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Red cell and platelet support during chemotherapy
LSCCN HAEMATOLOGY PROTOCOLS
ACUTE PROMYELOCYTIC LEUKAEMIA – Spanish Protocol and
Maintenance Chemotherapy (AML 15)
Prior to treatment
Assess cardiac function by history & examination, ECG and CXR. If there is evidence of cardiac disease, prior anthracyclines or patient > 70yrs formal assessment of cardiac function by MUGA scan may be indicated – discuss with consultant.
Check recent liver & renal function tests – anthracycline dose reduction may be indicated in these cases or ‘Spanish protocol’ may be inappropriate – discuss with consultant
If appropriate discuss possibility of pregnancy with female patients and need for contraception with both male and female patients. Discuss risk of infertility - offer semen cryopreservation to males
A central venous line, e.g Hickman, Groshong, PICC, must be in situ
All-trans retinoic acid therapy (ATRA)
Starting on day 1 of induction chemotherapy all patients should receive ATRA (Tretinoin)
45mg/m2/day divided into two daily doses (10mg capsules
) until CR is reached.
If WBC at presentation is >10 x109/L prophylaxis against the retinoic acid syndrome must be started with dexamethasone 10mg 12-hourly IV for the first 5 days of chemotherapy.
Idarubicin 12mg/m2 IV in 100ml Nsaline over 10mins
Start courses 2, 3 and 4 when neutrophils >1.0 and platelets >100
Idarubicin 7mg/m2 IV in 100ml Nsaline over 10mins
Mitozantrone 10mg/m2 IV in 100ml Nsaline over 30mins
Idarubicin 12mg/m2 IV in 100ml Nsaline over 20mins
* Note there is also a randomisation to +/- Mylotarg with course 3 in the AML 15 trial
Prophylaxis for acute emesis
5HT antagonist on each day of chemotherapy
Prophylaxis for delayed emesis
5HT antagonist + metaclopramide for 3-4 days (avoid dexamethasone due to its immunosuppressive effects)
Allopurinol 300mg od for each day of chemotherapy
Corsodyl 10ml qds & Nystatin 10ml qds mouthwash
Norethisterone 5mg tds for menstruating females
Itraconazole 200mg bd when neutrophils <0.5 *
Ciprofloxacin 500mg bd when neutrophils <0.5
LSCCN HAEMATOLOGY PROTOCOLS
Retinoic acid syndrome
This is a major cause of mortality in patients treated with ATRA. The patient may have unexplained fever, weight gain, respiratory distress, interstitial pulmonary infiltrates, and pleural or pericardial effusions. Usually there is also hyperleucocytosis but the syndrome may occur at any level of WBC.
At the earliest suspicion of the ATRA syndrome discuss the case with the consultant
. Administer dexamethasone 10mg 12-hourly IV until disappearance of symptoms and signs and for a minimum of 3 days, and discontinue ATRA.
This may develop in patients under 20years of age. It presents with headaches, nausea, vomiting and visual disturbances. Discuss with the consultant
and temporarily stop ATRA.
Start not less than 1 month after completion of the ‘Spanish protocol’ and only when neutrophils have recovered to >1.5 x109/l and platelets > 100 x109/l.
6-mercaptopurine 50mg tablets Methotrexate 2.5mg and 10mg tablets
Treatment is to be continued for 2 years
a. Start ATRA four months after recovery from last consolidation chemotherapy
b. Discontinue mercaptopurine and methotrexate while taking ATRA
c. Doses of mercaptopurine and methotrexate are to be adjusted according to toxicity
if WBC 2.5 - 3.5 reduce doses by 50% if WBC <2.5 temporarily discontinue maintenance
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