regimen-monograph

PEME(MNT)

Intent

Palliative

Regimen Category

Standard

Drugs Used

pemetrexed

A - Regimen Name

PEME(MNT) Regimen

Pemetrexed

(Maintenance)

Disease Site

Lung

Intent

Palliative

Regimen Category

Standard : Standard therapy endorsed by the Disease Site Group or a regimen widely used by most Regional Cancer Centres in this disease site. The category is unrelated to the source or availability of funding.

Rationale and Uses

Monotherapy for the maintenance treatment of locally advanced or metastatic NSCLC following 4 to 6 cycles of platinum doublet induction treatment, which may include pemetrexed, for patients who achieved stable disease or better and who have an ECOG performance status of 0 or 1 (NDFP criteria)

B - Drug Regimen

pemetrexed

500 mg /m²

IV in 100mL NS over 10 minutes

Day 1

C - Cycle Frequency

REPEAT EVERY 21 DAYS

Continue until disease progression or unacceptable toxicity

D - Premedication and Supportive Measures

Antiemetic Regimen:

Low

Other Supportive Care:

Vitamin B12 1000mcg IM every 9 weeks, Folic acid 0.4 - 1 mg PO daily (both starting ≥ 1 week prior to pemetrexed administration; continue throughout and until 3 weeks after last dose of Pemetrexed).
Dexamethasone 4mg PO BID for 3 days starting day before chemotherapy suggested for rash prophylaxis.
Note: NSAIDs should be held for 2-5 days prior and 2 days after pemetrexed (refer to pemetrexed monograph)

E - Dose Modifications

Doses should be modified according to the protocol by which the patient is being treated. The following recommendations have been adapted from clinical trials or product monographs and could be considered.

Dosage with toxicity

Worst toxicity in previous cycle	Pemetrexed (% of previous dose)*
Thrombocytopenic bleeding	50%
Grade 4 ANC or ≥ Grade 3 platelets	75%
Grade 2 neurotoxicity	100%
Grade 3 or 4 mucositis	50%
Diarrhea requiring hospitalization, or grade 3 or 4	75%
Grade 3 or 4 neurotoxicity	Discontinue
Worst toxicity in previous cycle (Continued)	Pemetrexed (% of previous dose)*
Symptoms suggesting pneumonitis	Hold and investigate; discontinue if confirmed
Other Grade 3 related organ / non-hematologic toxicity	75%
Other Grade 4 related organ / non-hematologic toxicity	Discontinue
Grade 3 or 4 toxicity after 2 prior dose reductions, any occurrence of SJS, TEN	Discontinue
_{*Start next cycle only when ANC ≥ 1.5 x 10⁹/L, platelets ≥ 100 x 10⁹/L and related organ/non-hematologic toxicity ≤ grade 2 (or recovery to baseline).}

Hepatic Impairment

Pemetrexed is not extensively metabolized in the liver. No specific studies have been performed in patients with moderate or severe hepatic impairment. Pemetrexed should be used with caution in patients with hepatic impairment. Refer to the dose modification table above.

Renal Impairment

Use with caution as pemetrexed exposure is increased in renal impairment.

Creatinine clearance (mL/min)	Pemetrexed (% of previous dose)
≥ 80	100%
45-79	100% but use NSAIDs with extreme caution
< 45	Discontinue

F - Adverse Effects

Refer to pemetrexed drug monograph(s) for additional details of adverse effects

Most Common Side Effects	Less Common Side Effects, but may be Severe or Life-Threatening
Nausea, vomiting Myelosuppression ± infection, bleeding (may be severe) Fatigue Anorexia Rash (may be severe), radiation recall Diarrhea Mucositis	Pneumonitis Arterial thromboembolism Venous thromboembolism GI perforation Hemolysis Arrhythmia Hypersensitivity Diarrhea ↑ LFTs Creatinine increased Neurotoxicity

G - Interactions

Refer to pemetrexed drug monograph(s) for additional details

H - Drug Administration and Special Precautions

Refer to pemetrexed drug monograph(s) for additional details

I - Recommended Clinical Monitoring

Recommended Clinical Monitoring

CBC; baseline and regular
Liver function tests; baseline and regular
Renal function tests; baseline and regular
Routine toxicity ratings of fatigue, pneumonitis, thromboembolism, mucositis, diarrhea, neurotoxicity, infection, bleeding and rash; at each visit
Grade toxicity using the current NCI-CTCAE (Common Terminology Criteria for Adverse Events) version

J - Administrative Information

Approximate Patient Visit

0.5 hour

Pharmacy Workload (average time per visit)

21.349 minutes

Nursing Workload (average time per visit)

36.667 minutes

K - References

Ciuleanu T, Brodowicz T, Zielinski C, et al. Maintenance pemetrexed plus best supportive care versus placebo plus best supportive care for non-small-cell lung cancer: a randomized, double-blind, phase 3 study. Lancet 2009; 374: 1432-40.

Paz-Ares L, de Marinis F, Dediu M, et al. Maintenance therapy with pemetrexed plus best supportive care versus placebo plus best supportive care after induction therapy with pemetrexed plus cisplatin for advanced non-squamous non-small-cell lung cancer (PARAMOUNT): a double-blind, phase 3, randomised controlled trial. Lancet Oncol 2012;13(3):247-55.

October 2017 Removed PEBC archived guideline

M - Disclaimer

Regimen Abstracts
A Regimen Abstract is an abbreviated version of a Regimen Monograph and contains only top level information on usage, dosing, schedule, cycle length and special notes (if available). It is intended for healthcare providers and is to be used for informational purposes only. It is not intended to constitute or be a substitute for medical advice, and all uses of the Regimen Abstract are subject to clinical judgment. Such information is provided on an “as-is” basis, without any representation, warranty, or condition, whether express, or implied, statutory or otherwise, as to the information’s quality, accuracy, currency, completeness, or reliability, and Cancer Care Ontario disclaims all liability for the use of this information, and for any claims, actions, demands or suits that arise from such use.
Information in regimen abstracts is accurate to the extent of the ST-QBP regimen master listings, and has not undergone the full review process of a regimen monograph. Full regimen monographs will be published for each ST-QBP regimen as they are developed.
Regimen Monographs
Refer to the New Drug Funding Program or Ontario Public Drug Programs websites for the most up-to-date public funding information.
The information set out in the drug monographs, regimen monographs, appendices and symptom management information (for health professionals) contained in the Drug Formulary (the "Formulary") is intended for healthcare providers and is to be used for informational purposes only. The information is not intended to cover all possible uses, directions, precautions, drug interactions or adverse effects of a particular drug, nor should it be construed to indicate that use of a particular drug is safe, appropriate or effective for a given condition. The information in the Formulary is not intended to constitute or be a substitute for medical advice and should not be relied upon in any such regard. All uses of the Formulary are subject to clinical judgment and actual prescribing patterns may not follow the information provided in the Formulary.
The format and content of the drug monographs, regimen monographs, appendices and symptom management information contained in the Formulary will change as they are reviewed and revised on a periodic basis. The date of last revision will be visible on each page of the monograph and regimen. Since standards of usage are constantly evolving, it is advised that the Formulary not be used as the sole source of information. It is strongly recommended that original references or product monograph be consulted prior to using a chemotherapy regimen for the first time.
Some Formulary documents, such as the medication information sheets, regimen information sheets and symptom management information (for patients), are intended for patients. Patients should always consult with their healthcare provider if they have questions regarding any information set out in the Formulary documents.
While care has been taken in the preparation of the information contained in the Formulary, such information is provided on an “as-is” basis, without any representation, warranty, or condition, whether express, or implied, statutory or otherwise, as to the information’s quality, accuracy, currency, completeness, or reliability.
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Last Updated: July 27, 2026

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