IV pulse cyclophosphamide for vasculitis- Addenbrooke's Hospital

CYC is given as intravenous pulses at weeks 0, 2, 4 and then every 3 weeks until the remission is reached at 3 - 6 months from start of therapy (max 10 doses min 6).

a) CYC may be stopped from 3 months onward provided patient in remission (BVAS 0 for 2 consecutive study assessments). After completion of CYC, AZA to be commenced.

b) Reductions for renal function and age according to table above.

c) Maximum CYC pulse is 1.2g.

d) Upon completion of CYC course AZA to be commenced.

e) Dissolve CYC in water for injection, then dilute in saline 0.9% 500 ml and administer as IV infusion over one hour.

f) Mesna is optional and will be administered orally in the same dose in mg as CYC in mg either from IV vials or in the form of tablets on days when CYC is administered. (If it has to be administered IV reduce mesna dose to 60% of the CYC dose).

g) Prevention of emesis: the choice of antiemetic drugs to cover the CYC pulses should follow local practice. Ondansetron is suitable for this indication.

h)Check FBC on day of pulse or previous day.
If WBC prior to pulse < 4 x 109/L, then postpone pulse until WBC > 4 x 109/L, while checking WBC at least weekly. Reduce dose of pulse by 25%. With any further episodes of leucopenia, make equivalent dose reduction.

i) Check FBC between days 10 and 14 after a pulse. If the leucocyte nadir (i.e. the lowest leucocyte count between two CYC pulses) is < 3 x 109/L, even if the WBC just previous to the next pulse is > 4 x 109/L, then reduce the dose of the next pulse by:
j) leucocyte nadir 1 - 2 x 109/L reduce CYC dose of last pulse by 40 % of previous dose.
k) leucocyte nadir 2 - 3 x 109/L reduce CYC dose of last pulse by 20 % of previous dose.

l) If in remission by three months, or between three and six months, may switch to AZA 2mg/kg/day.