What is the recommended maintenance plan for a patient (Pt)?

Patient Maintenance Plan

The recommended maintenance plan depends entirely on the underlying disease being treated—maintenance therapy is disease-specific and cannot be generalized across conditions.

Disease-Specific Maintenance Strategies

For Non-Small Cell Lung Cancer (NSCLC)

Maintenance therapy should be offered only to patients with performance status (PS) 0-1 after first-line chemotherapy. 1

Non-Squamous Histology

• Pemetrexed switch maintenance is recommended following four cycles of platinum-based chemotherapy, demonstrating improvements in both progression-free survival (PFS) and overall survival (OS) 1
• Continuing pemetrexed following cisplatin plus pemetrexed first-line therapy is the preferred approach 1
• Bevacizumab continuation maintenance may be continued beyond 4-6 cycles until disease progression or unacceptable toxicity in eligible patients 1
• Erlotinib switch maintenance demonstrates PFS and OS benefit across all histologies, with greatest benefit in patients with stable disease after first-line treatment 1

Squamous Histology

• Cetuximab continuation maintenance may be continued beyond 4-6 cycles following cisplatin, vinorelbine, and cetuximab therapy 1
• Erlotinib switch maintenance is an option for patients with unknown EGFR status or EGFR wild-type 1

Key Decision Factors

• Histology type (squamous vs. non-squamous) 1
• Response to platinum-doublet chemotherapy 1
• Remaining toxicity after first-line chemotherapy 1
• Performance status 1
• Patient preference 1

Common Pitfall: Four cycles of chemotherapy are recommended for most patients, with a maximum of six cycles—continuation beyond this requires specific maintenance agents, not continuation of cytotoxic doublet chemotherapy 1

For Acute Lymphoblastic Leukemia (ALL)

Maintenance therapy is strongly recommended in all patients—attempts to omit maintenance have resulted in inferior outcomes. 1

Standard Maintenance Regimen

• Mercaptopurine (MP) and methotrexate (MTX) are the main drugs in maintenance therapy 1
• Total treatment duration of 2 to 2.5 years including maintenance is recommended 1
• Intermittent intrathecal (IT) prophylaxis is part of most regimens 1

What NOT to Include

• Maintenance without vincristine or steroid pulses is preferred by most groups—the benefit of these additions is debated and dexamethasone may increase infection-related deaths 1

Monitoring During Maintenance

• MRD testing intervals of approximately 3 months are suggested during maintenance 1
• Long-term drug exposure is necessary to eradicate minimal residual disease (MRD) 1

For Ovarian Cancer

Maintenance therapy selection depends on BRCA/HRD status, prior treatments, and response to platinum-based chemotherapy. 1

BRCA Wild-Type or Unknown, No Prior PARPi or Bevacizumab

• PARPi maintenance (after CR/PR/NED) or bevacizumab are both recommended options 1
• Bevacizumab added to chemotherapy followed by maintenance should be prioritized for patients needing rapid symptom control 1

Prior Bevacizumab, No Prior PARPi

• Platinum-based chemotherapy followed by PARPi maintenance is preferred as long as CR/PR/NED is achieved, regardless of BRCA/HRD status 1

Prior PARPi, No Prior Bevacizumab

• Platinum-based combination with bevacizumab followed by maintenance is recommended 1
• Carboplatin-pegylated liposomal doxorubicin (PLD) is the preferred chemotherapy partner for bevacizumab in recurrent setting 1

Duration

• PARPi maintenance should continue until progressive disease or unacceptable toxicity 1

For Autoimmune Hepatitis (AIH)

Long-term azathioprine 2 mg/kg/day is recommended as maintenance therapy after achieving remission. 1

After First Remission

• Continuing azathioprine long-term is recommended in younger patients, those with predictors of relapse (LKM- and SLA-positive), those with cirrhosis or decompensation, and those with observed or anticipated prednisolone-related side effects 1
• After treatment of one relapse, continuation of azathioprine 2 mg/kg/day as long-term maintenance therapy is recommended 1

Alternative Approach

• Treatment withdrawal with monitoring may be considered in select patients: those without cirrhosis, without features associated with relapse, with good tolerance of initial prednisolone, with potential precipitant of initial episode, or with history of malignancy 1

Monitoring

• Monitoring should be lifelong regardless of strategy pursued 1

For Tuberculosis

Directly observed therapy (DOT) is the preferred core management strategy for all patients with tuberculosis. 1

DOT Implementation

• DOT involves providing antituberculosis drugs directly to the patient and watching as they swallow the medications 1
• A patient-centered approach with tailored treatment plans is essential, with the patient as an active participant 1
• A specific case manager should be assigned individual responsibility for assuring treatment completion 1

Promoting Adherence

• Identify and address barriers including cultural/linguistic barriers, homelessness, substance abuse, and competing priorities 1
• Use the least restrictive measures likely to achieve success, ranging from monthly outpatient monitoring to legally mandated hospitalization if needed 1

General Principles for Medication Adherence

Successful long-term maintenance requires combinations of interventions—no single approach is sufficient. 2, 3

Evidence-Based Adherence Strategies

• Clinical pharmacist consultation for chronic disease co-management (maximum observed absolute improvement in adherence: 15%) 3
• Medication-taking reminders such as telephone calls to prompt refills (maximum observed absolute improvement: 33%) 3
• Using combination pills to reduce daily pill burden (maximum observed absolute improvement: 10%) 3
• Recurrent and personalized telephone counseling sessions with health educators 3

Key Components

• Clear information about the regimen 2
• Counseling about importance of adherence and how to organize medication taking 2
• Reminders about appointments and adherence 2
• Rewards and recognition for patient efforts 2
• Enlisting social support from family and friends 2

Common Pitfall: Typical adherence rates are only about 50% for medications—simply prescribing maintenance therapy without implementing adherence strategies will result in treatment failure 2