DECC (Relapsed and progressive Hodgkin and Non Hodgkin Lymphoma). Cumbria, Northumberland, Tyne & Wear Area Team

Following publication of a letter to the Annals of Oncology the PECC protocol has been amended – all new patients commencing PECC should receive the regimen outlined below, now renamed DECC.

DRUG ADMINISTRATION SCHEDULE

Day Drug Dose Route Frequency 1- 5 Ondansetron 8mg Oral Twice Daily 80 mg/m2 Fo r 1 day 1 Lomustine (CCNU) ORAL ONCE ONLY (max 160mg) only Fo r 3 days 1 - 3 Etoposide 150mg/m2 ORAL Once Daily only 15 mg/m2 In three divided Fo r 4 days 1 - 4 Chlorambucil ORAL (max 30mg) doses daily only Fo r 5 days 1 - 5 Dexamethasone 6mg/m2 ORAL Once Daily only

CYCLE LENGTH AND NUMBER OF DAYS Cycle length is normally 6 weeks. In patients with rapidly progressing disease or significant symptoms, where the first cycle is well tolerated at the discretion of a consultant haematologist this can be reduced to 28 days (provided this is clearly documented in the patient’s medical records). Treatment is usually given for up to 6 cycles

APPROVED INDICATIONS Salvage therapy for Advanced Relapsed Hodgkin’s Lymphoma Salvage therapy for Advanced Relapsed Non-Hodgkin’s Lymphoma

RECOMMENDED TAKE HOME MEDICATION Allopurinol 300mg once daily on days 1 to 5 of first cycle. Ondansetron 8mg twice daily for 5 days (DECC is moderately emetogenic, however, to avoid the risk of losing the lomustine dose through vomiting relatively aggressive anti-emetic cover is recommended) Consider prescribing gastro prophylaxis (proton pump inhibitor or H 2-antagonist) for cover with dexamethasone.

INVESTIGATIONS / MONITORING REQUIRED

Prior to first cycle: CT Scan, Chest X-Ray, FBC, U&E’s, LFT’s, LDH, ß2- MicroGlobulin

Prior to each cycle: U&E’s, LFT’s, FBC

ASSESSMENT OF RESPONSE CT scan at mid-point of treatment and after completion of treatment if appropriate.

DECC CNTW protocol CRP08 H006 Page 1 of 3 Expiry Date: May 2016

DECC (Relapsed and progressive Hodgkin and Non Hodgkin Lymphoma).

REVIEW BY CLINICIAN

Prior to each cycle

ADMINISTRATION NOTES • Etoposide should be taken on an empty stomach • Hodgkin’s lymphoma patients requiring blood transfusions will require irradiated blood. • Steroid dose may cause impaired glucose tolerance. Diabetic patients should increase frequency of glucose monitoring. • Chlorambucil dose can be divided into three doses to reduce GI irritation • There have been fatalities with this regimen when the course of lomustine and etoposide have been given for longer than recommended. • Lomustine is supplied as 40mg capsules – the dose should be rounded to the nearest multiple of 40mg. • Chlorambucil is supplied as 2mg tablets – the dose should be rounded to the nearest 2mg. • Etoposide is supplied as 50mg and 100mg capsules – the dose should be rounded to the nearest 50mg.

TOXICITIES Common : Nausea and vomiting, myelosuppression (moderate to severe), fatigue, glucose intolerance, alopecia Less Common : Flushing, rash/dermatitis, peripheral neuropathy, hallucinations, constipation / diarrhoea.

DOSE MODIFICATION / TREATMENT DELAYS

Haematological Toxicity: (Note: Where haematological disease is affecting bone marrow function, lower treatment parameters may be acceptable. This should be clearly documented for the specific patient.)

Delay treatment on day 1 if ANC < 1.5 x 10 9cells/l or PLT < 50 x 10 9cells/l. There will be two nadirs with this regimen. One caused by etoposide (between day 7 and 14, and one caused by lomustine which may not present until day 28)

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DECC (Relapsed and progressive Hodgkin and Non Hodgkin Lymphoma).

Renal Function: Lomustine and etoposide are both excreted by the kidney and dose modification is required in mild renal impairment:

CrCl Lo mustine Chlorambuci l Etop osi de >60ml/min 100% 100% 100% 50-60 ml/min 75% 100% 100% 45–50ml/min 75% 100% 75% 30-45 ml/min 50% 100% 75% 15-30ml/min 100% 75% Not recommended <15ml/min 100% 50%

Hepatic Function: Lomustine is partly excreted by the liver, however, no data exists on its safety in hepatic disease. In event of hepatic impairment consider dose reduction with dose escalation if no toxicity on first cycle.

Etoposide is metabolised by the liver (as well as the kidney), If bilirubin > 26µmol/l or AST > 60iu/l reduce dose to 50%, if bilirubin > 51µmol/l or AST > 180iu/l clinical decision required to proceed with treatment.

TREATMENT LOCATION Suitable for self administration in patients own homes, under the supervision of haematology teams from Level 1 – 4 Haematology Services.

REFERENCES: • Lennard AL et al: An effective oral combination in advanced relapsed Hodgkin’s disease: prednisolone, etoposide, chlorambucil and CCNU. Cancer chemotherapy and pharmacology – 26; 301-305 (1990) • Proctor SJ, Lennard AL, Jackson et al, The role of an all-oral chemotherapy containing lomustine (CCNU) in advanced, progressive Hodgkin lymphoma: a patient- friendly palliative option which can result in long-term disease control (Letter). Anals of Oncol. Published Online: 9 Nov 2009

Document Control

Document Title: DECC CNTW protocol CRP08 H006 Curr ent Document No: CRP08 H006 2.3 Version: Calum Polwart, Cancer Pharmacist Reviewed Author: Calum Polwart by: Date Approved by: Diane Plews, Steve Proctor 28 May 2014 Reviewed:

Due for Review: May 2016 Summ ary of Revised doses in line with Annals of Oncol letter. Other Minor Spelling 2.0b Changes corrections.

2.0c Minor grammar and spelling changes

2.1a Regimen renamed DECC. Course length clarified.

2.2 Protocol reviewed. Renal impairment dosing advice updated.

2.3 Formatting updated..

DECC CNTW protocol CRP08 H006 Page 3 of 3 Expiry Date: May 2016

DECC (Relapsed and progressive Hodgkin and Non Hodgkin Lymphoma).

DECC CNTW protocol CRP08 H006 Page 4 of 3 Expiry Date: May 2016