Hodgkin Lymphoma Treatment Regimens

Hodgkin Lymphoma Treatment Regimens

Clinical Trials: The NCCN recommends cancer patient participation in clinical trials as the gold standard for treatment.

Cancer therapy selection, dosing, administration, and the management of related adverse events can be a complex process that should be handled by an experienced health care team. Clinicians must choose and verify treatment options based on the individual patient; drug dose modifications and supportive care interventions should be administered accordingly. The cancer treatment regimens below may include both U.S. Food and Drug Administration-approved and unapproved indications/regimens. These regimens are provided only to supplement the latest treatment strategies.


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These Guidelines are a work in progress that may be refined as often as new significant data become available. The NCCN Guidelines® are a consensus statement of its authors regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult any NCCN Guidelines® is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient’s care or treatment. The NCCN makes no warranties of any kind whatsoever regarding their content, use, or application and disclaims any responsibility for their application or use in any way.

Note: All recommendations are category 2A unless otherwise indicated.

▶CHL (Age ≥18 years)1,a

REGIMEN

DOSING

Stage IA, IIA Favorable (Non-Bulky) CHL1,a

Primary Treatment

ABVD
(Doxorubicin/Bleomycin/
Vinblastine/Dacarbazine) (Category 1)2-6,b,c
Consider premedication with Bleomycin.

Days 1 and 15: Doxorubicin 25mg/m2 IV push

Days 1 and 15: Bleomycin 10units/m2 IV over 10 minutes

Days 1 and 15: Vinblastine 6mg/m2 IV over 5-10 minutes

Days 1 and 15: Dacarbazine 375mg/m2 IV over 30 minutes.

Repeat cycle every 4 weeks for 2 cycles followed by additional therapy.

Additional Therapy

ABVD
(Doxorubicin/Bleomycin/
Vinblastine/Dacarbazine)2-6,b,c
Consider premedication with Bleomycin.

Days 1 and 15: Doxorubicin 25mg/m2 IV push

Days 1 and 15: Bleomycin 10units/m2 IV over 10 minutes

Days 1 and 15: Vinblastine 6mg/m2 IV over 5-10 minutes

Days 1 and 15: Dacarbazine 375mg/m2 IV over 30 minutes.

Repeat cycle every 4 weeks for 1–2 cycles or combined modality (based on Deauville score).

AVD
(Doxorubicin/Vinblastine/
Dacarbazine)7,c

Days 1 and 15: Doxorubicin 25mg/m2 IV push

Days 1 and 15: Vinblastine 6mg/m2 IV over 5-10 minutes

Days 1 and 15: Dacarbazine 375mg/m2 IV over 30 minutes.

Repeat cycle every 4 weeks for 4 cycles following 2 cycles of ABVD.

Stage I-II Unfavorable (B symptoms or bulky mediastinal disease or >10cm adenopathy) CHL1,a

Primary Treatment

ABVD
(Doxorubicin/Bleomycin/
Vinblastine/Dacarbazine)3,4,b,c
Consider premedication with Bleomycin.

Days 1 and 15: Doxorubicin 25mg/m2 IV push

Days 1 and 15: Bleomycin 10units/m2 IV over 10 minutes

Days 1 and 15: Vinblastine 6mg/m2 IV over 5-10 minutes

Days 1 and 15: Dacarbazine 375mg/m2 IV over 30 minutes.

Repeat cycle every 4 weeks for 2 cycles followed by additional therapy.

Additional Therapy

ABVD
(Doxorubicin/Bleomycin/
Vinblastine/Dacarbazine)3,4,b.c
Consider premedication with Bleomycin.

Days 1 and 15: Doxorubicin 25mg/m2 IV push

Days 1 and 15: Bleomycin 10units/m2 IV over 10 minutes

Days 1 and 15: Vinblastine 6mg/m2 IV over 5-10 minutes

Days 1 and 15: Dacarbazine 375mg/m2 IV over 30 minutes.

Repeat cycle every 4 weeks for 2 cycles following 2 cycles of ABVD.

AVD
(Doxorubicin/Vinblastine/
Dacarbazine)7,c

Days 1 and 15: Doxorubicin 25mg/m2 IV push

Days 1 and 15: Vinblastine 6mg/m2 IV over 5-10 minutes

Days 1 and 15: Dacarbazine 375mg/m2 IV over 30 minutes.

Repeat cycle every 4 weeks for 4 cycles, following 2 cycles of ABVD.

Escalated BEACOPP
(Bleomycin/Etoposide/
Doxorubicin/Cyclophosphamide/
Vincristine/Prednisone/
Procarbazine)5,7,b-e
(for patients aged 18-59 years)
Consider premedication with Bleomycin.

Day 1: Doxorubicin 35mg/m2 IV push

Day 1: Cyclophosphamide 1,250mg/m2 IV over 1 hour

Day 1: Mesna 250mg/m2 IV over 15 minutes three times daily (one dose before cyclophosphamide, then at 4 and 8 hours from the start of each cyclophosphamide dose)

Days 1-3: Etoposide 200mg/m2 IV over 1 hour daily

Days 1-14: Prednisone 40mg/m2 orally daily

Days 1-7: Procarbazine 100mg/m2 orally daily

Day 8: Bleomycin 10units/m2 IV over 10 minutes

Day 8: Vincristine 1.4mg/m2 (maximum 2mg) IV over 5-10 minutes.

Repeat cycle every 3 weeks for 2–4 cycles following 2 cycles of ABVD dependent on Deauville score.

Stage III-IV CHL1,a

Primary Treatment

Preferred

ABVD
(Doxorubicin/Bleomycin/
Vinblastine/Dacarbazine)7-9,b,c
Consider premedication with Bleomycin.

Days 1 and 15: Doxorubicin 25mg/m2 IV push

Days 1 and 15: Bleomycin 10units/m2 IV over 10 minutes

Days 1 and 15: Vinblastine 6mg/m2 IV over 5-10 minutes

Days 1 and 15: Dacarbazine 375mg/m2 IV over 30 minutes.

Repeat cycle every 4 weeks for 2 cycles.

Other Recommended Regimen

Brentuximab vedotin + AVD
(Doxorubicin/Vinblastine/
Dacarbazine) (use with caution in patients aged >60 years; contraindicated in those with neuropathy).11,12,c,d,f
Consider premedication with Brentuximab vedotin.

Days 1 and 15: Brentuximab vedotin 1.2mg/kg (maximum dosing weight is 100kg) IV over 30 minutes within 1 hour after completion of AVD

Days 1 and 15: Doxorubicin 25mg/m2 IV push

Days 1 and 15: Vinblastine 6mg/m2 IV over 5-10 minutes

Days 1 and 15: Dacarbazine 375mg/m2 IV over 30 minutes.

Repeat cycle every 4 weeks for 6 cycles.

Useful in certain circumstances

Escalated BEACOPP
(Bleomycin/Etoposide/
Doxorubicin/Cyclophosphamide/
Vincristine/Prednisone/
Procarbazine)
(in select patients if IPS ≥4, age 18-59 years).7-10,13,b-e
Consider premedication with Bleomycin.

Day 1: Doxorubicin 35mg/m2 IV push

Day 1: Cyclophosphamide 1,250mg/m2 IV over 1 hour

Day 1: Mesna 250mg/m2 IV over 15 minutes three times daily (one dose before cyclophosphamide, then at 4 and 8 hours from the start of each cyclophosphamide dose)

Days 1-3: Etoposide 200mg/m2 IV over 1 hour daily

Days 1-14: Prednisone 40mg/m2 orally daily

Days 1-7: Procarbazine 100mg/m2 orally daily

Day 8: Bleomycin 10units/m2 IV over 10 minutes

Day 8: Vincristine 1.4mg/m2 (maximum 2mg) IV over 5-10 minutes.

Repeat cycle every 3 weeks for 2 cycles.

Additional Therapy

A(B)VD
(Doxorubicin/Bleomycin/
Vinblastine/Dacarbazine)
(in select patients if IPS >4, aged <60 years).7-9,b,c
Consider premedication with Bleomycin.

Days 1 and 15: Doxorubicin 25mg/m2 IV push

Days 1 and 15: Bleomycin 10units/m2 IV over 10 minutes

Days 1 and 15: Vinblastine 6mg/m2 IV over 5-10 minutes

Days 1 and 15: Dacarbazine 375mg/m2 IV over 30 minutes.

Repeat cycle every 4 weeks for 4 cycles OR repeat cycle every 4 weeks for a total of 6 cycles (if Bleomycin is omitted) following 2 cycles of escalated BEACOPP with Deauville 1-3 after restage with PET/CT.

AVD
(Doxorubicin/Vinblastine/
Dacarbazine)7,b

Days 1 and 15: Doxorubicin 25mg/m2 IV push

Days 1 and 15: Vinblastine 6mg/m2 IV over 5-10 minutes

Days 1 and 15: Dacarbazine 375mg/m2 IV over 30 minutes.

Repeat cycle every 4 weeks for 4 cycles following 2 cycles of ABVD or 2 cycles of BEACOPP.

Escalated BEACOPP
(Bleomycin/Etoposide/
Doxorubicin/Cyclophosphamide/
Vincristine/Prednisone/
Procarbazine)7-10,13,b-e
Consider premedication with Bleomycin.

Day 1: Doxorubicin 35mg/m2 IV push

Day 1: Cyclophosphamide 1,250mg/m2 IV over 1 hour

Day 1: Mesna 250mg/m2 IV over 15 minutes three times daily (one dose before cyclophosphamide, then at 4 and 8 hours from the start of each cyclophosphamide dose)

Days 1-3: Etoposide 200mg/m2 IV over 1 hour daily

Days 1-14: Prednisone 40mg/m2 orally daily

Days 1-7: Procarbazine 100mg/m2 orally daily

Day 8: Bleomycin 10units/m2 IV over 10 minutes

Day 8: Vincristine 1.4mg/m2 (maximum 2mg) IV over 5-10 minutes.

Repeat cycle every 3 weeks for 2-4 dependent on Deauville score.

Refractory and Suspected Relapse CHL1,a

Second-line and Subsequent Therapy

Brentuximab vedotin11,14,15,f
Consider premedication with Brentuximab vedotin.

Day 1: Brentuximab vedotin 1.8mg/kg (maximum dosing weight is 100kg) IV over 30 minutes.

Repeat cycle every 3 weeks.

Brentuximab vedotin + Bendamustine11,16,17,f
Consider premedication with Brentuximab vedotin.

Day 1: Brentuximab vedotin 1.8mg/kg (maximum dosing weight is 100kg) IV over 30 minutes

Day 1-2: Bendamustine 90mg/m2 IV over 10-60 minutes (based on product selection) daily.

Repeat cycle every 3 weeks for 6 cycles.

Brentuximab vedotin + Nivolumab11,18,19,f,g
Consider premedication with Brentuximab vedotin.

Day 1: Brentuximab vedotin 1.8mg/kg (maximum dosing weight is 100kg) IV over 30 minutes, followed by:

Day 8, Cycle 1: Nivolumab 3mg/kg IV over 30 minutes, followed by:

Day 1, Cycles 2-4: Nivolumab 3mg/kg IV over 30 minutes.

Repeat cycle every 3 weeks for 4 cycles.

DHAP
(Dexamethasone/Cisplatin/
High-dose Cytarabine)20,21,d,h

Days 1-4: Dexamethasone 40mg orally or IV daily

Day 1: Cisplatin 100mg/m2 IV continuous infusion over 24 hours

Day 2: Cytarabine 2,000mg/m2 IV over 3 hours every 12 hours.

Repeat cycle every 3 to 4 weeks for 2-4 cycles (transplant candidates) or 4-8 cycles (nontransplant candidates).

ESHAP
(Etoposide/Methylprednisolone/
High-dose Cytarabine/Cisplatin)22-24,d,h

Days 1-4: Etoposide 40mg/m2 IV over 60 minutes daily

Days 1-4: Methylprednisolone 500mg IV over 15 minutes daily

Days 1-4: Cisplatin 25mg/m2 IV continuous infusion over 24 hours daily

Day 5: Cytarabine 2,000mg/m2 IV over 3 hours.

Repeat cycle every 3-4 weeks for 2-4 cycles (transplant candidates) or 4-8 cycles (nontransplant candidates).

Gemcitabine/Bendamustine/
Vinorelbine16,25,d

Days 1 and 4: Gemcitabine 800mg/m2 IV over 30 minutes

Day 1: Vinorelbine 20mg/m2 IV over 5-10 minutes

Days 2 and 3: Bendamustine 90mg/m2 IV over 10-60 minutes (based on product selection) daily

Days 1-4: Prednisolone 100mg orally daily.

Repeat cycle every 3 weeks for 4 cycles.

GVD
(Gemcitabine/Vinorelbine/
Liposomal Doxorubicin)26,c,i

Days 1 and 8: Vinorelbine 20mg/m2 IV over 5-10 minutes, followed by:

Days 1 and 8: Gemcitabine 1,000mg/m2 IV over 30 minutes, followed by:

Days 1 and 8: Liposomal doxorubicin 15mg/m2 IV.

Repeat cycle every 3 weeks for 2-6 cycles (transplant-naïve).

OR

Days 1 and 8: Vinorelbine 15mg/m2 IV over 5-10 minutes, followed by:

Days 1 and 8: Gemcitabine 800mg/m2 IV over 30 minutes, followed by:

Days 1 and 8: Liposomal doxorubicin 10mg/m2 IV.

Repeat cycle every 3 weeks for 2-6 cycles (prior transplant).

GVD
(Gemcitabine/Vinorelbine/
Liposomal Doxorubicin) + Pembrolizumab27,,28,a,c,d,g,i

Day 1: Pembrolizumab 200mg IV over 30 minutes, followed by:

Days 1 and 8: Vinorelbine 20mg/m2 IV over 5-10 minutes, followed by:

Days 1 and 8: Gemcitabine 1,000mg/m2 IV over 30 minutes, followed by:

Days 1 and 8: Liposomal doxorubicin 15mg/m2 IV.

Repeat cycle every 3 weeks for 2-4 cycles followed by evaluation for HDT/AHCT if complete response.

ICE
(Ifosfamide/Carboplatin/
Etoposide)21,29-31,d,j

Inpatient:

Days 1-3: Etoposide 100mg/m2 IV over 1 hour daily

Day 2: Carboplatin AUC 5 IV over 30 minutes

Day 2: Ifosfamide 5,000mg/m2 IV continuous infusion over 24 hours, concurrent with:

Day 2: Mesna 5,000mg/m2 IV continuous infusion over 24 hours.

Repeat cycle every 2-3 weeks for 2-4 cycles (transplant candidates) or 4-8 cycles (nontransplant candidates).

Outpatient:

Days 1-3: Etoposide 100mg/m2 IV over 30 minutes daily

Day 1: Carboplatin AUC 5 IV over 1 hour

Days 1-3: Ifosfamide 1,667mg/m2 IV over 2-3 hours daily (total dose 5000mg/m2 over 3 days), concurrent with:

Days 1-3: Mesna 1,667mg/m2 IV over 2-3 hours daily (total dose 5000mg/m2 over 3 days).

Repeat cycle every 3 weeks for 2 cycles.

IGEV
(Ifosfamide/Gemcitabine/
Vinorelbine)32,d,j

Days 1-4: Mesna 400mg/m2 IV over 15 minutes three times daily (one dose before ifosfamide, then at 4 and 8 hours from the start of each ifosfamide dose)

Days 1-4: Ifosfamide 2,000mg/m2 IV over 3 hours daily

Days 1 and 4: Gemcitabine 800mg/m2 IV over 30 minutes

Day 1: Vinorelbine 20mg/m2 IV over 5-10 minutes

Days 1-4: Prednisone 100mg orally daily.

Repeat cycle every 3 weeks for 2-4 cycles (transplant candidates) or 4-8 cycles (nontransplant candidates).

Pembrolizumab27,33-35,g
(nontransplant candidates)

Day 1: Pembrolizumab 200mg IV over 30 minutes.

Repeat cycle every 3 weeks until up to 2 years of therapy has been completed .

OR

Day 1: Pembrolizumab 400mg IV over 30 minutes.

Repeat every 6 weeks until up to 2 years of therapy has been completed.

Third-Line and Subsequent Systemic Therapy

Bendamustine16,36

Days 1-2: Bendamustine 90-120mg/m2 IV over 10-60 minutes (based on product selection) daily.

Repeat cycle every 4 weeks for a maximum of 6 cycles.

Bendamustine/Carboplatin/
Etoposide16,37,d

Days 1-2: Bendamustine 60-120mg/m2 IV over 10-60 minutes (based on product selection) daily

Day 1: Carboplatin AUC 5 IV over 30 minutes

Days 1-3: Etoposide 100mg/m2 IV over 1 hour daily.

Repeat cycle every 3 weeks for a maximum of 2 cycles.

C-MOPP
(Cyclophosphamide/Vincristine/
Procarbazine/Prednisone)38-41,e

Day 1: Cyclophosphamide 650mg/m2 IV over 30 minutes

Day 1: Vincristine 1.4mg/m2 (maximum 2mg) IV over 5-10 minutes

Days 1-14: Prednisone 40mg/m2 orally daily

Days 1-7: Procarbazine 100mg/m2 orally daily.

Repeat cycle every 4 weeks for 4-8 cycles (nontransplant candidates)

OR

Days 1 and 8: Cyclophosphamide 500mg/m2 IV over 30 minutes

Days 1 and 8: Vincristine 1.4mg/m2 (maximum 2mg) IV over 5-10 minutes

Days 1-3 and 8-10: Prednisone 40mg/m2 orally daily

Days 1-14: Procarbazine 100mg/m2 orally daily.

Repeat cycle every 4 weeks for 4-8 cycles (nontransplant patients).

Everolimus42,43

Days 1-28: Everolimus 10mg orally daily.

Repeat cycle every 4 weeks.

GCD
(Gemcitabine/Cisplatin/
Dexamethasone)44,h

Days 1 and 8: Gemcitabine 1,000mg/m2 IV over 30 minutes

Day 1: Cisplatin 75mg/m2 over 2 hours

Days 1-4: Dexamethasone 40mg orally daily.

Repeat cycle every 3 weeks for 2-3 cycles.

GEMOX
(Gemcitabine/Oxaliplatin)45

Day 1: Gemcitabine 1,000mg/m2 IV over 30 minutes

Day 1: Oxaliplatin 100 mg/m2 IV over 2 hours.

Repeat cycle every 15 or 21 days for 2-4 cycles (transplant candidates) or 4-8 cycles (nontransplant candidates).

Lenalidomide46,47

Days 1-21: Lenalidomide 25mg orally daily.

Repeat cycle every 4 weeks.

MINE
Etoposide/Ifosfamide/Mesna/
Mitoxantrone)48,d,j

Days 1-3: Mesna 300 mg/m2 IV over 15 minutes three times daily (one dose before ifosfamide, then at 4 and 8 hours from the start of each ifosfamide dose)

Days 1-3: Ifosfamide 1,330 mg/m2 IV over 3 hours daily

Day 1-3: Etoposide 65mg/m2 IV over 1 hour daily

Day 1: Mitoxantrone 8mg/m2 IV over 30 minutes.

Repeat cycle every 3 weeks for 2-4 cycles (transplant candidates) or 4-8 cycles (nontransplant candidates).

Mini-BEAM
(Carmustine/Cytarabine/
Etoposide/Melphalan)49,d

Day 1: Carmustine 60mg/m2 IV over 2 hours

Days 2-5: Etoposide 75mg/m2 IV over 1 hour daily

Days 2-5: Cytarabine 100mg/m2 IV over 3 hours every 12 hours

Day 6: Melphalan 30mg/m2 IV over 15 minutes.

Repeat cycle every 4-6 weeks for 2-4 cycles (transplant and nontransplant candidates).

Nivolumab18,51-53,g

Day 1: Nivolumab 240mg IV over 30 minutes.

Repeat cycle every 2 weeks.

OR

Day 1: Nivolumab 480mg IV over 30 minutes.

Repeat cycle every 4 weeks.

Pembrolizumab27,33-35,g

Day 1: Pembrolizumab 200mg IV over 30 minutes.

Repeat cycle every 3 weeks until up to 2 years of therapy has been completed.

OR

Day 1: Pembrolizumab 400mg IV over 30 minutes.

Repeat cycle every 6 weeks until up to 2 years of therapy has been completed.

Maintenance Therapy

Brentuximab vedotin11,14,15,f
Consider premedication with Brentuximab vedotin.

Day 1: Brentuximab vedotin 1.8mg/kg (maximum dosing weight is 100kg) IV over 30 minutes beginning within 4-6 weeks post-transplant or upon recovery from transplant.

Repeat cycle every 3 weeks for up to 16 cycles.

▶CHL (Age >60 years)1,a

Stage I-II Favorable Disease in Older Adults (Age >60)1,a

Preferred Regimen

A(B)VD
(Doxorubicin/Bleomycin/
Vinblastine/Dacarbazine)2,7,54,55,b,c
Consider premedication with Bleomycin.

Days 1 and 15: Doxorubicin 25mg/m2 IV push

Days 1 and 15: Bleomycin 10units/m2 IV over 10 minutes

Days 1 and 15: Vinblastine 6mg/m2 IV over 5-10 minutes

Days 1 and 15: Dacarbazine 375mg/m2 IV over 30 minutes.

Repeat cycle every 4 weeks for 2 cycles with subsequent ISRT.

A(B)VD
(Doxorubicin/Bleomycin/
Vinblastine/Dacarbazine) +
AVD
(Doxorubicin/Vinblastine/
Dacarbazine)2,7,54,55,b,c
Consider premedication with Bleomycin.

Days 1 and 15: Doxorubicin 25mg/m2 IV push

Days 1 and 15: Bleomycin 10units/m2 IV over 10 minutes

Days 1 and 15: Vinblastine 6mg/m2 IV over 5-10 minutes

Days 1 and 15: Dacarbazine 375mg/m2 IV over 30 minutes.

Repeat cycle every 4 weeks for 2 cycles with subsequent ISRT followed by:

Days 1 and 15: Doxorubicin 25mg/m2 IV push

Days 1 and 15: Vinblastine 6mg/m2 IV over 5–10 minutes

Days 1 and 15: Dacarbazine 375mg/m2 IV over 30 minutes.

Repeat cycle every 4 weeks for 2 cycles.

Alternatively, the bleomycin may be omitted and patients may receive a total of 4 cycles of AVD alone.

Other Recommended Regimen

CHOP
(Cyclophosphamide/Doxorubicin/
Vincristine/Prednisone)56,c-e

Day 1: Cyclophosphamide 750mg/m2 IV over 30 minutes

Day 1: Doxorubicin 50mg/m2 IV push

Day 1: Vincristine 1.4mg/m2 (maximum 2 mg) IV over 5 – 10 minutes

Days 1-5: Prednisone 100mg orally daily.

Repeat cycle every 3 weeks for 4 cycles with subsequent ISRT.

Stage I-II Unfavorable or Stage III-IV Disease in Older Adults (Age >60)

Suggested Treatment Regimens

A(B)VD
(Doxorubicin/Bleomycin/
Vinblastine/Dacarbazine)2,7,54,55,b,c
Consider premedication with Bleomycin.

Days 1 and 15: Doxorubicin 25mg/m2 IV push

Days 1 and 15: Bleomycin 10units/m2 IV over 10 minutes

Days 1 and 15: Vinblastine 6mg/m2 IV over 5-10 minutes

Days 1 and 15: Dacarbazine 375mg/m2 IV over 30 minutes.

Repeat cycle every 4 weeks for 2 cycles, followed by:

Days 1 and 15: Doxorubicin 25mg/m2 IV push

Days 1 and 15: Vinblastine 6mg/m2 IV over 5–10 minutes

Days 1 and 15: Dacarbazine 375mg/m2 IV over 30 minutes.

Repeat cycle every 4 weeks for 4 cycles if PET scan is negative after 2 cycles of ABVD.

Alternatively, the bleomycin may be omitted and patients may receive a total of 6 cycles (or consider a total of 4 cycles for State I-II Unfavorable) of AVD alone.

Brentuximab vedotin followed by AVD
(Doxorubicin/Vinblastine/
Dacarbazine)11,57,c,f
Consider premedication with Brentuximab vedotin.

Day 1: Brentuximab vedotin 1.8mg/kg (maximum dosing weight is 100kg) IV over 30 minutes.

Repeat cycle every 3 weeks for 2 cycles, followed by:

Days 1 and 15: Doxorubicin 25mg/m2 IV push

Days 1 and 15: Vinblastine 6mg/m2 IV over 5–10 minutes

Days 1 and 15: Dacarbazine 375mg/m2 IV over 30 minutes.

Repeat cycle every 4 weeks for 6 cycles, conditionally followed by consolidation in responding patients:

Day 1: Brentuximab vedotin 1.8mg/kg (maximum dosing weight is 100kg) IV over 30 minutes.

Repeat cycle every 3 weeks for 4 cycles.

Brentuximab vedotin + DTIC
(Dacarbazine)11,58,59,f
Consider premedication with Brentuximab vedotin.

Day 1: Brentuximab vedotin 1.8mg/kg (maximum dosing weight is 100kg) IV over 30 minutes

Day 1, Cycles 1-12: Dacarbazine 375mg/m2 IV over 30 minutes.

Repeat cycle every 3 weeks.

CHOP
(Cyclophosphamide/Doxorubicin/
Vincristine/Prednisone)56,c,e

Day 1: Cyclophosphamide 750mg/m2 IV over 30 minutes

Day 1: Doxorubicin 50mg/m2 IV push

Day 1: Vincristine 1.4mg/m2 (maximum 2 mg) IV over 5-10 minutes

Days 1-5: Prednisone 100mg orally daily.

Repeat cycle every 3 weeks for 6 cycles with or without subsequent ISRT.

Relapsed or Refractory Disease in Older Adults (Age >60)

Suggested Palliative Therapy Treatment Regimens

Bendamustine16,36

Days 1-2: Bendamustine 90-120mg/m2 IV over 10-60 minutes daily.

Repeat cycle every 4 weeks for a maximum of 6 cycles.

Brentuximab vedotin11,14,15,f
Consider premedication with Brentuximab vedotin.

Day 1: Brentuximab vedotin 1.8mg/kg (maximum dosing weight is 100kg) IV over 30 minutes.

Repeat cycle every 3 weeks.

Nivolumab18,51-53,g

Day 1: Nivolumab 240 mg IV over 30 minutes.

Repeat cycle every 2 weeks.

OR

Day 1: Nivolumab 480mg IV over 30 minutes.

Repeat cycle every 4 weeks.

Pembrolizumab27,33-35,g

Day 1: Pembrolizumab 200mg IV over 30 minutes.

Repeat cycle every 3 weeks until up to 2 years of therapy has been completed.

OR

Day 1: Pembrolizumab 400mg IV over 30 minutes.

Repeat cycle every 6 weeks until up to 2 years of therapy has been completed.

Second-line, third-line and subsequent therapy options (only for CHL) can be used.

▶NLPHL1,a

CS IB, IIB or CS 1A (Bulky)/CS IIA (Bulky or noncontiguous) NLPHL1,a

Primary Treatment

R-ABVD
(Rituximab + Doxorubicin/
Bleomycin/Vinblastine/
Dacarbazine)60-63,b,c,k,l
Rituximab requires premedication and consider premedication with Bleomycin.

Day 1: Rituximab 375mg/m2 IV

Days 1 and 15: Doxorubicin 25mg/m2 IV push

Days 1 and 15: Bleomycin 10units/m2 IV over 10 minutes

Days 1 and 15: Vinblastine 6mg/m2 IV over 5–10 minutes

Days 1 and 15: Dacarbazine 375 mg/m2 IV over 30 minutes.

Repeat cycle every 4 weeks for 6 cycles.

R-CHOP
(Rituximab + Cyclophosphamide/
Doxorubicin/Vincristine/
Prednisone)60,64,65,c,e,k,l
Rituximab requires premedication

Day 1: Rituximab 375mg/m2 IV

Day 1: Cyclophosphamide 750mg/m2 IV over 30 minutes

Day 1: Doxorubicin 50mg/m2 IV push

Days 1: Vincristine 1.4mg/m2 (maximum 2 mg) IV over 5-10 minutes

Days 1-5: Prednisone 100mg orally daily,

Repeat cycle every 3 weeks for 6 cycles.

R-CVbP
(Rituximab + Cyclophosphamide/
Vinblastine/Prednisolone)60,66,e,k,l
Rituximab requires premedication

Day 1: Rituximab 375mg/m2 IV

Day 1: Cyclophosphamide 500mg/m2 IV over 30 minutes

Days 1 and 8: Vinblastine 6mg/m2 IV over 5–10 minutes

Days 1–8: Prednisolone 40mg/m2 orally daily.

Repeat cycle every 3 weeks for 3 cycles.

Rituximab60,63,67-70,k,l
Rituximab requires premedication

Days 1,8,15,22: Rituximab 375mg/m2 IV.

Administer for one 4-week cycle, followed by maintenance therapy with:

Days 1,8,15,22: Rituximab 375mg/m2 IV.

Repeat cycle every six months for 2 years.

CS II-IV (Based on Clinical Judgement) NLPHLa

Primary Treatment

R-ABVD
(Rituximab + Doxorubicin/
Bleomycin/Vinblastine/
Dacarbazine)60-63,b,c,k,l
Rituximab requires premedication and consider premedication with Bleomycin.

Day 1: Rituximab 375mg/m2 IV

Days 1 and 15: Doxorubicin 25mg/m2 IV push

Days 1 and 15: Bleomycin 10units/m2 IV over 10 minutes

Days 1 and 15: Vinblastine 6mg/m2 IV over 5–10 minutes

Days 1 and 15: Dacarbazine 375 mg/m2 IV over 30 minutes.

Repeat cycle every 4 weeks for 6 cycles.

R-CHOP
(Rituximab + Cyclophosphamide/
Doxorubicin/Vincristine
Prednisone)60,64,65,c,e,k,l
Rituximab requires premedication.

Day 1: Rituximab 375mg/m2 IV

Day 1: Cyclophosphamide 750mg/m2 IV over 30 minutes

Day 1: Doxorubicin 50mg/m2 IV push

Days 1: Vincristine 1.4mg/m2 (maximum 2 mg) IV over 5-10 minutes

Days 1-5: Prednisone 100mg orally daily,

Repeat cycle every 3 weeks for 6 cycles.

R-CVbP
(Rituximab + Cyclophosphamide Vinblastine/Prednisolone)60,66,e,k,l
Rituximab requires premedication.

Day 1: Rituximab 375mg/m2 IV

Day 1: Cyclophosphamide 500mg/m2 IV over 30 minutes

Days 1 and 8: Vinblastine 6mg/m2 IV over 5–10 minutes

Days 1–8: Prednisolone 40mg/m2 orally daily.

Repeat cycle every 3 weeks for 3 cycles.

Rituximab60,63,67-70,k,l
Rituximab requires premedication.

Days 1,8,15,22: Rituximab 375mg/m2 IV.

Administer for one 4-week cycle, followed by maintenance therapy with:

Days 1,8,15,22: Rituximab 375mg/m2 IV.

Repeat cycle every 6 months for 2 years.

Refractory and Suspected Relapse NLPHLa

Primary Treatment

Rituximab60,63,67-70,k,l
Rituximab requires premedication.

Days 1,8,15,22: Rituximab 375mg/m2 IV.

Administer for one 4-week cycle, followed by maintenance therapy with:

Days 1,8,15,22: Rituximab 375mg/m2 IV.

Repeat cycle every six months for 2 years.

Rituximab + Bendamustine16,60,71,72,k,l
Rituximab requires premedication

Days 1-2: Bendamustine 90-120mg/m2 IV over 10-60 minutes (based on product selection) daily

Day 1: Rituximab 375mg/m2 IV.

Repeat cycle every 4 weeks for a maximum of 6 cycles.

Rituximab + DHAP
(Dexamethasone/Cisplatin/
High-dose Cytarabine)20,21,60,68 d,h,k,l
Rituximab requires premedication.

Day 1: Rituximab 375mg/m2 IV

Days 1-4: Dexamethasone 40mg orally or IV daily

Day 1: Cisplatin 100mg/m2 IV continuous infusion over 24 hours

Day 2: Cytarabine 2,000mg/m2 IV over 3 hours every 12 hours.

Repeat cycle every 3-4 weeks for 2-4 cycles (transplant candidates) or 4-8 cycles (nontransplant candidates).

Rituximab + ESHAP
(Etoposide/Methylprednisolone/
High-dose Cytarabine/
Cisplatin)22-24,60,68,d,h,k,l
Rituximab requires premedication.

Day 1: Rituximab 375mg/m2 IV

Days 1-4: Etoposide 40mg/m2 IV over 60 minutes daily

Days 1-4: Methylprednisolone 500mg IV over 15 minutes daily

Days 1-4: Cisplatin 25mg/m2 IV continuous infusion over 24 hours daily

Day 5: Cytarabine 2,000mg/m2 IV over 3 hours.

Repeat cycle every 3-4 weeks for 2-4 cycles (transplant candidates) or 4-8 cycles (nontransplant candidates).

Rituximab + ICE
(Ifosfamide/Carboplatin/
Etoposide)21,29,31,60-68,j-l
Rituximab requires premedication.

Inpatient:

Day 1: Rituximab 375mg/m2 IV

Days 1-3: Etoposide 100mg/m2 IV over 1 hour daily

Day 2: Carboplatin AUC 5 IV over 30 minutes

Day 2: Ifosfamide 5,000mg/m2 IV continuous infusion over 24 hours, concurrent with:

Day 2: Mesna 5,000mg/m2 IV continuous infusion over 24 hours.

Repeat cycle every 2-3 weeks for 2-4 cycles (transplant candidates) or 4-8 cycles (nontransplant candidates).

Outpatient:

Day 1: Rituximab 375mg/m2 IV

Days 1-3: Etoposide 100mg/m2 IV over 30 minutes daily

Day 1: Carboplatin AUC 5 IV over 1 hour

Days 1-3: Ifosfamide 1,667mg/m2 IV over 2-3 hours daily (total dose 5000mg/m2 over 3 days), concurrent with:

Days 1-3: Mesna 1,667mg/m2 IV over 2-3 hours daily (total dose 5000mg/m2 over 3 days).

Repeat cycle every 3 weeks for 2 cycles.

Rituximab + IGEV
(Ifosfamide/Gemcitabine/
Vinorelbine/Prednisone)32,60,68,d,j-l
Rituximab requires premedication.

Day 1: Rituximab 375mg/m2 IV

Days 1-4: Mesna 400mg/m2 IV over 15 minutes three times day (one dose before ifosfamide, then at 4 and 8 hours from the start of each ifosfamide dose on Days 1-4)

Days 1-4: Ifosfamide 2,000mg/m2 IV over 3 hours daily

Days 1 and 4: Gemcitabine 800mg/m2 IV over 30 minutes

Day 1: Vinorelbine 20mg/m2 IV over 5-10 minutes

Days 1-4: Prednisone 100mg orally daily.

Repeat cycle every 3 weeks for 2-4 cycles (transplant candidates) or 4-8 cycles (nontransplant candidates).

If Not Previously Used:

R-ABVD
(Rituximab + Doxorubicin/
Bleomycin/Vinblastine/
Dacarbazine)60-63,b,c,k,l
Rituximab requires premedication and consider premedication with Bleomycin.

Day 1: Rituximab 375mg/m2 IV

Days 1 and 15: Doxorubicin 25mg/m2 IV push

Days 1 and 15: Bleomycin 10units/m2 IV over 10 minutes

Days 1 and 15: Vinblastine 6mg/m2 IV over 5–10 minutes

Days 1 and 15: Dacarbazine 375 mg/m2 IV over 30 minutes.

Repeat cycle every 4 weeks for 6 cycles.

R-CHOP
(Rituximab + Cyclophosphamide/
Doxorubicin/Vincristine/
Prednisone)60,64,65,c,d,k,l
Rituximab requires premedication.

Day 1: Rituximab 375mg/m2 IV

Day 1: Cyclophosphamide 750mg/m2 IV over 30 minutes

Day 1: Doxorubicin 50mg/m2 IV push

Days 1: Vincristine 1.4mg/m2 (maximum 2 mg) IV over 5 – 10 minutes

Days 1-5: Prednisone 100mg orally daily,

Repeat cycle every 3 weeks for 6 cycles.

R-CVbP
(Rituximab + Cyclophosphamide/
Vinblastine/Prednisolone)60,64,66,k,l
Rituximab requires premedication.

Day 1: Rituximab 375mg/m2 IV

Day 1: Cyclophosphamide 500mg/m2 IV over 30 minutes

Days 1 and 8: Vinblastine 6mg/m2 IV over 5–10 minutes

Days 1–8: Prednisolone 40mg/m2 orally daily.

Repeat cycle every 3 weeks for 3 cycles.

  a AHCT = autologous hematopoietic cell transplant; CHL = classic Hodgkin Lymphoma; CS = clinical stage; HDT = high-dose therapy; NLPHL = nodular lymphocyte predominant Hodgkin Lymphoma.

  b Consider premedication for anaphylactoid reaction for Bleomycin: acetaminophen 650mg orally 30-60 minutes pre-bleomycin and/or diphenhydramine 12.5-50mg IV or orally 30-60 minutes pre-bleomycin.

  c Doxorubicin is an anthracycline. Cumulative anthracycline dosage should be monitored.

  d Administration of myeloid growth factors are recommended for this regimen.

  e Oral hydration is strongly encouraged with Cyclophosphamide; poorly hydrated patients may need supplement IV hydration. Patients should attain combined oral and IV hydration of 2,000 to 3,000mL/day on day of chemotherapy.

  f Consider premedication for Brentuximab vedotin for hypersensitivity: acetaminophen 650-1,000mg orally 30-60 minutes pre-brentuximab vedotin AND diphenhydramine 12.5-50mg IV or orally 30-60 minutes pre-brentuximab vedotin WITH OR WITHOUT corticosteroid per institution protocol 30-60 minutes pre-brentuximab vedotin (consider for subsequent infusions if prior reaction).

  g Early- and late-onset immune-related adverse events affecting multiple organ systems can occur in patients receiving immune checkpoint inhibitors. Patients with neurologic or life-threatening autoimmune disorders as well as those receiving high levels of immunosuppression for their underlying disease should be approached with caution when considering immunotherapy. All patients will require extensive resources including ongoing intensive monitoring and supportive care.

  h Hydration is required with supplemental electrolytes pre- and post-administration of Cisplatin.

  i Do not substitute with standard Doxorubicin on a mg per mg basis. Product doses are different.

  j Hydration is required pre- and post-administration of Ifosfamide.

  k An FDA-approved biosimilar is an acceptable substitution for Rituximab.

  l For Rituximab: Premedication for infusion reactions is required. The recommended dosing is: Diphenhydramine 12.5-50mg IV/orally 30-60 minutes pre-Rituximab AND Acetaminophen 650mg orally 30-60 minutes pre-Rituximab.

References

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(Revised 9/2022; NCCN Hodgkin Lymphoma Guidelines v2.2022) © 2022 by Haymarket Media, Inc.

This article originally appeared on Cancer Therapy Advisor