CTD
Regimen
Indication
Multiple myeloma
Therapeutic Intent
Disease modification
Day
Medication
1, 8, 15
Cyclophosphamide
500mg
PO
Once a week
1 to 21
Thalidomide
100mg
PO
Once a day in the evening
After 3 weeks, increase to 200mg od if tolerated
(maximum dose)
1 to 4
and
12 to 15
Dexamethasone
40mg
PO
As a single dose in the morning with food
Cycle Frequency
Tests required prior to
initiation of course
Tests required prior to
individual cycle
Concurrent Medication
Dose
Route
Administration Details
Every 21 days up to a maximum of 6 cycles
FBC, LFT, U+E, bone profile, glucose
Serum Igs/ electrophoresis/ serum free light chains
Neurological assessment for neuropathy
FBC, LFT, U+E
Serum Igs/ electrophoresis/ serum free light chains (if indicated)
Neurological assessment for neuropathy
Allopurinol (during 1st cycle)
PPI
Anti-emetics as per local policy
GCSF support as per local policy
Antimicrobial prophylaxis as per local policy – include PCP and antiviral
prophylaxis
Bisphosphonate monthly
Laxatives
Anticoagulation – options include prophylactic dose of a LMWH, treatment
dose LMWH in high risk patients or full anti-coagulation with warfarin (to
achieve a target INR of 2-3). If these 2 options are not considered suitable,
aspirin 75-300mg may be considered. Patients at higher risk of thrombosis
should receive full anti-coagulation.
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Dose Modifications
Hepatic
No hepatic dose modifications
Renal
Haematological
Neurotoxicity
Thromboembolism
Steroid Intolerance
Serum Creatinine
(micromol/L)
Modification
>300
Omit cyclophosphamide
Dose modification is not usually indicated if cytopenias are thought be due to
marrow infiltration.
If neutrophil <1 x 109/l or platelets <50 x 109/l are treatment related:
 Omit cyclophosphamide for 1 to 3 weeks and reduce dose (e.g. to 400mg or
300mg)
 Add G-CSF for 2 to 3 days per cycle or week (usually only requires low
doses)
Thalidomide-related grade 1-2 toxicity, but sometimes grade 3-4 toxicity, may be
encountered and include constipation, neuropathy, fatigue, sedation, rash, tremor
and oedema. Grade 3-4 toxicity is an indication to stop thalidomide for the
remainder of the current cycle and then re-introduce at 50 mg daily with the next or
subsequent cycle. Assuming tolerance at the lower dose level, escalation to 100 mg
daily may be considered, and possibly to 150 mg or the full dose of 200 mg daily if
the symptoms resolve and do not recur.
The occurrence of a thromboembolic event such as a DVT or pulmonary embolism is
an indication for full anticoagulation following standard treatment guidelines.
Thalidomide may be stopped, but can be re-introduced, assuming good
anticoagulant control and no other untoward side effects.
Patients unable to tolerate dexamethasone at the protocol dose can dose reduce
e.g. 20mg daily or omit one of the two 4 day pulses of dexamethasone in a 3 week
cycle. Switching to an alternative corticosteroid can also be considered.
Additional Information
Thalidomide must be supplied via an MHRA approved risk management
programme only.
Refer to thalidomide SPC (available at www.medicines.org.uk) for further
information on thalidomide risk management programme run by Celgene.
References
Myeloma XI Trial
Author
Pharmacy CNG
Approved & Checked by
Haematology CNG (Review Date = Sept 2017)
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