Our health service displays a habit symptomatic of a broader need to standardise decision-making regarding CNS-prophylactic treatment in DLBCL. While intrathecal methotrexate has shown little to no efficacy in preventing CNS relapse in DLBCL, it is still commonly recommended in high risk patients. Investigations of retrospective data have shown large variation in physicians’ preference for CNS-prophylactic therapy within other institutions indicating they also lack coherence in the area.
The alternative with some evidence, being high-dose intravenous methotrexate, has an inherently high morbidity requiring a long hospital stay; a significant barrier to changing guidelines.
This article details the process from problem to a co-created solution appropriate to our health service from the motivation of a pharmacist. Considerations discussed include international guidelines and literature review, the lack of clear evidence, creation of a very high-risk group, reversal versus replacement and barriers for implementation from the physicians’ perspective.