Dear OncoLink "Ask The Experts,"
My question is about the ESHAP protocol for lymphoma. The most descriptive protocol I've been able to find states to run cisplatin for 4 days with concurrent doses of etoposide during that time. I have oncology coworkers who are questioning the safety of running 2 chemo drugs concurrently, and would rather stop the cisplatin, run the etoposide, then continue the cisplatin. I'm thinking that perhaps there is a synergistic action between these 2 drugs and a reason to run them together?
Michael Vozniak, PharmD, BCOP, Hematology/Oncology Clinical Pharmacy Specialist, responds:
ESHAP stands for etoposide, methylprednisolone, high-dose cytarabine, and cisplatin.
Etoposide (VP-16) is known to have synergistic activity when given with cisplatin, but the effect is likely the same whether or not they are given concurrently or back-to-back.
An important part of the ESHAP regimen is the cisplatin that is given by continuous infusion for (hopefully) maximal cell death. Early studies gave cisplatin over 24 hours, but toxicity was high, so we now give it over several days in order to reduce toxicity. Physicians would rather that the continuous infusion NOT be interrupted, and there really is no reason to do so. The two medications are compatible in the IV and there are no safety concerns with running these drugs together. Below is the protocol we use at our institution and a reference that discusses the protocol’s results in trials.
- Etoposide 40mg/m2/day IV Day 1, 2, 3 and 4
- Solumedrol 500mg/day IV Day 1, 2, 3, 4 and 5
- Cytarabine 2Gm/m2/day IV Day 5 -To start immediately after Cisplatin completed.
- Cisplatin 25mg/m2/day IV Day 1, 2, 3 and 4; Given as a continuous infusion over 24 hours.
- Regimen (Cisplatin, and Cytarbine) is emetogenic and should never be given without antiemetic pre-medication (Level 5).
- Aggressive hydration with Cisplatin.
- Urinary output >100cc's/hour prior to Cisplatin and for duration of therapy.
- Decadron eye drops with Cytarabine.
- Cerebellar function checks prior to each Cytarabine dose.
- VP16-vital signs per nursing protocol.
Velasquez, WS et al. (1994) ESHAP – An Effective Chemotherapy Regimen in Refractory and Relapsing Lymphoma: A 4 Year Follow Up Study. Journal of Clinical Oncology, 12(6): 1169-1176.