Waldenstrom’s Macroglobulinaemia
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6.02
Regimen name:
DRC
Indications
Transplantation candidate: cytopenias and high M-protein
Non-transplantation candidate: cytopenias
Pre-treatment Evaluation
 Document FBC (with film), reticulocytes, U&E, creatinine, LFTs, calcium, glucose,
serum protein electrophoresis and paraprotein quantitation, CRP, immunoglobulin
levels, (plasma viscosity, 2-microglobulin, cryoglobulins)
 Urine for BJP (and formal evaluation of 24 hour urinary BJP excretion if light chain
only myeloma)
 Serum free ligth chains
 Antibody screen
 In case of neuropathy anti-MAG antibodies; consider anti-gangliosides and
sulphatides
 Bone marrow aspirate ± trephine (and cytogenetics if part of local protocol)
 Skeletal survey
 Document WHO performance status of patient.
 Document height and weight and surface area.
 Consider ECG ± echocardiogram if clinical suspicion of cardiac dysfunction.
 Give adequate verbal and written information for patients and relatives concerning
patient’s disease, treatment strategy and side effects.
 Obtain written consent from patient or guardian.
 Rituximab has been associated with potentially serious hepatitis ‘flare’ in patients
with chronic hepatitis B infection. All patients should have hepatitis B serology
checked before therapy, and in those who have positive serology lamivudine
100mg po daily should be commenced 1-2 weeks prior to rituximab therapy.
Currently it is recommended that lamivudine is continued for 6 months after
rituximab is discontinued
Drug Regimen
Days
(OPCS code: )
Drug
Dose
Route
1
Dexamethasone
20mg
IV
1
Rituximab
375mg/m²
IV
Cyclophosphamide
100mg/m², BD
po
1-5
Comments
Pre-medication: paracetamol,
chlorphenamine
See below for infusion speed
Rituximab infusion speed:

First infusion: Initiate at 50 mg/h; if tolerated increase rate by 50mg/h increments
every 30 minutes to a maximum of 400 mg/h.
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
Subsequent infusions: Initiate at 100 mg/h; if tolerated increase rate by 100mg/h
increments every 30 minutes to a maximum of 400 mg/h.
 High tumour burden: Consider reduction of infusion rate in patients with circulating
tumour cells of > 50 x 109/l or with high tumour burden.
 Fast rate infusion: Many day-care units have implemented this locally as a safe and
time efficient method of reducing the infusion time.
Patients MUST have tolerated their first cycle of rituximab (at the standard recommended
infusion rates as specified above) before being given the rapid infusion rate.
All rituximab doses are prepared in 250mls 0.9% sodium chloride, with 50mls being given
over the first 30 minutes and the remaining 200mls given over 1 hour.
If a 500ml volume of 0.9% sodium chloride is used, then 100mls is given over the first 30
minutes and the remaining 400mls given over 1 hour.
Cycle Frequency and Duration

Repeated every 21days for 6 courses
Dose Modifications
Renal impairment:
Cyclophosphamide:

CrCl >50ml/min: 100% dose

CrCl 10-50ml/min: 75% dose

CrCl <10ml/min: 50% dose
Investigations prior to subsequent cycles


FBC, U+E, Creat and LFTs
Serum protein electrophoresis and paraprotein quantitation, CRP, 2microglobulin and immunoglobulin levels
Concurrent Medication

Allopurinol 300mg od PO (100mg if significant renal impairment) for first 2 cycles
Anti-emetics
This regimen has moderate emetic potential - refer to local protocol
Reference
Dimopoulos M A, Anagnostopoulos A, et al. Primary treatment of Waldenstrom’s
Macroglobulinaemia with dexamethasone, rituximab and cyclophosphamide. J Clin
Oncol, 2007, 25: 3344-3349
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Patient Information
http://www.macmillan.org.uk/Cancerinformation/Cancertreatment/Treatmenttypes/Supp
ortivetherapies/Steroids.aspx
http://www.cancerbackup.org.uk/Treatments/Biologicaltherapies/Monoclonalantibodies/
Rituximab
http://www.macmillan.org.uk/Cancerinformation/Cancertreatment/Treatmenttypes/Che
motherapy/Individualdrugs/Cyclophosphamide.aspx
Written by:
Dr S Abdalla, Dr A Rahemtulla, Dr S Kirschke, September 2009
Authorised by:
WLCN Haematology TWG, March 2010
Date for review by Haematology TWG: March 2011
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