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Treatment Name: Bendamustine (Bendeka®) + Rituximab (Rituxan®)

Bendamustine (Bendeka®) + Rituximab (Rituxan®) is a Chemotherapy Regimen for Lymphoma, Mantle Cell

How does bendamustine + rituximab work?
Rituximab is an  antibody  that is designed to target and bind to a protein on the surface of cancerous b-cells. When rituximab binds to this protein, it helps your immune system destroy the cancer cell. Bendamustine is designed to kill rapidly dividing cells such as cancerous lymphocyte cells.

Goals of therapy:
Bendamustine + rituximab is given to shrink lymph nodes and decrease symptoms from mantle cell lymphoma such as enlarged lymph nodes and spleen. It is not commonly given with the goal of  cure , but to put the lymphoma in remission and keep it in remission.
 
Alternative names:
R-Benda, Rbenda, B-R, br

Schedule

  • Rituximab intravenous (I.V.) infusion Day 1. The time of infusion varies depending upon tolerability
  • Bendamustine I.V. infusion over 10 minutes on Days 1 and 2 

Estimated total infusion time for this treatment:

  • Up to 8 hours for Cycle 1, Day 1; as short as three hours for the first day of Cycles 2 through 6, if well tolerated. Day 2 of each cycle can take as little as one hour
  • Infusion times are based on clinical studies, but may vary depending on doctor preference or patient tolerability. Pre-medications and I.V. fluids, such as hydration, may add more time 

Bendamustine + rituximab is usually given in an outpatient infusion center, allowing the person to go home afterwards. On occasion, it may be given in the hospital if someone is too sick for outpatient care.

Bendamustine + rituximab is repeated every 28 days. This is known as one Cycle. Each cycle may be repeated up to six times, depending upon the stage of the disease. Duration of therapy may last up to six months, depending upon response, tolerability, and number of cycles prescribed.

Click here for the common bendamustine + rituximab starting doses.

Side Effects

In a multi-drug regimen, each medication has unique side effects. When these medicines are given together, drug-related side effects reported in clinical studies give the best estimate of what to expect. In clinical studies, the most commonly reported bendamustine + rituximab side effects are shown here:

Note: hair loss was not reported for any patients receiving bendamustine + rituximab in the above clincal study.

Side effect videos Side Effect Videos
AnemiaAnemiaNausea and VomitingNausea and VomitingFatigue Fatigue DiarrheaDiarrheaConstipationConstipationPainPain

Monitoring

How often is monitoring needed?
Labs (blood tests) may be checked before treatment and as often as once a week during treatment. Labs often include: Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), plus any others your doctor may order. A physical exam, bone marrow biopsy, Hepatitis B screening, serum immunoglobulin concentrations, and Human Immunodeficiency Virus (HIV) screening may also be done before starting treatment.

How often is imaging needed?
Imaging is usually checked before treatment begins or as often as needed by your doctor. Imaging may include: chest X-ray or computerized tomography (CT) scan of the chest, abdomen, and pelvis. Re-imaging scans may be recommended after Cycles 3 and 6 to see how you are responding to chemotherapy.

How might blood test results/imaging affect treatment?
Depending upon the results, your doctor may advise to continue bendamustine + rituximab as planned, change drug doses, or delay or switch therapy.

On occasion, if the white blood cell count or platelet counts drop too low, the dose of bendamustine may be lowered while keeping the rituximab dose the same.

ChemoExperts Tips

  • Premedications such as diphenhydramine (Benadryl®), acetaminophen (Tylenol®), and hydrocortisone (Solu-Cortef®) may be given before rituximab to help avoid infusion related reactions
  • The first dose of rituximab is often the hardest. It may lead to fever, shaking, and chills even if medications are given beforehand to help prevent these side effects. Side effects generally go away when the rituximab is stopped. It may be restarted at a slower rate. Most patients are able to receive the entire dose, although it may take longer. In some cases, after the first dose, rituximab can be given over 90 minutes
  • Bendamustine may cause mild irritation to the vein during infusion
  • In some cases, a white blood cell growth factor such as filgrastim (Neupogen®) or pegfilgrastim (Neulasta®) may be given after chemotherapy to stimulate production of white blood cells and avoid periods of neutropenia
  • Let your doctor know if you are allergic to polyethylene glycol 400, propylene glycol, or monothioglycerol before receiving bendamustine
  • A pharmacist should ALWAYS review your medication list to ensure that drug interactions are prevented or managed appropriately
  • Clinical trials may exist for mantle cell lymphoma. Ask your doctor if any studies are currently enrolling in your area. If not, go to clinicaltrials.gov to search for other centers offering study medications

Patient Assistance & Co-payment Coverage

Patients under the age of 65 years, or those with private insurance plans:
If you have insurance and are looking for patient assistance or copay assistance for Bendamustine (Bendeka®) + Rituximab (Rituxan®), we have provided links that may help.

Visit our Patient Assistance page and click the links to various patient assistance programs for help paying for Bendamustine (Bendeka®) + Rituximab (Rituxan®). Depending upon your income, they may be able to help cover the cost of:

  • Rituximab
  • Bendamustine

For Branded medications (may be available for generic medications too), check with the manufacturer to determine if a co-pay card is offered and if it could reduce your monthly copay.

  • If you are uninsured, check with the manufacturer to determine if you are eligible to receive medication at no cost.

Medicare and Medicaid patients (Patients 65 years or older):
The clinic providing treatment will likely pre-authorize medications and immune therapies such as Bendamustine (Bendeka®) + Rituximab (Rituxan®) and are the best source to help you understand drug cost.

  • Ask to speak with a patient assistance technician or financial counselor at the clinic or hospital administering this therapy.

Emotional Wellness

What is Emotional Wellness?
Emotional wellness is having a positive outlook balanced with a realistic understanding of current life events. This requires both an awareness and acceptance of your emotions. It is with this knowledge that you can develop a plan to take the necessary actions to positively impact your life.

Emotional wellness uses an ongoing process to continually reflect on the stressors of life in a constructive manner to move forward and create happiness.

Because emotional wellness is deeply connected with physical, social, and spiritual wellness, pursuing it often becomes particularly difficult in times of major illness. Despite this difficulty, working toward emotional wellness has been connected to improved treatment outcomes and a higher likelihood of achieving goals of therapy.

Learn more about pursuing emotional wellness while receiving treatment with Bendamustine (Bendeka®) + Rituximab (Rituxan®)

Individual Drug Label Information

Rituximab (Rituxan®)

  • Rituximab is an intravenous infusion
  • Acetaminophen (Tylenol®) and antihistamines (e.g. diphenhydramine = Benadryl®) should be given prior to each dosePatients should be screened for hepatitis B as rituximab can cause a re-activation of this infection
  • May cause vaccines to work less well. It is advised that vaccines be given two to four weeks prior to rituximab if possible
General Rituximab (Rituxan) Side Effects
  • May cause an infusion reaction, which could include skin reaction, shaking, chills, fever, or shortness of breath. These reactions may be severe, but are very rarely life-threatening
  • Infusion reactions does not usually happen after the first dose, but are possible
  • May increase the risk of infection. Your doctor may prescribe antibiotics to prevent certain infections associated with rituximab use
  • Click on the rituximab (Rituxan) package insert below for reported side effects and potential drug Interactions
See DailyMed package insert.

Bendamustine (Bendeka®)

  • Bendamustine is an intravenous infusion
  • Dosage adjustments may be required for low white blood cells, low red blood cells, low platelets, or decreased kidney function 
  • Let your doctor know if you are allergic to polyethylene glycol 400, propylene glycol, or monothioglycerol
  • May cause birth defects if given during pregnancy. Use effective contraception during treatment and for 3 months following treatment
General Bendamustine (Bendeka) Side Effects
  • Fatigue
  • Skin rash or itching
  • Mild nausea or vomiting
  • Low red blood cells, white blood cells, or platelets may occur during treatment
  • Diarrhea
  • Neutropenic fever 
  • May cause mild irritation to the vein during infusion 
  • Serious infusion related reactions such as rash, swelling, and trouble breathing can occur 
  • Although rare, may increase your risk of developing blood-related cancers such as acute myeloid leukemia (AML), myelodysplastic syndrome (MDS) or myeloproliferative disorders (essential thrombocytosis, polycythemia vera, myelofibrosis)
  • Does not usually cause hair loss, and if hair loss does occur, it is usually not complete hair loss 
  • Click on the bendamustine (Bendeka) package insert below for reported side effects and possible drug interactions

Side Effect Videos
Nausea and VomitingNausea and VomitingDiarrheaDiarrheaHair LossHair LossFatigue Fatigue PainPainAnemiaAnemiaNeutropenic FeverNeutropenic Fever

See DailyMed package insert.

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References

Rummel MJ, Niederle N, Maschmeyer G, et al. Bendamustine plus rituximab versus CHOP plus rituximab as first-line treatment for patients with indolent and mantle-cell lymphomas: an open-label, multicentre, randomised, phase 3 non-inferiority trial. Lancet 2013;381:1203–10.

Created: May 2, 2017 Updated: May 2, 2017

What is Lymphoma, Mantle Cell?

Mantle Cell lymphoma (MCL) is one of about 30 sub-types of Non-Hodgkin Lymphoma. MCL represents up to 8% of all diagnosed lymphomas. It is a cancer of the B-lymphocyte. Most patients who have MCL are 60 years old or greater and more commonly male than female. Many patients are diagnosed with swollen lymph nodes in the neck, armpit, or groin, or an enlarged spleen, which may cause fullness under the left rib cage or abdominal pain.

The cause(s) of MCL are unknown. The stage of MCL can vary at diagnosis and throughout treatment. Stages of MCL include stage I, II, III, or IV. Although therapies are usually given with curative intent, many times the lymphoma returns within 1 – 2 years. Stem cell transplant and combined, multi-drug therapies are usually more effective than single medications.

Medications for MCL may include intravenous infusions, oral tablets or capsules, or a combination of IV and oral medications. Patients may be diagnosed with MCL without having any symptoms. Others may go to their doctor with symptoms of swollen lymph nodes, a large spleen, or decreased appetite. The effectiveness of the treatment may depend upon the stage at diagnosis.

NOTE: Treatment Options listed below are not all-inclusive. Other treatments may be available. ChemoExperts provides drug information and does not recommend any one treatment over another. Only your Doctor can choose which therapy is appropriate for you.

What does Cure mean?

The word “cure” means there are no cancer cells left in the body and cancer will never come back. Depending on the cancer type and stage, this may be the true goal of therapy. However, it is very difficult to prove all cancer cells are gone. Even though images, like X-rays and MRI’s, and blood tests may not show any signs of cancer, there can be a small amount of cancer cells still left in the body. Because of this, the word “remission” is used more often. This means there are no signs or symptoms of cancer. Patients in remission are followed closely for any signs of cancer returning. Sometimes, more chemotherapy may be given while in remission to prevent the cancer from coming back.

Doctors usually do not consider a patient “cured” until the chance of cancer returning is extremely low. If cancer does return, it usually happens within 5 years of having a remission. Because of this, doctors do not consider a patient cured unless the cancer has not come back within 5 years of remission. The five-year cutoff does not apply to all cancers.

What is an Antibody?

An antibody is a small protein shaped like a “Y” that can attach to specific things in the blood, such as a cancer cell.
  • Once an antibody binds to something, your immune system may attempt to get rid of it.
  • Antibodies may also work by binding to the cancer cell surface and prevent other things from binding to the cancer cell that help it survive. Without the ability to bind growth factors, cancer cells may be forced to die"

What is a CBC?

A Complete Blood Count (CBC) is a frequently ordered blood test that tells clinicians the status of your: 1) White blood cell count, 2) Hemoglobin, and 3) Platelet count at the time the test was taken.

Common uses:
1) White blood cell count (WBC): is used to determine infection risk, or response to chemotherapy. Certain chemotherapy agents may harm our good infection-fighting cells. Sometimes chemotherapy may need to be delayed to allow these cells to recover.

2) Hemoglobin: is used to determine if someone is anemic. Anytime the hemoglobin is below 12 g/dL, the person is said to be anemic. Red blood cell transfusions, and sometimes iron can be given to restore the hemoglobin level, but anemia treatment should always aim at treating the underlying cause or condition.

3) Platelet count: is used to determine if the risk of bleeding is increased or if a platelet transfusion is required to prevent bleeding. Certain medications that increase bleeding risk, such as: aspirin, certain chemotherapy agents, and blood thinners, may need to be stopped temporarily until the platelet count is within a safe range.

What is a CMP?

A Comprehensive Metabolic Panel (CMP) is a frequently ordered blood test that tells clinicians the status of your: 1) Electrolytes & Acid/Base status2) Kidney function, 3) Liver function, 4) Blood sugar, and 5) Calcium at the time the test was taken. It is commonly used to monitor liver and kidney function when beginning new medications such as chemotherapy. A total of 14 tests are run simultaneously and are shown below.

Electrolytes & Acid/Base status:
1) Sodium, 2) Potassium, 3) Carbon dioxide, 4) Chloride

Kidney Function:
5) BUN (blood urea nitrogen), 6) Serum creatinine (Scr)

Liver Function:
7) AST, 8) ALT, 9) Total bilirubin, 10) Alk Phos, 11) Albumin, 12) Total protein

Blood sugar:
13) Serum glucose

Calcium:
14) Serum calcium

What is neutropenia?

This occurs when there is an abnormally low amount of a certain type of white blood cells, called neutrophils, in the blood. These neutrophils help the body fight infections caused by bacteria and viruses.

Many chemotherapy drugs temporarily damage bone marrow where white blood cells are created, resulting in neutropenia. Please watch our video on neutropenic fever to learn more.

Common Starting Doses

  • Rituximab 375 mg/m2 intravenous infusion Day 1
  • Bendamustine 90 mg/m2 intravenous infusion over 10 minutes on Days 1 and 2

Cycle length is 28 days

Note: Individual doses may vary based upon your Doctor's recommendation, or drug availability.