Contributions
Abstract: PB1772
Type: Publication Only
Background
Adrenal insufficiency (AI) is caused by insufficient production or action of glucocorticoids. The most frequent cause of AI is high dose and prolonged use of corticosteroids. However, there is evidence that even shorter periods of corticosteroid therapy may affect adrenal function. The standard protocol for diffuse large B cell lymphoma (DLBCL) is 6 to 8 cycles of R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone), which includes five days of prednisone at a dose of 100 mg/d. DA- EPOCH- R (rituximab, etoposide, doxorubicin, vincristine, cyclophosphamide and prednisone) is an alternative protocol used in patients with aggressive lymphomas and especially for primary mediastinal B cell lymphoma (PMBCL). The protocol consists of higher doses of prednisone compared to R-CHOP (five days of prednisone 60 mg/m2 twice daily). In both regimens, there is no recommendation for tapering down of corticosteroids or assessment of potential AI. Because the DA -EPOCH-R protocol includes higher dose of corticosteroids we hypothesized that it may induces higher rates of AI.
Aims
To determine the incidence of AI in non-Hodgkin's lymphoma (NHL) patients treated with R-CHOP or DA- EPOCH- R.
Methods
We prospectively enrolled patients with newly diagnosed NHL that received either DA - EPOCH- R (study group) or R- CHOP (control group) protocols. We excluded patients with known adrenal disorders, patients receiving corticosteroid treatment at any time during the past six months, known adrenal involvement with lymphoma and treatment with drugs that are known to cause a false positive ACTH test. We evaluated adrenal function by 250 microgram ACTH tests at 5 time points: prior to first treatment cycle, on day 5 or 6 of the cycle and 21 after the first cycle, at the completion of the 5th cycle and on the first day of the 6th cycle. A positive ACTH test was defined as a cortisol level of less than 500 nmol/liter at least in one of these test.
Results
Between May 2015 and May 2017, ten patients who received DA- R-EPOCH and 17 patients who received R-CHOP were enrolled. The median age at time of diagnosis was 60 years (range: 21-89) and 52% (14 patients) were females. The diagnosis was DLBCL in 19 patients and other (PMBCL, follicular lymphoma grade 3a, primary effusion lymphoma) in 8 patients. There was no difference between the two groups with regards to baseline characteristics in terms of blood pressure, hemoglobin or platelet levels, white blood cells, eosinophils, glucose, sodium or potassium levels. However, patients in the control group that received R-CHOP were significantly older than those in the DA- EPOCH- R arm (the median age was 63 in R-CHOP group and 34 in DA-EPOCH-R, p=0.001). Out of the 27 patients included in the trial 2 died at the time of data collection, both were in the R-CHOP arm. ACTH test was positive at least once during the study follow-up in 9 patients -7 patients who received DA -EPOCH-R and 2 patients who received R-CHOP (P = 0.04). Tests were mostly positive on day 5 (8 patients. Patients with positive ACTH test were more likely to develop fever during treatment (P=0.04), but did not develop overt electrolyte disturbances, reduced mean arterial pressure or elevated eosinophil levels.
Conclusion
Our study demonstrates that patients who received DA- EPOCH- R were more likely to develop AI. We believe that clinicians should be aware of this limited adrenal response to stress and that the option of AI as an alternative cause of fever in these patients should be considered.
Session topic: 21. Aggressive Non-Hodgkin lymphoma - Clinical
Keyword(s): DLBCL
Abstract: PB1772
Type: Publication Only
Background
Adrenal insufficiency (AI) is caused by insufficient production or action of glucocorticoids. The most frequent cause of AI is high dose and prolonged use of corticosteroids. However, there is evidence that even shorter periods of corticosteroid therapy may affect adrenal function. The standard protocol for diffuse large B cell lymphoma (DLBCL) is 6 to 8 cycles of R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone), which includes five days of prednisone at a dose of 100 mg/d. DA- EPOCH- R (rituximab, etoposide, doxorubicin, vincristine, cyclophosphamide and prednisone) is an alternative protocol used in patients with aggressive lymphomas and especially for primary mediastinal B cell lymphoma (PMBCL). The protocol consists of higher doses of prednisone compared to R-CHOP (five days of prednisone 60 mg/m2 twice daily). In both regimens, there is no recommendation for tapering down of corticosteroids or assessment of potential AI. Because the DA -EPOCH-R protocol includes higher dose of corticosteroids we hypothesized that it may induces higher rates of AI.
Aims
To determine the incidence of AI in non-Hodgkin's lymphoma (NHL) patients treated with R-CHOP or DA- EPOCH- R.
Methods
We prospectively enrolled patients with newly diagnosed NHL that received either DA - EPOCH- R (study group) or R- CHOP (control group) protocols. We excluded patients with known adrenal disorders, patients receiving corticosteroid treatment at any time during the past six months, known adrenal involvement with lymphoma and treatment with drugs that are known to cause a false positive ACTH test. We evaluated adrenal function by 250 microgram ACTH tests at 5 time points: prior to first treatment cycle, on day 5 or 6 of the cycle and 21 after the first cycle, at the completion of the 5th cycle and on the first day of the 6th cycle. A positive ACTH test was defined as a cortisol level of less than 500 nmol/liter at least in one of these test.
Results
Between May 2015 and May 2017, ten patients who received DA- R-EPOCH and 17 patients who received R-CHOP were enrolled. The median age at time of diagnosis was 60 years (range: 21-89) and 52% (14 patients) were females. The diagnosis was DLBCL in 19 patients and other (PMBCL, follicular lymphoma grade 3a, primary effusion lymphoma) in 8 patients. There was no difference between the two groups with regards to baseline characteristics in terms of blood pressure, hemoglobin or platelet levels, white blood cells, eosinophils, glucose, sodium or potassium levels. However, patients in the control group that received R-CHOP were significantly older than those in the DA- EPOCH- R arm (the median age was 63 in R-CHOP group and 34 in DA-EPOCH-R, p=0.001). Out of the 27 patients included in the trial 2 died at the time of data collection, both were in the R-CHOP arm. ACTH test was positive at least once during the study follow-up in 9 patients -7 patients who received DA -EPOCH-R and 2 patients who received R-CHOP (P = 0.04). Tests were mostly positive on day 5 (8 patients. Patients with positive ACTH test were more likely to develop fever during treatment (P=0.04), but did not develop overt electrolyte disturbances, reduced mean arterial pressure or elevated eosinophil levels.
Conclusion
Our study demonstrates that patients who received DA- EPOCH- R were more likely to develop AI. We believe that clinicians should be aware of this limited adrenal response to stress and that the option of AI as an alternative cause of fever in these patients should be considered.
Session topic: 21. Aggressive Non-Hodgkin lymphoma - Clinical
Keyword(s): DLBCL