsequent cycles. If grade 4 neutropenia or febrile neutropenia occurs despite HGF support, or if the patient develops grade 3 (25,000 to 50,000 platelets) or 4 (<25,000 platelets) thrombocytopenia with any cycle, the doses of cyclophosphamide and doxorubicin should be decreased by 50% for subsequent cycles.
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| Neuropathy | - Dose adjustment of vincristine may be necessary if the severity of neuropathy persists or worsens. No specific guidelines are available for dose adjustments.
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| If there is a change in body weight of at least 10%, doses should be recalculated. |
