Precautions before administration | Â |
Fertility preservation should be ensured, or at least offered to patients, to women of childbearing age as well as to men | Â |
Hydration prior to and during the infusion is essential. It is supplemented by the administration of mesna (off-label and without certainty of its value for doses of cyclophosphamide < 600 mg/m2 per bolus), administered during and after the cyclophosphamide infusion: |  |
One-third of the equivalent dose of cyclophosphamide (in milligrams) by IV bolus at hour 0 |  |
Then two-thirds of the IV dose at the end of the infusion (90th minute) | Â |
And two-thirds of the dose at hour 4, orally |  |
When cyclophosphamide is delivered orally, mesna can also be administered orally (equivalent daily dose in milligrams, orally—possible off-label use) |  |
Monitoring of the cyclophosphamide treatment is based on the complete blood count and platelet count, serum creatinine, and the search for hematuria as a minimum: | Â |
Before each infusion | Â |
Every 2Â weeks for the first 3Â months | Â |
Then monthly if the oral treatment is continued | Â |
If the neutrophils are < 1.5 × 109/L on the scheduled bolus date, the dose will be reduced by 25% or even postponed (trying not to postpone treatment for more than 2 weeks, in which case another therapy should be discussed) |  |
Cyclophosphamide administration regimen | Â |
In patients with normal kidney function under 65 years of age, the recommended regimen is the following: IV bolus of cyclophosphamide prescribed at a dose of 0.6 g/m2 on days 1, 15, and 29; then 0.7 g/m2 every 21 days (total of six boluses) |  |
In patients with normal kidney function under 65 years of age, the recommended regimen is the following: IV bolus of cyclophosphamide prescribed at a dose of 0.5 g/m2 on days 1, 15, and 29; then 0.7 g/m2 every 21 days (total of six boluses) |  |
In patients over 65 years of age, regardless of kidney function, the recommended regimen is as follows: IV bolus of cyclophosphamide prescribed at a fixed dose of 0.5 g on days 1, 15, and 29, then every 21 days (total of six boluses). The benefit of this regimen has been demonstrated in the prospective CORTAGE trial, providing efficacy comparable to a conventional treatment but with better tolerance. These low doses of cyclophosphamide have not been evaluated compared to rituximab in this population |  |
In the event of incomplete remission, three additional boluses can be given | Â |
The maximum dose of each bolus is limited to 1200Â mg | Â |
After induction therapy with cyclophosphamide, maintenance therapy should be started between 2 and 4Â weeks after the last cyclophosphamide bolus, regardless of the maintenance therapy selected | Â |