NHL Dosing

Established dosing regimens for a variety of treatment settings in NHL

RITUXAN DOSING BY TREATMENT SETTING IN NHL1

Treatment setting Indicated regimen
Schedule
RITUXAN dose
First-line DLBCL R-CHOP Every 21 days ×8 375 mg/m2
First-line follicular NHL R-CHEMO Every 21 days ×8
Following a response to first-line induction in: Follicular NHL R-CHEMO*→R Every 2 months
(for up to 2 years)
Follicular/
low-grade NHL

CVP→R Weekly ×4
every 6 months
(for up to 2 years)
Relapsed or refractory, low-grade or follicular NHL R Weekly ×4
R Weekly ×8
R (bulky disease) Weekly ×4
R (retreatment) Weekly ×4

Standard Infusion

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90-minute RITUXAN Infusion in Cycles 2-8
for Appropriate Patients

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  • *R-CHEMO: Approximately 75% of patients in both arms of the PRIMA trial received R-CHOP, 22% received R-CVP, and 3% received R-FCM.1
  • NHL=non-Hodgkin's lymphoma; DLBCL=diffuse large B-cell lymphoma; R=RITUXAN; CHOP=cyclophosphamide, doxorubicin, vincristine, and prednisone; CVP=cyclophosphamide, vincristine, and prednisone; PRIMA= Primary RItuximab and MAintenance; FCM=fludarabine, cyclophosphamide, and mitoxantrone.

Previously untreated follicular, B-cell NHL1

Previously untreated follicular, CD20-positive, B-cell NHL in combination with first-line chemotherapy and, in patients achieving a complete or partial response to RITUXAN in combination with chemotherapy, as single-agent maintenance therapy.

RITUXAN is not recommended for use in patients with severe, active infections.

  • The recommended dose of RITUXAN in combination with chemotherapy is 375 mg/m2 IV infusion, given on Day 1 of each 21-day cycle of CVP chemotherapy, for up to 8 doses

MARCUS (M39021) DOSING SCHEDULE1,2

Chart: MARCUS (M39021) TREATMENT PROTOCOL: R-CVP ×8
  • The recommended dose of RITUXAN in patients achieving a complete or partial response to R-CHEMO is 375 mg/m2 IV infusion, given 8 weeks after the completion of induction therapy, every 2 months for up to 12 doses

PRIMA DOSING SCHEDULE1

Chart: PRIMA TREATMENT PROTOCOL
  • To ensure that all patients received an equal number of courses of RITUXAN prior to maintenance randomization, an additional 2 courses of RITUXAN were given to R-CHOP– and R-FCM–treated patients. For the R-CHOP patients, the 2 additional courses were given on Day 1 of Cycles 7 and 8; for the R-FCM patients, the 2 additional courses were given on Day 15 of Cycles 1 and 4.5
  • R-CHEMO: Approximately 75% of patients in both arms of the PRIMA trial received R-CHOP, 22% received R-CVP, and 3% received R-FCM.1
  • PRIMA=Primary RItuximab and MAintenance; PR=partial response; CR=complete response; CRu=complete response, unconfirmed.

Non-progressing, low-grade, B-cell NHL1

Non-progressing (including stable disease), low-grade, CD20-positive, B-cell NHL, as a single agent, after first-line CVP chemotherapy.

RITUXAN is not recommended for use in patients with severe, active infections.

  • The recommended dose of RITUXAN in patients who have not progressed following 6 to 8 twenty-one-day cycles of CVP chemotherapy is 375 mg/m2 IV infusion once weekly for 4 weeks, every 6 months, for up to 16 doses

ECOG 1496 DOSING SCHEDULE1

Chart: ECOG 1496 TREATMENT PROTOCOL: <br />16 DOSES OF RITUXAN FOLLOWING CVP
  • CVP=cyclophosphamide 1 g/m2 on Day 1; vincristine 1.4 mg/m2 on Day 1; prednisone 100 mg/m2 on Days 1–5. After the completion of 6 to 8 twenty-one–day cycles of CVP, patients achieving a CR, PR, or SD were randomized to receive no further treatment or to receive post-induction therapy with RITUXAN. Beginning 4 weeks after completion of induction therapy, patients randomized to RITUXAN received 1 cycle of 4 weekly treatments with 375 mg/m2 RITUXAN, every 6 months for up to 4 cycles.3
  • ECOG=Eastern Cooperative Oncology Group; SD=stable disease; PR=partial response; CR=complete response.

Relapsed or refractory, low-grade or follicular, B-cell NHL1

Relapsed or refractory, low-grade or follicular, CD20-positive, B-cell NHL as a single agent.

RITUXAN is not recommended for use in patients with severe, active infections.

  • The recommended dose of RITUXAN is 375 mg/m2 IV infusion once weekly for 4 or 8 doses

McLAUGHLIN DOSING SCHEDULE1

Chart: McLAUGHLIN WEEKLY ×4 TREATMENT PROTOCOL

PIRO DOSING SCHEDULE1

Chart: PIRO WEEKLY ×8 TREATMENT PROTOCOL
  • PD=progressive disease; NR=no response.

Retreatment therapy

  • The recommended dose of RITUXAN is 375 mg/m2 IV infusion once weekly for 4 doses in patients who develop progressive disease after previous RITUXAN therapy

Diffuse large B-cell NHL (DLBCL)1

Previously untreated diffuse large B-cell, CD20-positive NHL in combination with CHOP or other anthracycline-based chemotherapy regimens.

RITUXAN is not recommended for use in patients with severe, active infections.

  • The recommended dose of RITUXAN is 375 mg/m2 IV infusion given on Day 1 of each 21-day cycle of CHOP or other anthracycline-based chemotherapy regimens, for up to 8 infusions

GELA DOSING SCHEDULE1,4

Chart: TREATMENT PROTOCOL FROM GELA: R-CHOP ×8
  • GELA=Groupe d'Etude des Lymphomes de l'Adulte.

Infusion reactions

  • RITUXAN can cause severe, including fatal, infusion reactions. Severe reactions typically occurred during the first infusion, with time to onset of 30 to 120 minutes
  • RITUXAN-induced infusion reactions and sequelae include urticaria, hypotension, angioedema, hypoxia, bronchospasm, pulmonary infiltrates, acute respiratory distress syndrome, myocardial infarction, ventricular fibrillation, cardiogenic shock, anaphylactoid events, or death
  • Premedicate patients with an antihistamine and acetaminophen prior to dosing. Depending on the severity of the infusion reaction and the required interventions, slow the infusion rate, interrupt the infusion, or permanently discontinue RITUXAN
  • Closely monitor the following patients: those with pre-existing cardiac or pulmonary conditions, those who experienced prior cardiopulmonary adverse reactions, and those with high numbers of circulating malignant cells (≥25,000/mm3)

References:
  1. RITUXAN® (Rituximab) full prescribing information, Genentech, Inc., 2013.
  2. Marcus R, Imrie K, Belch A, et al. CVP chemotherapy plus rituximab compared with CVP as first-line treatment for advanced follicular lymphoma. Blood. 2005;105:1417-1423.
  3. Hochster H, Weller E, Gascoyne RD, et al. Maintenance rituximab after cyclophosphamide, vincristine, and prednisone prolongs progression-free survival in advanced indolent lymphoma: results of the randomized phase III ECOG 1496 study. J Clin Oncol. 2009;27:1607-1614.
  4. Coiffier B, Lepage E, Brière J, et al. CHOP chemotherapy plus rituximab compared with CHOP alone in elderly patients with diffuse large-B-cell lymphoma. N Engl J Med. 2002;346:235-242.
  5. Data on file, Genentech, Inc.

Indications

RITUXAN® (Rituximab) is indicated for the treatment of patients with:

  • Relapsed or refractory, low-grade or follicular, CD20-positive, B-cell NHL as a single agent
  • Previously untreated follicular, CD20-positive, B-cell NHL in combination with first-line chemotherapy and, in patients achieving a complete or partial response to RITUXAN in combination with chemotherapy, as single-agent maintenance therapy
  • Non-progressing (including stable disease), low-grade, CD20-positive, B-cell NHL, as a single agent, after first-line CVP chemotherapy
  • Previously untreated diffuse large B-cell, CD20-positive NHL in combination with CHOP or other anthracycline-based chemotherapy regimens
  • Previously untreated and previously treated CD20-positive CLL in combination with fludarabine and cyclophosphamide (FC)

RITUXAN is not recommended for use in patients with severe, active infections.

Important Safety Information

BOXED WARNINGS

WARNING: FATAL INFUSION REACTIONS, SEVERE MUCOCUTANEOUS REACTIONS, HEPATITIS B VIRUS REACTIVATION and PROGRESSIVE MULTIFOCAL LEUKOENCEPHALOPATHY

  • Infusion Reactions: RITUXAN administration can result in serious, including fatal infusion reactions. Deaths within 24 hours of RITUXAN infusion have occurred. Approximately 80% of fatal infusion reactions occurred in association with the first infusion. Monitor patients closely. Discontinue RITUXAN infusion for severe reactions and provide medical treatment for Grade 3 or 4 infusion reactions
  • Severe Mucocutaneous Reactions: Severe, including fatal, mucocutaneous reactions can occur in patients receiving RITUXAN
  • Hepatitis B Virus (HBV) Reactivation: HBV reactivation can occur in patients treated with RITUXAN, in some cases resulting in fulminant hepatitis, hepatic failure, and death. Screen all patients for HBV infection before treatment initiation, and monitor patients during and after treatment with RITUXAN. Discontinue RITUXAN and concomitant medications in the event of HBV reactivation
  • Progressive Multifocal Leukoencephalopathy (PML), including fatal PML, can occur in patients receiving RITUXAN

Warnings and Precautions

Tumor Lysis Syndrome

  • Acute renal failure, hyperkalemia, hypocalcemia, hyperuricemia, or hyperphosphatemia from tumor lysis, some fatal, can occur within 12−24 hours after the first infusion of RITUXAN in patients with NHL. A high number of circulating malignant cells (≥25,000/mm3) or high tumor burden, confers a greater risk of TLS. Administer aggressive intravenous hydration and anti hyperuricemic therapy in patients at high risk for TLS

Infections

  • Serious, including fatal, bacterial, fungal, and new or reactivated viral infections can occur during and following the completion of RITUXAN-based therapy. Discontinue RITUXAN for serious infections and institute appropriate anti infective therapy

Cardiovascular

  • Discontinue infusions for serious or life threatening cardiac arrhythmias. Perform cardiac monitoring during and after all infusions of RITUXAN for patients who develop clinically significant arrhythmias, or who have a history of arrhythmia or angina

Renal

  • Severe, including fatal, renal toxicity can occur after RITUXAN administration in patients with NHL. Monitor closely for signs of renal failure and discontinue RITUXAN in patients with a rising serum creatinine or oliguria

Bowel Obstruction and Perforation

  • Abdominal pain, bowel obstruction and perforation, in some cases leading to death, can occur in patients receiving RITUXAN in combination with chemotherapy. Evaluate if symptoms of obstruction such as abdominal pain or repeated vomiting occur

Immunization

  • The safety of immunization with live viral vaccines following RITUXAN therapy has not been studied and vaccination with live virus vaccines is not recommended

Laboratory Monitoring

  • Obtain complete blood counts (CBC) prior to each RITUXAN course

Additional Important Safety Information

  • The most common Grade 3 or 4 adverse reactions in clinical trials of NHL and CLL were infusion reactions, neutropenia, leukopenia, anemia, thrombocytopenia, and infections. Additionally, lymphopenia and lung disorder were seen in NHL trials; and febrile neutropenia, pancytopenia, hypotension, and hepatitis B were seen in CLL trials
  • The most common adverse reactions (incidence ≥25%) in clinical trials of NHL and CLL were infusion reactions. Additionally, fever, lymphopenia, chills, infection, and asthenia were seen in NHL trials; and neutropenia was seen in CLL trials
  • Pregnancy: Category C. There are no adequate and well-controlled studies of rituximab in pregnant women

For additional safety information, please see the full prescribing information, including BOXED WARNINGS and Medication Guide.

Attention Healthcare Provider: Provide Medication Guide to patient prior to RITUXAN infusion.

You may report side effects to the FDA at (800) FDA-1088 or www.fda.gov/medwatch.

You may also report side effects to Genentech at (888) 835-2555.