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Bleomycin * 10 units/m 2 IV Dilute in 50 mL NS and administer over 10 minutes or IV push through a peripheral line. Test dose of 2 units given one hour before full dose can be considered for the first cycle Δ . Days 1 and 15

Dacarbazine 375 mg/m 2 IV Central line: Dilute in 250 mL of 5 percent dextrose (D5W) and administer over 30 minutes. Peripheral line: Dilute in 500 mL of D5W and administer over 60 minutes. Dacarbazine should be protected from light. Days 1 and 15 Pretreatment considerations: •

Prophylaxis for infusion reactions: A bleomycin test dose may be administered before the first cycle. Premedicate with acetaminophen prior to administration of the full bleomycin dose. Refer to UpToDate topic on "Infusion reactions to systemic chemotherapy". •

Infection prophylaxis: Primary prophylaxis with G-CSF is generally not indicated, and G-CSF is avoided in some centers because of concerns that concurrent use may increase bleomycin lung toxicity. Refer to UpToDate topic on "Bleomycin-induced lung injury". •

Dose adjustment for baseline liver or renal dysfunction: A 25 percent dose reduction in bleomycin is recommended for patients with creatinine clearance 10 to 50 mL/min, and a 50 percent reduction for clearance <10 mL/min. Chemotherapy dose adjustments for doxorubicin and vinblastine are needed in patients with cholestasis or AST/ALT abnormalities. Refer to UpToDate topics on "Chemotherapy hepatotoxicity and dose modification in patients with liver disease" and "Chemotherapy-related nephrotoxicity and dose modification in patients with renal insufficiency". Monitoring parameters: • Assess CBC with differential weekly during treatment. Assess electrolytes, renal function, and liver function prior to each treatment cycle. • Cumulative doxorubicin dose should be monitored. Measure left ventricular ejection fraction prior to first cycle, then as clinically indicated. • Monitor for respiratory complaints or unexplained findings on lung exam (eg, rales). Maximum bleomycin lifetime dose not to exceed 400 mg. Measure pulmonary diffusion capacity before first cycle and then per institutional policy. Refer to UpToDate topic on "Bleomycin-induced lung injury". Suggested dose modifications for toxicity: •

Neuropathy: For severe paresthesias and/or constipation, the dose of vinblastine should be reduced by 50 percent. Vinblastine should be discontinued permanently if an adynamic ileus occurs. If there is a change in body weight of at least 10 percent, dose should be recalculated for all drugs. This table is provided as an example of how to administer this regimen; there may be other acceptable methods. This regimen must be administered by a clinician trained in the use of chemotherapy. The clinician is expected to use his or her independent medical judgment in the context of individual circumstances to make adjustments, as necessary. IV: intravenous; G-CSF: granulocyte-colony stimulating factors; AST: aspartate aminotransferase; ALT: alanine aminotransferase; CBC: complete blood count; WBC: white blood cell. * 1 mg bleomycin = 1 unit bleomycin. Δ A test dose of bleomycin before the first dose is recommended by the manufacturer [2] ; however, many institutions no longer perform this test dose. Refer to UpToDate topic on "Infusion reactions to systemic chemotherapy". References: Canellos GP, et al. N Engl J Med 1992; 327:1478. Blenoxane (bleomycin sulfate) injection. US FDA-approved manufacturer's package insert. US National Library of Medicine. (Available online at dailymed.nlm.nih.gov, accessed on January 3, 2012).