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regimen-monograph
CHOP+R
Regimen Category
Evidence-Informed
Funding Program
ODB - General Benefit
prednisone
Drugs Used
A - Regimen Name
CHOP+R Regimen
Cyclophosphamide-Hydroxyldaunorubicin (DOXOrubicin)-ONCOVIN® (VinCRIStine)-Prednisone-riTUXimab
Disease Site
Hematologic - Lymphoma - Non-Hodgkin's Intermediate Grade
Intent
Curative
Palliative
Palliative
Regimen Category
Evidence-Informed :
Regimen is considered appropriate as part of the standard care of patients; meaningfully improves outcomes (survival, quality of life), tolerability or costs compared to alternatives (recommended by the Disease Site Team and national consensus body e.g. pan-Canadian Oncology Drug Review, pCODR). Recommendation is based on an appropriately conducted phase III clinical trial relevant to the Canadian context OR (where phase III trials are not feasible) an appropriately sized phase II trial. Regimens where one or more drugs are not approved by Health Canada for any indication will be identified under Rationale and Use.
Rationale and Uses
Therapy for previously untreated patients for CD20 positive, Diffuse Large B-Cell Lymphoma (DLBCL) or a variant of DLBCL (such as mediastinal sclerosing B-cell lymphoma, T-cell–rich B-cell lymphoma, Burkitt-like lymphoma, or intravascular lymphoma).
Supplementary Public Funding
prednisone
ODB - General Benefit (prednisone)
riTUXimab
New Drug Funding Program (Rituximab - Aggressive Histology Lymphoma) (NDFP Website )
riTUXimab
New Drug Funding Program (Rituximab - HIV-Related, Aggressive Histology, B-cell Lymphoma) (NDFP Website )
B - Drug Regimen
| prednisone | 100 mg | PO daily | Days 1 to 5* |
|
*On Day 1 to be given as part of pre-medication before Rituximab (Outpatient prescription in multiples of 50mg tablets)
|
|||
| riTUXimab | 375 mg /m² | IV | Day 1 |
| vinCRIStine | 1.4 mg /m² | IV (max 2 mg) | Day 1 |
| DOXOrubicin | 50 mg /m² | IV | Day 1 |
| cyclophosphamide | 750 mg /m² | IV | Day 1 |
C - Cycle Frequency
REPEAT EVERY 21 DAYS
For a usual total of 6 to 8 cycles unless disease progression or unacceptable toxicity occurs
D - Premedication and Supportive Measures
Antiemetic Regimen:
Moderate
Febrile Neutropenia Risk:
Moderate
Other Supportive Care:
- Rituximab premedication:
- Acetaminophen 650mg PO
- Diphenhydramine 50mg PO/IV
- Other:
- If high volume disease, consider steroids and prophylaxis for tumour lysis
E - Dose Modifications
Doses should be modified according to the protocol by which the patient is being treated. The following recommendations are in use at some centres.
Dosage with toxicity
Hematologic and Non-Hematologic Toxicities: See Appendix 6 for general recommendations.
|
Toxicity
|
Doxorubicin1 (% previous dose) |
Vincristine1 (% previous dose) |
Cyclophosphamide1 (% previous dose) |
Rituximab1,2 (% previous dose) |
Grade 4 hematological ≥ 7 days, febrile neutropenia, bleeding |
75%, or G-CSF for low ANC |
100%
|
75%, or G-CSF for low ANC |
100%
|
|
Grade 3 non-hematological toxicity
|
75%
|
100%
|
75%
|
100% or delay |
|
Grade 4 organ toxicity
|
Discontinue
|
Discontinue
|
Discontinue
|
Discontinue
|
|
Neurotoxicity
|
100%
|
Mild: 67%; |
100%
|
100%
|
|
Discontinue
|
Discontinue
|
Discontinue
|
Discontinue
|
| Toxicity | Doxorubicin1 (% previous dose) | Vincristine1 (% previous dose) | Cyclophosphamide1 (% previous dose) | Rituximab1,2 (% previous dose |
| Grade 1-2 infusion related | -- | -- | -- | Stop or slow infusion; exclude respiratory symptoms; treat symptomatically. Re-start at 50% previous rate after resolution of symptoms. |
| ≥Grade 3 infusion-related/pulmonary | -- | -- | -- | Discontinue; Manage appropriately; monitor patient until complete resolution. |
1Prior to retreatment, major organ toxicity should have recovered to ≤ grade 2 and ANC to ≥ 1.5 x 109/L and platelets ≥ 100 x 109/L.
2Missed or delayed doses may be administered at a later time point, based on physician’s discretion
Hepatic Impairment
Consider dose modification for doxorubicin and vincristine for severe increase in transaminases.
|
Bilirubin
|
Doxorubicin (% previous dose) |
Vincristine |
Cyclophosphamide |
Rituximab |
1 – 2 X ULN |
50%
|
50%
|
100%
|
No adjustment required |
2 – 4 x ULN |
25%
|
25%
|
Caution
|
No adjustment required |
> 4 ULN |
OMIT
|
OMIT
|
Caution
|
No adjustment required |
Renal Impairment
Creatinine Clearance (mL/min) |
Doxorubicin
(% previous dose) |
Vincristine
(% previous dose) |
Cyclophosphamide
(% previous dose) |
Rituximab
|
|
30-50
|
No dose adjustment required. |
No dose adjustment required. |
100%
|
No adjustment required. |
|
10-30
|
50-75%
|
|||
< 10 |
50% or Omit |
F - Adverse Effects
Refer to prednisone, riTUXimab, vinCRIStine, DOXOrubicin, cyclophosphamide drug monograph(s) for additional details of adverse effects
| Most Common Side Effects | Less Common Side Effects, but may be |
|
|
G - Interactions
Refer to prednisone, riTUXimab, vinCRIStine, DOXOrubicin, cyclophosphamide drug monograph(s) for additional details
H - Drug Administration and Special Precautions
Refer to prednisone, riTUXimab, vinCRIStine, DOXOrubicin, cyclophosphamide drug monograph(s) for additional details
Rituximab:
- First infusion: initial rate of 50 mg/h, then escalate rate in 50 mg/h increments every 30 minutes, to a maximum of 400 mg/h.
- If first infusion well-tolerated, start subsequent infusions at 100 mg/hr, then escalate rate in 100 mg/hr increments every 30 minutes, to a maximum of 400 mg/hr as tolerated
- Published data suggest that a 90 minute infusion (20% of the dose in the first 30 min then the remaining 80% over 60 min) can be used for second and subsequent infusions if no reaction occurred with the 1st infusion.
- Consider a slower infusion rate for patients with high bulk disease who are at a higher risk of tumor lysis syndrome and infusion related reactions.
I - Recommended Clinical Monitoring
Treating physicians may decide to monitor more or less frequently for individual patients but should always consider recommendations from the product monograph.
Recommended Clinical Monitoring
- CBC; baseline and before each cycle
- LFTs; baseline and before each cycle
- Renal functions tests; baseline and before each cycle
- Hepatitis B screening prior to treatment; seropositive patients should see hepatologist and be closely monitored for up to 12 months after the last infusion.
- Clinical assessment of hypersensitivity reactions, tumour lysis syndrome, infection, bleeding, GI, pulmonary, skin or CNS toxicity, cardiotoxicity, hypotension, neurotoxicity and cystitis
- Baseline and regular cardiac examination for patients with cardiac risk factors (including prior therapy with epirubicin, mitoxantrone, or other cardiotoxic drug) and cumulative doxorubicin doses > 450mg/m2.
Grade toxicity using the current NCI-CTCAE (Common Terminology Criteria for Adverse Events) version
Suggested Clinical Monitoring
- Monitor closely for cardiovascular symptoms for patients who have cardiac conditions or recurrent cardiac events with rituximab
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J - Administrative Information
Approximate Patient Visit
4 to 7 hours
Pharmacy Workload (average time per visit)
46.499 minutes
Nursing Workload (average time per visit)
89.833 minutes
K - References
Coiffier B, Lepage E, Briere J, et al. CHOP chemotherapy plus rituximab compared with CHOP alone in elderly patients with diffuse large-B-cell lymphoma. N Engl J Med 2002;346:235-42.
Feugier P, Van Hoof A, Sebban C, et al. Long-term results of the R-CHOP study in the treatment of elderly patients with diffuse large B-cell lymphoma: a study by the Groupe d’Etudes des Lymphomes de l’Adulte. J Clin Oncol 2005;23(18):4117-26.
Habermann TM, Weller EA, Morrison VA, et al. Rituximab-CHOP versus CHOP alone or with maintenance rituximab in older patients with diffuse large B-cell lymphoma. J Clin Oncol 2006;24(19):3121-7.
Salar A, Casao D, Cervera M, et al. Rapid infusion of rituximab with or without steroid-containing chemotherapy: 1-yr experience in a single institution. Eur J Haematol 2006: 77: 338–40.
Sehn LH, Donaldson J, Filewich A, et al. Rapid infusion rituximab in combination with corticosteroid-containing chemotherapy or as maintenance therapy is well tolerated and can safely be delivered in the community setting. Blood 2007;109(10):4171-3.
PEBC Advice Documents or Guidelines
October 2017 Replaced regimen category with evidence-informed
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.
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Last Updated: July 21, 2026
