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CSC BMT INPT Cyclophosphamide Fludarabine ATG (EQUINE) VER 7-6-17 (HL 6036)

CSC BMT INPT Cyclophosphamide Fludarabine ATG (EQUINE) VER 7-6-17 (HL 6036) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, BMT


CSC BMT INPT CYCLOPHOSPHAMIDE/FLUDARABINE/ATG(EQUINE) VER: 7-6-17 –  Properties
Conditioning Regimen for Allogeneic Transplant –  7/6/2017 through 7/24/2017 (19 days), Planned
Treatment Orders for Day -7 through Day +11, Conditioning Regimen for Allogeneic
Transplant –  Planned for 7/6/2017
Treatment Plan Information
Reference Information (1)
PAROXYSMAL NOCTURNAL HEMOGLOBINURIA: Pantin J, et al. Biol Blood Marrow Transplant 2014;20(9):1435-9.
Treatment Plan Summary
DISEASE: Paroxysmal Nocturnal Hemoglobinuria (PNH) (Advanced); THERAPY: cyclophosphamide 60 mg/kg IV Day -7
and Day -6, fludarabine 25 mg/m2 IV Days -5, -4, -3, -2 and -1, antithymocyte globulin (equine) 40 mg/kg IV Days -5,
-4, -3 and -2; GRAFT VERSUS HOST DISEASE PROPHYLAXIS: tacrolimus 0.06 mg/kg by mouth twice daily beginning Day
-3 and continuing through Day +90; methotrexate 15 mg/m2 IV on Day +1, methotrexate 10 mg/m2 IV on Day +3, +6,
and +11; CYCLE LENGTH: 19 days; COURSE: 1 cycle.
Dose Calculation Instructions
All chemotherapy for BMT conditioning regimens should be dosed based on the medication-specific weight in
Standard Operating Procedure (SOP) B4.400: Calculation of High Dose Chemotherapy Doses. Document can be
accessed from the Reference Link of the Navigator.
Consent
Verify Consent
Verify informed consent has been obtained.
Additional Labs
METHOTREXATE
ONCE Starting S+14 at 0000
METHOTREXATE
ONCE Starting S+19 at 0000
Treatment Conditions
Treatment Parameters
Hold treatment and notify authorizing prescriber for Creatinine Clearance less than 70 mL/min.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to antithymocyte globulin (horse) can occur. See Emergency Medications.
Vital Signs
SEE COMMENTS Starting S+2 at 0000 Until Specified
Day -5, -4, -3 and -2. Evaluate prior to each antithymocyte globulin (horse) dose, then every 30 minutes x 2 for the first
hour, then every hour during the infusion and then every hour x 2 after infusion completed.
Measure Intake And Output
EVERY 4 HOURS Starting when released Until Specified
Day -7 and Day -6. Once cyclophosphamide begins, monitor urine output and notify BMT team if less than 400 mL over
4 hours.
Hydration
dextrose 5%-NaCl 0.45% with KCl 20 mEq/L infusion
Intravenous, CONTINUOUS, For 24 hours Starting when released
Day -7. Administer at rate of 3 L/m2/day.
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Zztestonc,Edward E [2435061]
7/6/2017 3:34:10 PM Page 1 of 4
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@uwhealth.org

dextrose 5%-NaCl 0.45% with KCl 20 mEq/L infusion
at 100 mL/hr, Intravenous, CONTINUOUS Starting S+1 at 0000 Until Discontinued
Day -6. Decrease IV fluid rate to 100 mL/hr.
Pre-Medications
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Day -7. Administer 30 minutes prior to cyclophosphamide. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, EVERY 24 HOURS, 2 doses Starting when released
Day -7 and Day -6. Administer 30 minutes prior to cyclophosphamide. May give IV if unable to tolerate PO.
ondansetron (ZOFRAN) 12 mg in sodium chloride 0.9 % 50 mL bag
12 mg, Intravenous, EVERY 24 HOURS PRN, For 72 hours Starting when released, nausea/vomiting
Day -7 and Day -6. Give if patient unable to tolerate PO.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, EVERY 24 HOURS, 5 doses Starting S+2 at 0000
Day -5 through Day -1. Administer 30 minutes prior to chemotherapy. May give IV if unable to tolerate PO.
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 24 HOURS PRN, For 120 hours Starting S+2 at 0000, nausea/vomiting, Administer over 3
Minutes
Day -5 through Day -1. Give if patient unable to tolerate PO.
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, EVERY 24 HOURS, 2 doses Starting when released
Day -7 and Day -6.  Administer 30 minutes prior to cyclophosphamide. May give IV if unable to tolerate PO.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, EVERY 24 HOURS PRN, For 48 hours Starting when released, nausea/vomiting
Day -7 and Day -6. Give if patient unable to tolerate PO.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, 3 X DAILY, 12 doses Starting S+2 As Scheduled
Day -5, -4, -3 and -2. Administer 30 minutes before antithymocyte globulin (horse) and at 4 hours and 8 hours after the
start of antithymocyte globulin (horse) for a total of 3 doses each day of therapy. No more than 4 grams
acetaminophen per 24 hours for adults.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, EVERY 6 HOURS, 12 doses Starting S+2 at 0000
Day -5, -4, -3 and -2. Administer every 6 hours around the clock while receiving antithymocyte globulin (horse). May
give IV if patient unable to tolerate PO.
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, EVERY 6 HOURS PRN, For 120 hours Starting S+2 at 0000, infusion reaction, Administer over 1
Minutes
Days -5, -4, -3 and -2. Administer every 6 hours around the clock while receiving antithymocyte globulin (horse). Give if
patient unable to tolerate PO.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
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Zztestonc,Edward E [2435061]
7/6/2017 3:34:10 PM Page 2 of 4
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
07/2017CCKM@uwhealth.org

albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
mesna (MESNEX) 4,608 mg in sodium chloride 0.9 % 1,000 mL bag
4,608 mg (60 mg/kg × 76.8 kg Treatment plan ideal weight), Intravenous, EVERY 24 HOURS, 2 doses Starting when
released
Day -7 and Day -6. Begin 15 minutes prior to start of cyclophosphamide and infuse as a continuous infusion over 24
hours for 2 days.
cyclophosphamide (CYTOXAN) 4,608 mg bag
4,608 mg (60 mg/kg × 76.8 kg Treatment plan ideal weight), Intravenous, EVERY 24 HOURS, 2 doses Starting when
released
Day -7 and Day -6. Administer over 120 minutes. Administer as undiluted drug.
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, 2 X DAILY, 4 doses Starting when released
Day -7 and Day -6. Administer 1 hour and 6 hours after start of cyclophosphamide. IV push rate 10 mg/minute.
fludarabine (FLUDARA) 50 mg in sodium chloride 0.9 % 100 mL bag
50 mg (25 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 24 HOURS, 5 doses Starting
S+2 at 0000
Days -5 through Day -1. Administer over 30 minutes.
For patients with Creatinine Clearance less than 70 mL/min (based on last calculated Creatinine Clearance prior to the
start of conditioning), fludarabine dose should be reduced by 20%. If patient's Creatinine changes on Days -4, -3  -2
and -1 dose will remain the same.
methylprednisolone sod. succ. in sodium chloride 0.9% (SOLU-MEDROL) injection 19.85 mg
19.85 mg (0.25 mg/kg × 79.4 kg Treatment plan recorded weight), Intravenous, EVERY 6 HOURS, 16 doses Starting S+2
at 0000
Day -5, -4, -3 and -2. Schedule first dose prior to Day -5 antithymocyte globulin (horse). Subsequent doses of
glucocorticoids to be determined by signs and symptoms of serum sickness.
antithymocyte globulin EQUINE (ATGAM) 3,176 mg in sodium chloride 0.9 % 1,000 mL bag
3,176 mg (40 mg/kg × 79.4 kg Treatment plan recorded weight), Intravenous, EVERY 24 HOURS, 4 doses Starting S+2 at
0000
Days -5, -4, -3, and -2. Administer with 0.2 or 0.22 micron filter over 8 hours. Hypersensitivity risk. See Emergency
Medications.
Maximum concentration = 4 mg/mL.
tacrolimus cap
Oral, EVERY 12 HOURS Starting S+4 at 0000
Day -3 through Day +90. Dose =0.12 mg/kg/day in two divided doses based on Actual body weight. May switch to IV
tacrolimus if patient unable to tolerate PO.
methotrexate PF (TREXALL) injection 30 mg
30 mg (15 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting S+8 at 0000
Day +1. IV push rate 10 mg/minute. Administer at least 24 hours after stem cell therapy.
methotrexate PF (TREXALL) injection 20 mg
20 mg (10 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting S+10 at 0000
Day +3. IV push rate 10 mg/minute. Check with BMT team before administering dose.
methotrexate PF (TREXALL) injection 20 mg
20 mg (10 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting S+13 at 0000
Day +6. IV push rate 10 mg/minute. Check with BMT team before administering dose.
methotrexate PF (TREXALL) injection 20 mg
20 mg (10 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting S+18 at 0000
Day +11. IV push rate 10 mg/minute. Check with BMT team before administering dose.
Conditional Orders
diphenhydramine (BENADRYL) cap RANGE 25-50 mg
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Zztestonc,Edward E [2435061]
7/6/2017 3:34:10 PM Page 3 of 4
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
07/2017CCKM@uwhealth.org

25-50 mg, Oral, EVERY 4 HOURS PRN, For 72 hours Starting when released, nasal burning
Day -7 and Day -6. Administer if patient experiences nasal burning or discomfort during cyclophosphamide infusion.
May give IV if unable to tolerate PO.
diphenhydramine (BENADRYL) injection RANGE 25-50 mg
25-50 mg, Intravenous, PRN, For 72 hours Starting when released, nasal burning, Administer over 1 Minutes
Day -7 and Day -6. Administer if patient experiences nasal burning or discomfort during cyclophosphamide
infusion. Give IV if patient unable to tolerate PO.
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Zztestonc,Edward E [2435061]
7/6/2017 3:34:10 PM Page 4 of 4
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
07/2017CCKM@uwhealth.org