Vincristine (Oncovin) is a chemotherapeutic medicine that is used to treat a variety of cancers.

These include:

• Acute lymphocytic leukemia:

• Hodgkin lymphoma:

• Neuroblastoma:

• Non-Hodgkin lymphomas:

• Rhabdomyosarcoma:

• Wilms tumor:

• Off Label Use of Vincristine in Adults:

  • Central nervous system tumors:

    • anaplastic oligodendrogliomas/oligoastrocytomas,

    • low-grade gliomas,

    • medulloblastoma,

    • recurrent glioblastoma)

  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) with Richter transformation;

  • Ewing sarcoma

  • High-risk gestational trophoblastic tumors

  • Advanced or recurrent Merkel cell carcinoma

  • Multiple myeloma

  • Ovarian germ cell tumors

  • Malignant pheochromocytoma

  • Primary CNS lymphoma;

  • Recurrent Small cell lung cancer

  • Advanced Thymoma 

Vincristine (Oncovin) Dose in Adults

 Note: Doses may be increased to a maximum of 2 mg/dose. Frequency and dosing may vary by protocol and/or treatment phase. Dispensing vincristine in a minibag (NOT a syringe).

---

Dose in the treatment of Acute lymphocytic leukemia (ALL):

• CALGB 10403 regimen:

  • Patients <40 years of age:

    • Induction phase:
      • 1.5 mg/m (maximum: 2 mg) on days 1, 8, 15, and 22;
    • Extended remission induction phase (if required):
      • 1.5 mg/m (maximum: 2 mg) on day 1 and 8;
    • Remission consolidation phase:
      • 1.5 mg/m (maximum: 2 mg) on days 15, 22, 43, and 50;
    • Delayed intensification phase:
      • 1.5 mg/m (maximum: 2 mg) on days 1, 8, 43, and 50;
    • Maintenance phase:
      • 1.5 mg/m (maximum: 2 mg) on days 1, 29, and 57 of a 12-week cycle;

Continue the maintenance phase until 2 years (females) or 3 years (males) from the start of interim maintenance.

• DFCI Consortium regimen:

  • Patients ≤50 years of age:

    • Induction phase:
      • 2 mg on days 1, 8, 15, and 22 (4-week treatment cycle)
    • CNS therapy phase:
      • 2 mg for one dose (3-week treatment cycle)
    • Intensification phase:
      • 2 mg on day 1 (3-week cycle; continue for 30 weeks)
    • Continuation phase:
      • 2 mg on day 1 (3-week cycle; continue for 74 weeks);

• Hyper-CVAD regimen:

  • • 2 mg on days 4 and 11 during odd-numbered cycles (cycles 1, 3, 5, 7 [in combination with cyclophosphamide, mesna, doxorubicin, and dexamethasone]) of an 8cycle phase,
    • followed by maintenance treatment (if needed) of 2 mg once monthly for 2 years (Kantarjian 2004), plus a tyrosine kinase inhibitor (for Philadelphia chromosome-positive disease)

• CALBG 8811 regimen:

  • • Induction phase:
      • 2 mg on days 1, 8, 15, and 22 (4-week treatment cycle);
    • Early intensification phase:
      • 2 mg on days 15 and 22 (4-week treatment cycle, repeat once);
    • Late intensification phase:
      • 2 mg on days 1, 8, and 15 (8-week treatment cycle);
    • Maintenance phase:
      • 2 mg on day 1 every 4 weeks until 24 months from diagnosis;

• GRAALL 2003 regimen:

  • Patients <60 years of age:
    • Induction phase:
      • 2 mg on days 1, 8, 15, and 22;
    • Consolidation phase:
      • 2 mg on day 15 of consolidation blocks 2, 5, and 8;
    • Late intensification phase:
      • 2 mg on days 1, 8, and 15;
    • Maintenance phase:
      • 2 mg on day 1 monthly for 12 months

• GRAALL 2005 regimen:

  • Patients <60 years of age:
    • Induction phase:
      • 2 mg on days 1, 8, 15, and 22;
    • Inter phase-1:
      • 2 mg on day 1
    • First, second, and third consolidation phases (block 2, block 5, and block 8, respectively):
      • 2 mg on day 15;
    • Late intensification phase (if the complete response after the first course):
      • 2 mg on days 1, 8, 15, and 22;
    • Maintenance phase:
      • 2 mg on day 1 monthly for 12 months;

• MRC UKALL XII/ECOG E2993:

  • Patients <60 years of age:
    • Induction (phase 1):
      • 1.4 mg/m on days 1, 8, 15, and 22;
    • Consolidation phase (cycle 1):
      • 1.4 mg/m on days 1, 8, 15, and 22;
    • Maintenance phase:
      • 1.4 mg/m once every 3 months
      • continue maintenance for 2.5 years from the start of intensification

---

Dose in the treatment of Philadelphia chromosome-positive ALL:

• Kim 2015:

  • 2 mg on days 1 and 8 of induction and consolidation A cycles (in combination with daunorubicin, prednisolone, cytarabine, etoposide, methotrexate, leucovorin, and nilotinib)

• Rousselot 2016:

  • Patients ≥55 to ≤70 years of age:
    • Induction:
      • 2 mg once weekly for 4 weeks (in combination with dexamethasone and dasatinib)
  • Patients >70 years of age:
    • Induction:
      • 1 mg once weekly for 4 weeks (in combination with dexamethasone and dasatinib);

---

Dose in the treatment of Central nervous system tumors (off-label): 

• Anaplastic oligodendroglioma/astrocytomas, low-grade gliomas: PCV regimen (in combination with procarbazine, lomustine, and radiation therapy):

  • 4 mg/m² (some protocols cap the vincristine dose at 2 mg; ) on days 8 and 29 of a 6- to 8-week treatment cycle for 4 to 6 cycles

• Glioblastoma, recurrent: PCV regimen (in combination with procarbazine and lomustine):

  • 4 mg/m² (maximum: 2 mg) on days 8 and 29 of a 6-week cycle for 7 cycles or 1.5 mg/m (maximum: 2 mg) on day 1 of a 6-week cycle for up to 6 cycles

• Medulloblastoma:

  • Adults ≤21 years of age:
    • 5 mg/m² (maximum dose: 2 mg) weekly for a maximum of 8 doses (in combination with radiation, cisplatin, and either lomustine or cyclophosphamide).

---

Dose in the treatment of Chronic lymphocytic leukemia/small lymphocytic leukemia (with Richter transformation) (off-label):

• 2 mg (flat dose) days intravenous 4 and 11 of courses 1, 3, 5, and 7 (in combination with cyclophosphamide, mesna, doxorubicin, and dexamethasone [± rituximab]) and alternates with even courses 2, 4, 6, and 8 (methotrexate, leucovorin, and cytarabine)
• or 1.4 mg/m² (maximum dose: 2 mg) on day 1 of a 21-day treatment cycle (in combination with cyclophosphamide, doxorubicin, and prednisone [± rituximab])

---

Dose in the treatment of Ewing sarcoma (off-label): 

• VDC/IE regimen:

  • VDC: 2 mg/m (maximum dose: 2 mg) on day 1 of a 21-day treatment cycle (in combination with doxorubicin and cyclophosphamide), alternates with IE (ifosfamide and etoposide) for a total of 17 cycles.

---

Dose in the treatment of high-risk Gestational trophoblastic tumors (off-label):

• IV: EMA/CO regimen:

  • 1 mg/m² on day 8 of a 2-week treatment cycle (in combination with etoposide, methotrexate, leucovorin, dactinomycin, and cyclophosphamide), continue for at least 2 treatment cycles after a normal hCG level.

---

Dose in the treatment of Hodgkin lymphoma: 

• BEACOPP (standard or escalated) regimen:

  • 4 mg/m² (maximum dose: 2 mg) on day 8 of a 21-day treatment cycle (in combination with bleomycin, etoposide, doxorubicin, cyclophosphamide, procarbazine, and prednisone) for 8 cycles.

• Stanford-V regimen:

  • 4 mg/m² (maximum dose: 2 mg) in weeks 2, 4, 6, 8, 10, and 12 (in combination with etoposide, mechlorethamine, bleomycin, vinblastine, doxorubicin, and prednisone).

---

Dose in the treatment of Merkel cell carcinoma, advanced or recurrent (off-label; based on limited data):

• CAV regimen:

  • 2 mg on day 1 every 21 days (in combination with doxorubicin and cyclophosphamide).

---

Dose in the treatment of Multiple myeloma (off-label):

• DVD regimen:

  • 4 mg/m² (maximum dose: 2 mg) on day 1 of a 28-day treatment cycle (in combination with pegylated doxorubicin and dexamethasone).

• VAD regimen:

  • 4 mg/day continuous IV infusion for 4 days (over 96 hours) (total 1.6 mg/cycle) of a 28-day treatment cycle (in combination with conventional doxorubicin and dexamethasone).

---

Dose in the treatment of Non-Hodgkin lymphoma:

• Burkitt lymphoma:

  • CALGB 10002 regimen (cycles 2 through 7):

    • 2 mg on day 1 every 3 weeks (in combination with cyclophosphamide, prednisone, ifosfamide, methotrexate, leucovorin, dexamethasone, cytarabine, doxorubicin, etoposide, rituximab, intrathecal therapy, and filgrastim);

  • CODOX-M/IVAC:

    • Cycles 1 and 3 (CODOX-M):
      • 1.5 mg/m² (no maximum dose) days 1 and 8 of cycle 1 and days 1, 8, and 15 of cycle 3
    • or 1.5 mg/m² (maximum dose: 2 mg) days 1 and 8 of cycles 1 and 3;
    • CODOX-M is in combination with doxorubicin, cyclophosphamide, methotrexate, and CNS prophylaxis and alternates with IVAC (etoposide, ifosfamide, mesna, cytarabine, and CNS prophylaxis) for a total of 4 cycles.

  • R-Hyper-CVAD:

    • 2 mg on days 4 and 11 of courses 1, 3, 5, and 7 (in combination with rituximab, cyclophosphamide, doxorubicin, and dexamethasone) and alternates with even courses 2, 4, 6, and 8 (rituximab, methotrexate, and cytarabine).

---

Dose in the treatment of Diffuse large B-cell lymphoma:

• CHOP/R-CHOP regimen:

  • 4 mg/m² (maximum dose: 2 mg) on day 1 of a 21-day treatment cycle for 8 cycles (in combination with cyclophosphamide, doxorubicin, and prednisone [± rituximab]).

• Dose-adjusted EPOCH/EPOCH-R regimen:

  • 4 mg/m² /day continuous infusion for 4 days (over 96 hours) (total 1.6 mg/m² /cycle; dose not usually capped) of a 21-day treatment cycle (in combination with etoposide, prednisone, cyclophosphamide, and doxorubicin, ± rituximab).

• R-CEOP regimen:

  • 4 mg/m² (maximum dose: 2 mg) on day 1 of a 21-day treatment cycle for 3 to 6 cycles (in combination with rituximab, cyclophosphamide, etoposide, and prednisone).

• Follicular lymphoma:

  • CVP regimen:

    • 4 mg/m² (maximum dose: 2 mg) on day 1 of a 21-day treatment cycle (in combination with cyclophosphamide and prednisone [± rituximab or obinutuzumab]) for 8 cycles.

  • R-CHOP regimen:

    • 4 mg/m² (maximum dose: 2 mg) on day 1 of a 21-day treatment cycle for 6 to 8 cycles (in combination with rituximab, cyclophosphamide, doxorubicin, and prednisone).

---

Dose in the treatment of Peripheral T-cell lymphoma:

• CHOEP regimen:

  • 2 mg on day 1 of a 21-day treatment cycle (in combination with etoposide, cyclophosphamide, doxorubicin, and prednisone) for 6 to 8 cycles.

• CHOP regimen:

  • 4 mg/m² (maximum dose: 2 mg) on day 1 of a 21-day treatment cycle (in combination with cyclophosphamide, doxorubicin, and prednisone).

---

Dose in the treatment of primary mediastinal B-cell lymphoma (PMBCL):

• DA-EPOCH-R regimen:
  • 4 mg/m² /day (no cap) as a continuous infusion on days 1 to 4 (over 96 hours) dose-adjusted for subsequent cycles based on neutrophil and platelet counts during nadir (in combination with etoposide, cyclophosphamide, prednisone, doxorubicin, rituximab, and filgrastim).
  • repeat cycle 3 weekly for a total of 6 to 8 cycles.

---

Dose in the treatment of Ovarian cancer (off-label): 

• VAC regimen:

  • 5 mg/m² (maximum dose: 2 mg) once weekly for 8 to 12 weeks (in combination with dactinomycin and cyclophosphamide).

---

Dose in the treatment of malignant Pheochromocytoma:

• • 4 mg/m² on day 1 every 3 or 4 weeks (in combination with cyclophosphamide and dacarbazine).

---

Dose in the treatment of primary CNS lymphoma:

• R-MPV regimen:
  • Induction:
    • 1.4 mg/m (maximum dose: 2.8 mg or per standard of practice) on day 1 or day 2 of a 14-day cycle for 5 to 7 cycles (in combination with rituximab, high-dose methotrexate, leucovorin, and procarbazine), followed by reduced-dose whole-brain radiotherapy and cytarabine
  • or autologous stem cell transplant. In partial response administer two additional cycles of R-MPV after initial induction chemotherapy

---

Dose in the treatment of Rhabdomyosarcoma:

• VAC regimen:
  • Patients <50 years:
    • 5 mg/m² (maximum dose: 2 mg) once weekly per-protocol.
    • The duration of therapy depends on risk status (in combination with dactinomycin, cyclophosphamide, and mesna).
• VA regimen:
  • Patients <50 years:
    • 5 mg/m² (maximum dose: 2 mg) once weekly per-protocol

---

Dose in the treatment of recurrent small-cell lung cancer::

• CAV regimen:
  • 2 mg/dose on day 1 of a 21-day treatment cycle (in combination with cyclophosphamide and doxorubicin).

---

Dose in the treatment of advanced Thymoma:

• ADOC regimen:
  • 6 mg/m² on day 3 every 3 weeks (in combination with cisplatin, doxorubicin, and cyclophosphamide).
  • Manufacturer's labeling:
    • Dosing in the prescribing information may not reflect current clinical practice.
    • 1.4 mg/m²/dose.
    • The frequency may vary based on indication and/or protocol.

Vincristine (Oncovin) Dose in Childrens

 Note:

• Doses may be increased to a maximum of 2 mg/dose.
• Frequency and dosing may vary by protocol and/or treatment phase.
• The WHO and the Institute for Safe Medication Practices (ISMP) recommends strongly dispensing vincristine in a minibag (NOT a syringe).
• In pediatric patients, dosing may be based on either BSA (mg/m²) or weight (mg/kg).
• Use extra precautions while calculating the dose.
• For infants and children <10 kg, dosing is typically reduced (eg, 30% reduction).

---

Dose in the treatment of Acute lymphocytic leukemia (ALL) of infancy: 

• Infants <1 year of age at diagnosis:
  • 5 mg/m²/dose Intravenously
  • Maximum dose: 2 mg/dose.
  • Reported frequency is variable but not more frequently than weekly
  • Administer on the following days:

  • Induction phase:

    • Days 8, 15, 22, and 29 (in combination with prednisone, dexamethasone, cytarabine, daunorubicin, l-asparaginase, and CNS intrathecal prophylaxis).

  • Reinduction:

    • Days 1, 8, 15, and 22 (in combination with dexamethasone, 6-thioguanine, daunorubicin, cytarabine, cyclophosphamide, and CNS intrathecal prophylaxis)

---

Dose in the treatment of standard risk and high risk Acute lymphocytic leukemia (ALL): 

• Children and Adolescents:
  • 5 mg/m²/dose intravenous to a maximum dose of 2 mg/dose.
  • Reported frequency variable but not more frequent than weekly:

  • Standard risk:

    • Avramis 2002:

    • Administer dose on the following days:

      • Induction phase:

        • Days 0, 7, 14, and 21

      • Consolidation phase:

        • Days 0, 28, and 56;

      • Interim maintenance phases:

        • Days 0 and 28

      • Delayed intensification phase:

        • Days 0, 7, and 14

      • Maintenance phase:

        • Every 4 weeks

    • Bostrom 2003:

    • Administer dose on the following days:

      • Induction phase:

        • Days 0, 7, 14, and 21;

      • Consolidation phase:

        • Days 0, 28, and 56;

      • Delayed intensification phase:

        • Days 0, 7, and 14;

      • Maintenance phase:

        • Days 0, 28, and 56

  • High risk:

    • Larsen 2016:

    • Administer on the following days:

      • Induction phase:

        • Days 1, 8, 15, and 22

      • Extended Induction:

        • Days 1 and 8

      • Consolidation:

        • Days 15, 22, 43, and 50

      • Interim Maintenance 1:

        • Days 1, 15, 29, and 42

      • Interim Maintenance 2:

        • Days 1, 11, 21, 31, and 41

      • Delayed Intensification 1:

        • Days 1, 8, 15, 43, and 50;

      • Delayed Intensification 2:

        • Days 1, 8, 15, 43, and 50

      • Maintenance phase:

        • Every 4 weeks

---

Dose in the treatment of Ewing sarcoma:

• Children and Adolescents:
  • Dose and frequency regimens variable:

    • Grier 2003:

      • 2 mg/m²/dose on day 1 of a 21-day cycle, administer either every cycle or during odd-numbered cycles (VDC/IE regimen)
      • The maximum dose is 2 mg/dose

    • Kolb 2003:

      • 0.67 mg/m²/day as a continuous intravenous infusion on days 1, 2, and 3.
      • Total dose for cycle: 2 mg/m² /cycle (maximum dose/cycle: 2 mg/dose/cycle) during cycles 1, 2, 3, and 6

---

Dose in the treatment of Hepatoblastoma: 

• Infants, Children, and Adolescents:

  • C5V Regimen:

    • 1.5 mg/m²/dose on Day 2 of a 3-week treatment cycle for 4 cycles (in combination with 5-fluorouracil and cisplatin.

---

Dose in the treatment of Hodgkin lymphoma:

• Children and Adolescents:

  • AV-PC (low-risk regimen):

    • 4 mg/m²/dose Intravenous (maximum dose: 2.8 mg/dose) on Day 1 and 8 of a 21-day treatment cycle for 3 cycles (in combination with doxorubicin, prednisone, and cyclophosphamide).

  • ABVE-PC (high-risk and intermediate regimens):

    • 4 mg/m²/dose Intravenous (maximum dose: 2.8 mg/dose) on Day 1 and 8 of a 21-day treatment cycle for 3 to 5 cycles (in combination with doxorubicin, bleomycin, etoposide, cyclophosphamide, and prednisone).

  • BEACOPP regimen (high-risk regimen):

    • 2 mg/m² /dose Intravenous on day 7 of a 21-day treatment cycle for 4 cycles (in combination with bleomycin, etoposide, doxorubicin, cyclophosphamide, procarbazine, and prednisone).
    • The maximum dose is 2 mg/dose.

---

Dose in the treatment of Low-grade glioma, CNS tumor (low-grade ependymoma, infantile desmoplastic astrocytoma, etc): 

• Children <10 years:
  • 5 mg/m²/dose intravenous to a maximum dose of 2 mg/dose
  • Reported combination chemotherapy and frequency variable but not more frequent than weekly.

    • Ater 2012:

      • CV regimen: Administer on the following days:

        • Induction phase:

          • Days 0, 7, 14, 21, 28, 35, 42, 49, 56, and 63 of an 84-day cycle (in combination with carboplatin)

        • Maintenance phase:

          • Day 0, 7, and 14 of a 42-day cycle for 8 cycles (in combination with carboplatin)

    • Ater 2012:

      • TPCV regimen:
        • Administer on days 14 and 28 of a 42-day cycle (in combination with thioguanine, procarbazine, and lomustine) for a total of 8 cycles

---

Dose in the treatment of Medulloblastoma:

• Average-risk regimen:

  • Children ≥3 years and Adolescents:
    • 5 mg/m²/dose Intravenous (maximum dose: 2 mg/dose) once weekly during radiation therapy for up to 8 doses followed by 1.5 mg/m²/dose (maximum dose: 2 mg/dose) on days 1, 7, and 14 per cycle (in combination with cisplatin and either lomustine or cyclophosphamide) for 8 cycles.

• High risk: Head Start II Protocol:

  • Children <10 years:
    • 05 mg/kg/dose Intravenous on Days 1, 8, and 15 of a 21-day cycle in cycles 1 to 3 only (9 total doses in combination with cisplatin, etoposide, cyclophosphamide, methotrexate).

---

Dose in the treatment of  Neuroblastoma:

• Infants:

  • Low-dose cyclophosphamide-vincristine regimen:

    • 0.05 mg/kg/dose vincristine on the first day, and repeat in 14 days.

  • CAdO regimen:

    • 0.05 mg/kg/dose on the first day and 5th day and repeated in 21 days (in combination with doxorubicin and cyclophosphamide).

• Children and Adolescents:

  • High risk:

    • Induction therapy:
      • 1.5 mg/m²/dose Day 1 in combination with doxorubicin and cyclophosphamide for cycles 2 and 5.

  • Refractory:

    • HD-CTV regimen:
      • 0.067 mg/kg/dose or 2 mg/m²/dose, whichever is lower
      • The maximum dose is 2 mg/dose on day 1.

---

Dose in the treatment of Non-Hodgkin Lymphomas:

• Burkitt lymphoma, Diffuse large B-cell lymphoma and B-cell ALL: 

• Children and Adolescents:

  • Reduction (COP regimen):

    • 1 mg/m² /dose.

    • The  maximum dose is 2 mg/dose on Day 1 (in combination with cyclophosphamide, prednisone, and intrathecal methotrexate)

  • Induction 1 and 2 (COPADM regimen):

    • 2 mg/m²/dose (maximum dose is 2 mg/dose) on Day 1 (in combination with cyclophosphamide, prednisone, doxorubicin, methotrexate, and intrathecal methotrexate)

  • Maintenance 1 (COPAM regimen) and 3 (COPA regimen):

  • 2 mg/m² /dose (maximum dose: 2 mg/dose) on Day 1 (in combination with cyclophosphamide, prednisone, doxorubicin, and methotrexate [maintenance 1 only])

    • Children and Adolescents:

      • 1.5 mg/m² /dose (maximum dose: 2 mg/dose)
      • Administer the dose on day 1 of cycle AA (in combination with dexamethasone, ifosfamide, methotrexate, cytarabine, etoposide, and CNS prophylaxis) and on day 1 of cycle BB (in combination with dexamethasone, cyclophosphamide, methotrexate, doxorubicin, and CNS prophylaxis).

    • Primary mediastinal B-cell Lymphoma (PMBCL):

      • DA-EPOCH-R regimen:

        • Children ≥9 years and Adolescents:
        • 0.4 mg/m² /day as a continuous infusion over 96 hours on days 1 to 4 (in combination with rituximab, doxorubicin, etoposide, cyclophosphamide, prednisone, and filgrastim). No maximum dose.
        • Doses for subsequent cycles are based on neutrophil and platelet counts.
        • A total of 6 - 8 cycles should be given, repeating the cycle every 3 weeks.

---

Dose in the treatment of Retinoblastoma: 

• Infants and Children ≤36 months:

  • 05 mg/kg/dose Intravenous (maximum dose: 2 mg/dose).
  • Infusion frequency is variable but it should not be more frequent than weekly.

  • Rodriguez-Galindo 2003:

    • Administer dose on day 1 every three weeks (21 days) in combination with carboplatin for 8 cycles

  • Friedman 2000:

    • Administer the dose on day 0 every four weeks (28 days) in combination with carboplatin and etoposide for 6 cycles

• Children >36 months:

  • 5 mg/m² Intravenous (maximum dose: 2 mg/dose) on day 0 every 28 days in combination with carboplatin and etoposide for 6 cycles.

---

Dose in the treatment of Rhabdomyosarcoma: 

Duration of therapy depends on risk status.

VAC regimen (in combination with dactinomycin and cyclophosphamide) or VA (in combination with dactinomycin):

• Infants:

  • 025 mg/kg/dose Intravenous.

• Children 1 to <3 years:

  • 05 mg/kg/dose Intravenous.

• Children ≥3 years and Adolescents:

  • 5 mg/m /dose Intravenous (maximum dose: 2 mg/dose)

---

Dose in the treatment of Wilms tumor:

• Infants and Children weighing ≤30 kg:

  • 05 mg/kg/dose Intravenous (maximum dose: 2 mg/dose) weeks 1, 2, 4, 5, 6, 7, 8, 10, and 11, followed by 0.067 mg/kg/dose (maximum dose: 2 mg/dose) weeks 12, 13, 18, and 24 (in combination with doxorubicin, cyclophosphamide, mesna, etoposide, and filgrastim)

• Children and Adolescents weighing >30 kg:

  • 5 mg/m /dose Intravenous (maximum dose: 2 mg) weeks 1, 2, 4, 5, 6, 7, 8, 10, and 11, followed by 2 mg/m /dose (maximum dose: 2 mg) weeks 12, 13, 18, and 24 (in combination with cyclophosphamide, doxorubicin, mesna, etoposide, and filgrastim)

Pregnancy Risk Factor D

• Animal studies have demonstrated teratogenicity, as well as fetal death. Vincristine can cause severe harm if administered to pregnant women.
• Vincristine treatment should not be used to induce pregnancy in women who are pregnant.

Use of vincristine during breastfeeding

• It is unknown if vincristine can be found in breast milk.
• The potential for serious adverse reactions in breastfed infants should be considered when deciding whether to stop taking vincristine or to cease breastfeeding.

Vincristine (Oncovin) Dose in Renal Disaease:

• No dosage adjustment necessary. 

Vincristine dose in Liver disease:

The manufacturer’s labeling recommends the following adjustment:

• Serum bilirubin >3 mg/dL:
  • Administer 50% of normal dose.

• The following adjustments have also been recommended:

  • Floyd 2006:

    • Serum bilirubin 1.5 to 3 mg/dL or transaminases 2 to 3 times ULN or alkaline phosphatase increased: Administer 50% of the dose.

  • Superfin 2007:

    • Serum bilirubin 1.5 to 3 mg/dL: Administer 50% of dose.
    • Serum bilirubin >3 mg/dL: Avoid use.

Side effects of Vincristine (Oncovin)

• Cardiovascular:

  • Edema
  • Hypertension
  • Hypotension
  • Ischemic Heart Disease
  • Myocardial Infarction
  • Phlebitis

• Central Nervous System:

  • Abnormal gait
  • Ataxia
  • Coma
  • Cranial Nerve Dysfunction (Auditory Impairment
  • Extraocular Muscle Impairment
  • Laryngeal Muscle Impairment
  • Motor Dysfunction
  • Paralysis
  • Paresis
  • Vestibular Damage
  • Vocal Cord Paralysis)
  • Decreased Deep Tendon Reflex
  • Dizziness
  • Headache
  • Neuralgia (Common)
  • Neurotoxicity (Dose-Related)
  • Paralysis
  • Paresthesia
  • Parotid Pain
  • Peripheral Neuropathy (Common)
  • Seizure
  • Sensorimotor Neuropathy
  • Sensory Disturbance
  • Vertigo

• Dermatologic:

  • Alopecia (Common)
  • Skin Rash

• Endocrine & Metabolic:

  • Hyperuricemia
  • Uric Acid Nephropathy (Acute)
  • Weight Loss

• Gastrointestinal:

  • Abdominal Cramps
  • Abdominal Pain
  • Anorexia
  • Constipation (Common)
  • Diarrhea
  • Intestinal Necrosis
  • Intestinal Perforation
  • Nausea
  • Oral Mucosa Ulcer
  • Paralytic Ileus
  • Sore Throat
  • Vomiting

• Genitourinary:

  • Bladder Dysfunction (Atony)
  • Dysuria
  • Urinary Retention

• Hematologic & Oncologic:

  • Anemia (Mild)
  • Hemolytic Uremic Syndrome
  • Leukopenia (Mild)
  • Thrombocytopenia (Mild)
  • Thrombotic Thrombocytopenic Purpura

• Hepatic:

  • Hepatic Sinusoidal Obstruction Syndrome.

• Local:

  • Local Irritation (If Infiltrated)

• Neuromuscular & Skeletal:

  • Amyotrophy
  • Back Pain
  • Foot-Drop
  • Jaw Pain
  • Limb Pain
  • Myalgia
  • Ostealgia

• Ophthalmic:

  • Cortical Blindness (Transient)
  • Nystagmus
  • Optic Atrophy With Blindness

• Otic:

  • Deafness

• Renal:

  • Polyuria

• Respiratory:

  • Bronchospasm
  • Dyspnea

• Miscellaneous:

  • Fever
  • Tissue Necrosis (If Infiltrated)

Contraindication to Vincristine Include:

Charcot-MarieTooth patients with demyelinating Charcot-Marietooth syndrome.

Warnings and precautions

• Extravasation: [US Boxed Warning]
  • Vincristine can cause blisters
  • Before and during infusion, ensure that the needle or catheter are properly placed.
  • Avoid excessive use.
  • Vincristine administration should be a familiar subject for those who administer it.
  • Extravasation can cause severe irritation.
  • Extravasation should be stopped immediately.
  • The appropriate treatment for extravasation includes local injections of hyaluronidase as well as moderate heat applications to the affected areas.
  • To complete administration, use a separate vein.
• Gastrointestinal effects
  • It is possible to experience paralytic ileus and/or constipation.
  • Constipation may be caused by impaction of the upper colon and an empty rectum. (May require a flat film of your abdomen to diagnose).
  • High-enemas and laxatives are generally well received.
  • Patients should follow a prophylactic bowel management program.
• Neurotoxicity:
  • It is possible for mental status changes to occur, such as insomnia, depression, and confusion.
  • Dose-limiting neurologic effects may be required to reduce dosage. 
  • Neurologic effects can be combined with other neurotoxic substances and spinal cord radiation.
  • Patients with neuromuscular disease or concomitant neurotoxic drugs should be cautious.
• Respiratory effects
  • Vinca alkaloids have been associated with severe bronchospasm, acute shortness of breathing, and mitomycin.
  • It may occur within minutes to hours following vincristine administration, and up to two weeks after mitomycin.
  • Progressive dyspnea can occur.
  • If you have pulmonary dysfunction, discontinue use of vincristine.
• Nephropathy caused by uric acid
  • Vincristine may cause acute uric acid neuropathy.
• Hepatic impairment
  • Patients with hepatic impairment should be cautious; dosage modifications may be necessary.
  • Children younger than 3 years old are at greater risk for hepatic sinusoidal obstruction syndrome.
  • Take care with hepatobiliary dysfunction.
  • You should monitor for any signs or symptoms of hepatic SOS. These include bilirubin >1.4mg/dL, unexplained obesity, ascites or right upper quadrant pain.

Vincristine (conventional): Drug Interaction

Risk Factor C (Monitor therapy)
Aprepitant	May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors).
Bosentan	May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers).
Clofazimine	May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors).
Coccidioides immitis Skin Test	Immunosuppressants may diminish the diagnostic effect of Coccidioides immitis Skin Test.
CYP3A4 Inducers (Moderate)	May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers).
CYP3A4 Inhibitors (Moderate)	May decrease the metabolism of CYP3A4 Substrates (High risk with Inhibitors).
Deferasirox	May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers).
Denosumab	May enhance the adverse/toxic effect of Immunosuppressants. Specifically, the risk for serious infections may be increased.
Duvelisib	May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors).
Erdafitinib	May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers).
Erdafitinib	May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors).
Erdafitinib	May increase the serum concentration of P-glycoprotein/ABCB1 Substrates.
Fluconazole	May increase the serum concentration of VinCRIStine.
Fosaprepitant	May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors).
Fosnetupitant	May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors).
Fosphenytoin	May decrease the serum concentration of VinCRIStine. VinCRIStine may decrease the serum concentration of Fosphenytoin.
Ivosidenib	May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers).
Larotrectinib	May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors).
MitoMYcin (Systemic)	Antineoplastic Agents (Vinca Alkaloids) may enhance the adverse/toxic effect of MitoMYcin (Systemic). Specifically, the risk of pulmonary toxicity may be increased.
Netupitant	May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors).
NIFEdipine	May increase the serum concentration of VinCRIStine.
Ocrelizumab	May enhance the immunosuppressive effect of Immunosuppressants.
Palbociclib	May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors).
P-glycoprotein/ABCB1 Inhibitors	May increase the serum concentration of Pglycoprotein/ABCB1 Substrates. P-glycoprotein inhibitors may also enhance the distribution of p-glycoprotein substrates to specific cells/tissues/organs where p-glycoprotein is present in large amounts (e.g., brain, T-lymphocytes, testes, etc.).
Phenytoin	May decrease the serum concentration of VinCRIStine. VinCRIStine may decrease the serum concentration of Phenytoin. Management: .
Pidotimod	Immunosuppressants may diminish the therapeutic effect of Pidotimod.
Ranolazine	May increase the serum concentration of P-glycoprotein/ABCB1 Substrates.
Sarilumab	May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers).
Siltuximab	May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers).
Simeprevir	May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors).
Siponimod	Immunosuppressants may enhance the immunosuppressive effect of Siponimod.
Teniposide	May enhance the neurotoxic effect of VinCRIStine.
Tertomotide	Immunosuppressants may diminish the therapeutic effect of Tertomotide.
Tocilizumab	May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers).
Trastuzumab	May enhance the neutropenic effect of Immunosuppressants.
Risk Factor D (Consider therapy modification)
Baricitinib	Immunosuppressants may enhance the immunosuppressive effect of Baricitinib. Management: Use of baricitinib in combination with potent immunosuppressants such as azathioprine or cyclosporine is not recommended. Concurrent use with antirheumatic doses of methotrexate or nonbiologic disease modifying antirheumatic drugs (DMARDs) is permitted.
CYP3A4 Inducers (Strong)	May increase the metabolism of CYP3A4 Substrates (High risk with Inducers). Management: Consider an alternative for one of the interacting drugs. Some combinations may be specifically contraindicated. Consult appropriate manufacturer labeling.
CYP3A4 Inhibitors (Strong)	May decrease the metabolism of CYP3A4 Substrates (High risk with Inhibitors).
Dabrafenib	May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Management: Seek alternatives to the CYP3A4 substrate when possible. If concomitant therapy cannot be avoided, monitor clinical effects of the substrate closely (particularly therapeutic effects).
Echinacea	May diminish the therapeutic effect of Immunosuppressants.
Enzalutamide	May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Management: Concurrent use of enzalutamide with CYP3A4 substrates that have a narrow therapeutic index should be avoided. Use of enzalutamide and any other CYP3A4 substrate should be performed with caution and close monitoring.
Fingolimod	Immunosuppressants may enhance the immunosuppressive effect of Fingolimod. Management: Avoid the concomitant use of fingolimod and other immunosuppressants when possible. If combined, monitor patients closely for additive immunosuppressant effects (eg, infections).
Itraconazole	May enhance the adverse/toxic effect of VinCRIStine. Itraconazole may increase the serum concentration of VinCRIStine.
Leflunomide	Immunosuppressants may enhance the adverse/toxic effect of Leflunomide. Specifically, the risk for hematologic toxicity such as pancytopenia, agranulocytosis, and/or thrombocytopenia may be increased. Management: Consider not using a leflunomide loading dose in patients receiving other immunosuppressants. Patients receiving both leflunomide and another immunosuppressant should be monitored for bone marrow suppression at least monthly.
Lenograstim	Antineoplastic Agents may diminish the therapeutic effect of Lenograstim. Management: Avoid the use of lenograstim 24 hours before until 24 hours after the completion of myelosuppressive cytotoxic chemotherapy.
Lipegfilgrastim	Antineoplastic Agents may diminish the therapeutic effect of Lipegfilgrastim. Management: Avoid concomitant use of lipegfilgrastim and myelosuppressive cytotoxic chemotherapy. Lipegfilgrastim should be administered at least 24 hours after the completion of myelosuppressive cytotoxic chemotherapy.
Lopinavir	May increase the serum concentration of VinCRIStine. Management: Monitor closely for signs and symptoms of vincristine toxicity; consider temporary interruption of lopinavir/ritonavir antiviral therapy if patients develop significant toxicity with concurrent use.
Lorlatinib	May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Management: Avoid concurrent use of lorlatinib with any CYP3A4 substrates for which a minimal decrease in serum concentrations of the CYP3A4 substrate could lead to therapeutic failure and serious clinical consequences.
Macrolide Antibiotics	May increase the serum concentration of Antineoplastic Agents (Vinca Alkaloids). Macrolides may also increase the distribution of Vinca Alkaloids into certain cells and/or tissues. Management: Consider an alternative to using a macrolide antibiotic when possible in order to avoid the potential for increased vinca alkaloid toxicity. Exceptions: Azithromycin (Systemic); Fidaxomicin; Roxithromycin; Spiramycin.
MiFEPRIStone	May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Management: Minimize doses of CYP3A4 substrates, and monitor for increased concentrations/toxicity, during and 2 weeks following treatment with mifepristone. Avoid cyclosporine, dihydroergotamine, ergotamine, fentanyl, pimozide, quinidine, sirolimus, and tacrolimus.
Mitotane	May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Management: Doses of CYP3A4 substrates may need to be adjusted substantially when used in patients being treated with mitotane.
Nivolumab	Immunosuppressants may diminish the therapeutic effect of Nivolumab.
Palifermin	May enhance the adverse/toxic effect of Antineoplastic Agents. Specifically, the duration and severity of oral mucositis may be increased. Management: Do not administer palifermin within 24 hours before, during infusion of, or within 24 hours after administration of myelotoxic chemotherapy.
Pitolisant	May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Management: Combined use of pitolisant with a CYP3A4 substrate that has a narrow therapeutic index should be avoided. Other CYP3A4 substrates should be monitored more closely when used with pitolisant.
Posaconazole	May enhance the adverse/toxic effect of Antineoplastic Agents (Vinca Alkaloids). Posaconazole may increase the serum concentration of Antineoplastic Agents (Vinca Alkaloids). Management: Avoid the concomitant use of posaconazole and vinca alkaloids when possible. If combined, monitor for increased vinca alkaloid toxicities (eg, neurotoxicity, gastrointestinal toxicity).
Ritonavir	May increase the serum concentration of VinCRIStine. Management: Monitor closely for signs and symptoms of vincristine toxicity; consider temporary interruption of ritonavir antiviral therapy if patients develop significant toxicity with concurrent use.
Roflumilast	May enhance the immunosuppressive effect of Immunosuppressants.
Sipuleucel-T	Immunosuppressants may diminish the therapeutic effect of Sipuleucel-T. Management: Evaluate patients to see if it is medically appropriate to reduce or discontinue therapy with immunosuppressants prior to initiating sipuleucel-T therapy.
St John's Wort	May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Management: Consider an alternative for one of the interacting drugs. Some combinations may be specifically contraindicated. Consult appropriate manufacturer labeling.
Stiripentol	May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Management: Use of stiripentol with CYP3A4 substrates that are considered to have a narrow therapeutic index should be avoided due to the increased risk for adverse effects and toxicity. Any CYP3A4 substrate used with stiripentol requires closer monitoring.
Tofacitinib	Immunosuppressants may enhance the immunosuppressive effect of Tofacitinib. Management: Concurrent use with antirheumatic doses of methotrexate or nonbiologic disease modifying antirheumatic drugs (DMARDs) is permitted, and this warning seems particularly focused on more potent immunosuppressants.
Vaccines (Inactivated)	Immunosuppressants may diminish the therapeutic effect of Vaccines (Inactivated). Management: Vaccine efficacy may be reduced. Complete all age-appropriate vaccinations at least 2 weeks prior to starting an immunosuppressant. If vaccinated during immunosuppressant therapy, revaccinate at least 3 months after immunosuppressant discontinuation.
Voriconazole	May enhance the adverse/toxic effect of Antineoplastic Agents (Vinca Alkaloids). Voriconazole may increase the serum concentration of Antineoplastic Agents (Vinca Alkaloids).
Risk Factor X (Avoid combination)
BCG (Intravesical)	Immunosuppressants may diminish the therapeutic effect of BCG (Intravesical).
Cladribine	May enhance the immunosuppressive effect of Immunosuppressants.
Conivaptan	May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors).
Fusidic Acid (Systemic)	May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors).
Idelalisib	May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors).
Natalizumab	Immunosuppressants may enhance the adverse/toxic effect of Natalizumab. Specifically, the risk of concurrent infection may be increased.
Pimecrolimus	May enhance the adverse/toxic effect of Immunosuppressants.
Tacrolimus (Topical)	May enhance the adverse/toxic effect of Immunosuppressants.
Vaccines (Live)	Immunosuppressants may enhance the adverse/toxic effect of Vaccines (Live). Immunosuppressants may diminish the therapeutic effect of Vaccines (Live). Management: Avoid use of live organism vaccines with immunosuppressants; live-attenuated vaccines should not be given for at least 3 months after immunosuppressants.

Monitor:

• Serum electrolytes (sodium).
• Hepatic function tests,
• CBC with differential,
• Serum uric acid
• Monitor the infusion site.
• Monitor Neurologic status.
• Monitor for constipation/ ileus and for signs/ symptoms of peripheral neuropathy

How to administer Vincristine?

For intravenous administration only. It is fatal if given by other routes. NOT to be delivered at the same time with any other medications intended for CNS administration.

Best if infused as a short 5- to 10-minute infusion in a 25 to 50 mL minibag. It causes blisters. Ensure needle or catheter is properly placed prior to and during infusion. Avoid extravasation.

Treatment of extravasation:

• If cannula/needle still in place, administer 1 to 6 mL hyaluronidase (150 units/mL) into the existing IV line.
• The usual dose is 1 mL hyaluronidase for each 1 mL of the extravasated drug.
• If cannula/needle was removed, inject 1 to 6 mL (150 units/mL) subcutaneously in a clockwise manner using 1 mL for each 1 mL of drug extravasated or administer 1 mL (150 units/mL) as 5 separate 0.2 mL injections (using a 25-gauge needle) subcutaneously into the extravasation site .

Mechanism of action of Vincristine (Oncovin):

• Vincristine blocks the formation of microtubules by binding to tubulin. This results in the arresting of the cell at metaphase and disrupting the formation the mitotic spindle.
• This is only applicable to the M and S phases. Vincristine can also inhibit glutamic acid use, so it may also interfere with nucleic acids and protein synthesis.

Distribution: It is quickly absorbed from the bloodstream and tightly bound in tissues.

MetabolismCYP3A4: Hepatic enlargement

Eliminating half-lifeTerminal: 85 hours (ranging from 19 to 155 hours).

Excretion: Feces (80%); Urine (10% to 20%); 1% as an unchanged drug  

International Brands of Vincristine:

• Alcavixin
• Biocristin
• Cellicristin
• Citomid
• Citomid RU
• Cristol
• Criston
• Cristovin
• Crivosin
• Cytocristin
• Farmistin CS
• Faulcris
• Kyocristine
• Oncocristin
• Oncovin
• Onvinc-2
• Rasteo
• Tecnocris
• Vinces
• Vincran
• Vincrina
• Vincrisin
• Vincristin
• Vincristina
• Vincristine Delta West
• Vincristine Sulfate
• Vincristine-David Bull
• Vinracine
• Vinstin
• Vintec
• Vincasar PFS

Vincristine (Oncovin) in Pakistan:

Vincristine (Sulphate) [Inj 1 Mg]
Pharmacristine	Pharmedic (Pvt) Ltd.
Vincristine	Turner Grahams Of Pakistan (Pvt) Ltd.
Vincristine	Swiss Pharmaceuticals (Pvt) Ltd.
Vincristine	Atco Laboratories Limited
Vinracine	Al-Habib Pharmaceuticals.
Vinracine	Al-Habib Pharmaceuticals.

Vincristine (Sulphate) [Inj 2 Mg]
Pharmacristine	Pharmedic (Pvt) Ltd.
Vincristine	Atco Laboratories Limited