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Treatment Name: POMP (6-Mercaptopurine + Vincristine + Methotrexate + Prednisone)

POMP (6-Mercaptopurine + Vincristine + Methotrexate + Prednisone) is a Treatment Regimen for Acute Lymphoid Leukemia (ALL)

How does POMP therapy work?

Each of the medications in POMP are designed to prevent leukemia or lymphoma cells from returning.

PPurinethol (6-Mercaptopurine)
OOncovin® (Vincristine)
M – Methotrexate
P – Prednisone

Goals of POMP therapy:

POMP maintenance therapy is typically given after all cycles of therapy are completed. On occasion, POMP therapy may be used as the primary method of treating leukemia.

Examples of regimens that use POMP maintenance may include: HyperCVAD A, HyperCVAD B. POMP is commonly given to keep the disease in remission and increase the chance of achieving a cure.

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How is POMP maintenance therapy for ALL taken?

  • Vincristine intravenous (I.V.) infusion given over 15 minutes once monthly
  • Methotrexate oral tablets by mouth once weekly
    • Take on the same day of the week every week. Do not alternate days. 
    • Your dose will depend on your weight. On average, the number of tablets that need to be taken are typically between 12 and 20 tabs per dose
  • 6-Mercaptopurine 50 mg oral tablet by mouth three times a day (at least one hour after evening meal) every day
    • 6-Mercaptopurine may also be prescribed to be taken by mouth once daily (at least one hour after evening meal) every day. If prescribed this way, different amounts of tablets may need to be taken on certain days of the week so double check the prescribed daily dose each day before taking mercaptopurine. Be sure to ask a pharmacist for help with this.
  • Prednisone 200 mg (four 50 mg tablets) by mouth once daily for 5 consecutive days once per month

Estimated total infusion time for POMP treatment:

  • The vincristine infusion appointment may take up to 1 hour for Day 1 of each Cycle
  • Infusion times are based on clinical studies, but may vary depending on doctor preference or patient tolerability. Pre-medications and intravenous (I.V.) fluids, such as hydration, may add more time

Vincristine is usually given in an outpatient infusion center, allowing the person to go home afterwards. Methotrexate, 6-mercaptopurine, and prednisone are usually taken at home. 6-Mercaptopurine must be filled at a retail pharmacy. Not all pharmacies carry this medicine so it is best to call ahead to ensure it is in stock before going there in person.

POMP therapy is given continuously for up to 2 or 3 years, if well tolerated.

Click here for common POMP maintenance therapy starting doses.

Side Effects

What are the most common side effects from POMP therapy for ALL?

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 serious (grade 3 or 4) side effects of POMP therapy are shown here:

  • Neutropenic fever (17%)
  • Infection (16%)
  • Increased blood sugar (12%)
  • Numbness or tingling in fingers or toes (9%)
  • Mouth sores (3%)
  • Fatigue (3%)
  • Increased blood triglycerides (2%)
  • Blood clot (1%)
  • Inflammation of the pancreas (1%)
  • Bleeding (1%)

On average, 1% of patients discontinue treatment due to unacceptable side effects.

Watch videos on common POMP maintenance therapy side effects below

Side effect videos Side Effect Videos
Neutropenic FeverNeutropenic FeverFatigue Fatigue Blood ClotsBlood ClotsBleedingBleedingNausea and VomitingNausea and Vomiting

Monitoring

How often is monitoring with POMP therapy needed?

Labs (blood tests) may be checked before each cycle or more often at the discretion of your doctor. Labs often include: Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), plus any others your doctor may order.

How often is imaging needed?

Imaging is not typically needed during POMP therapy, but may be checked if there are concerns for side effects. Imaging may include: X-rays, magnetic resonance imaging (MRI), computerized tomography (CT) scans.

How might blood test results/imaging affect POMP treatment?

Depending upon the results, your doctor may advise to continue POMP as planned, reduce the dose of one or more of the medications in POMP, delay treatment until the side effect goes away, or discontinue therapy. To prevent infection, doses of 6-mercaptopurine or methotrexate may be delayed or reduced during periods of neutropenia (low white blood cell count).

ChemoExperts Tips

What are the 6 most important things to know about POMP when receiving treatment?

  • Continuous exposure to 6-mercaptopurine (6-MP), rather than frequent stopping and restarting, has been shown to have better anti-leukemia effect. If 6-MP is causing side effects to the point where it is difficult to take, talk with your doctor to see if reducing the dose may be safe, yet still effective
  • Unless your doctor specifically tells you it is okay, you should NOT take allopurinol while taking 6-MP due to a drug interaction between these two medicines. If taken together, the allopurinol could lead to an unsafe build up of 6-MP in your body
  • Omeprazole (Prilosec®), or a similar medications may be given to prevent ulcers from prednisone, however it is best not to take omeprazole on the days that methotrexate is given as it could make the methotrexate more toxic. Famotidine (Pepcid®) is usually considered a safe alternative. Check with your doctor or pharmacist first before taking famotidine to make sure it is safe.
  • Patients may differ in the amount and activity of an enzyme they have that metabolizes 6-mercaptopurine, called TPMT. In some cases, genetic testing for TPMT may recommended before or during treatment with 6-mercaptopurine to test for low levels of this enzyme that could lead to increased side effects
  • A pharmacist should ALWAYS review your medication list to ensure that drug interactions are prevented or managed appropriately
  • Clinical trials may exist for ALL. 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 POMP (6-Mercaptopurine + Vincristine + Methotrexate + Prednisone), 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 POMP (6-Mercaptopurine + Vincristine + Methotrexate + Prednisone). Depending upon your income, they may be able to help cover the cost of:

  • Pred­nisone
  • Vincristine
  • Methotrexate
  • 6-Mercapto­purine

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 POMP (6-Mercaptopurine + Vincristine + Methotrexate + Prednisone) 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 POMP (6-Mercaptopurine + Vincristine + Methotrexate + Prednisone)

Individual Drug Label Information

Pred­nisone (Deltasone®)

  • Prednisone is an oral medication, usually supplied as a white tablet
  • Prednisone may increase the risk of infection. Depending upon how much prednisone is taken, antibiotics may be prescribed to help prevent infections during treatment with prednisone
  • Should be taken with food and with a large glass of water to avoid stomach irritation or ulcers
  • Should be taken before 6 P.M. when possible, to avoid trouble falling asleep
  • May decrease the response to vaccines; vaccines may need to be repeated at a later date to obtain maximal response
  • If taken daily for several days or weeks, the dose of prednisone may need to be gradually decreased to avoid withdrawal symptoms
  • If you miss a dose, take the next dose as soon as possible
  • Should be stored at room temperature
General Prednisone Side Effects
  • May cause high blood sugar, weight gain, irritability, high blood pressure, difficulty sleeping, stomach ulcers, bone loss, muscle weakness
  • Click on the Prednisone package insert below for reported side effects and potential drug Interactions
See DailyMed package insert.

Vincristine (Oncovin®)

  • ​Vincristine MUST only be given by intravenous infusion. May NOT be administered any other way
  • Dosage may be reduced in patients with poor liver function
  • May interact with certain antifungal medications
  • Vincristine will cause death if administered into spinal fluid
General Vincristine (Oncovin) Side Effects
  • Nerve pain in hands or feet may increase after each dose. It is usually reversible if treatment is stopped or dose is adjusted
  • Hair loss is NOT common if vincristine is given by itself
  • May cause constipation; preventative medicines may help decrease or avoid constipation
  • Leakage into skin or surrounding muscle may cause severe irritation (extravasation)
  • Click on the vincristine (Oncovin) package insert below for reported side effects and potential drug interactions

Side Effect Videos
ConstipationConstipationPainPain

See DailyMed package insert.

Methotrexate (Trexall®)

  • Methotrexate is an intravenous infusion and is bright yellow in color 
  • Methotrexate has the following FDA Black-Box Warnings. The risk of experiencing these side effects is much higher if methotrexate is not cleared from the body appropriately:  
    1. Low red blood cells, white blood cells, and platelets
    2. Kidney injury
    3. Liver injury
    4. Severe diarrhea
    5. Mouth ulcers
    6. Stomach ulcers
  • Dosage adjustments may be required for poor kidney function or poor liver function 
  • May cause severe skin reactions a few days after administration 
  • Is harmful to the fetus during pregnancy. If you are of childbearing age, use multiple forms of birth control 
  • May interact with non-steroidal inflammatory drugs (NSAIDs), aspirin, proton-pump inhibitors, phenytoin, and sulfa or penicillin antibiotics. These drugs should NOT be used the day before or the day of therapy with methotrexate. 
  • Ask your doctor or pharmacist to review your medications prior to receiving methotrexate 
  • Click on the methotrexate 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.

6-Mercapto­purine (6-MP)

  • Is an oral tablet available in 50 mg
  • It is usually recommend to swallow mercaptopurine tablets whole. On occasion, your doctor may prescribe a half-tab to make a total daily dose. Ask a pharmacist before you split any tablets in half as this may not be necessary and could unnecessarily expose others to the medicine
  • Take without food, preferably at least 1 hour after evening meal. Food decreases absorption so it is best to take on an empty stomach to avoid possible decrease in effectiveness. DO NOT take with milk or citrus products
  • If you miss a dose, take the next dose as scheduled. DO NOT take two doses at once to make up for the missed dose
  • Store at room temperature and keep protected from light
  • Dosage adjustments may be required for decreased kidney or liver function
  • May interact with allopurinol. If allopurinol is used, the dose of mercaptopurine should be decreased and close monitoring should occur
  • May decrease the effects of warfarin. INR levels may need to be monitored more frequently and warfarin doses may need to be adjusted
  • May interact with olsalazine, mesalazine, or sulfasalazine causing an increased risk of side effects
  • Some patients may lack or have decreased activity in the enzyme that metabolizes mercaptopurine, known as TPMT. Genetic testing may be needed if unexpected severe side effects are experienced
  • Can cause fetal harm when given to pregnant women with the highest risk during the first trimester of pregnancy
General side effects from mercaptopurine (6-MP)
  • Commonly causes low white blood cells, red blood cells, and platelets
  • May cause liver toxicity which is often reversible when therapy with mercaptopurine is stopped
  • Can cause nausea, vomiting, and loss of appetite
  • May cause diarrhea
  • Skin rash or increased skin pigmentation can occur
  • Click on the mercaptopurine (6-MP) package insert below for reported side effects and possible drug interactions

Side Effect Videos
Nausea and VomitingNausea and VomitingDiarrheaDiarrheaFatigue Fatigue BleedingBleedingPainPainAnemiaAnemiaNeutropenic FeverNeutropenic Fever

See DailyMed package insert.

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References

1) Thomas DA, O'Brien S, Cortes J, et al. Outcome with the hyper-CVAD regimens in lymphoblastic lymphoma. Blood 2004;104:1624-1630.

2) Stock W, Luger SM, Advani AS, et al. A pediatric regimen for older adolescents and young adults with acute lymphoblastic leukemia: results of CALGB 10403. Blood. 2019;133:1548-1559.

Created: March 3, 2020 Updated: March 6, 2020

What is Acute Lymphoid Leukemia (ALL)?

Acute Lymphoid Leukemia (ALL), also known as acute lymphoblastic leukemia, is a disease of the lymphoid cells found in the bone marrow. Lymphoid cells are responsible for developing into cells of the immune system called B-cells, T-cells, or Natural Killer cells. In ALL, immature lymphoid cells know as "blasts" replicate at a very fast rate. Sometimes blasts crowd out the normal cells in the bone marrow so that red blood cells or platelets are unable to develop.

Common symptoms of ALL include fatigue, infection, and bruising or bleeding. ALL is the most common cancer diagnosed in children, but is rare in adults. Most cases of ALL are considered "de novo" meaning that the cause is unknown; however, some cases can be linked to certain genetic syndromes. There is no staging system for ALL. Chromosomes are often analyzed to determine which mutations in the chromosomes exist. The effectiveness of the treatment may depend upon the specific chromosome mutations that are present.

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 your therapy.

Common POMP starting doses

  • Vincristine 2 mg intravenous (I.V) infusion over 15 minutes once monthly
  • Methotrexate 20 mg/m2 by mouth on once weekly
  • Prednisone 200 mg by mouth once daily for 5 consecutive days once per month
  • 6-Mercaptopurine 50 mg oral tablet by mouth 3 times daily (at least one hour after evening meal) every day
                                                               OR

    75 mg/m2 by mouth once daily (at least one hour after evening meal) every day

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

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 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