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CSC BMT Cyclophosphamide-ATG-TBI VER 7-6-17 (HL 4449)

CSC BMT Cyclophosphamide-ATG-TBI VER 7-6-17 (HL 4449) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, BMT


CSC BMT CYCLOPHOSPHAMIDE/ATG/TBI VER: 7-6-17 –  Properties
Conditioning Regimen for Allogeneic Transplant –  7/6/2017 through 7/21/2017 (16 days), Planned
Treatment Orders for Day -5 through Day 11, Conditioning Regimen for Allogeneic
Transplant –  Planned for 7/6/2017
Treatment Plan Information
Reference Information (1)
BMT: Storb R, et al. Blood 1994;84:941-9.
Reference Information (2)
BMT: Deeg HJ, et al. Blood 2006;109(5):1485-1491.
Reference Information (3)
BMT: Champlin RE, et al. Blood 2007;109(10):4582-4585.
Treatment Plan Summary
DISEASE: Aplastic Anemia;  THERAPY: cyclophosphamide 50 mg/kg IV daily  Day -5, -4, -3, -2, mesna 50 mg/kg IV
continuous infusion over 24 hours Day -5, -4, -3, -2 for a total of 96 hours, antithymocyte globulin (horse) 30 mg/kg IV
daily Day -4, -3, -2,  total body irradiation 200 cGy given in 1 fraction on Day -1 (only used for unrelated donor),
methotrexate 15 mg/m2 IV on Day +1, methotrexate 10 mg/m2 IV on Day +3, +6, +11 (Graft vs Host Disease
prophylaxis); CYCLE LENGTH: 6 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+12 at 0000
METHOTREXATE
ONCE Starting S+17 at 0000
Treatment Conditions
Treatment Condition A
Patient with severe aplastic anemia. Check that baseline ECG done and evaluated prior to initiation of high dose
chemotherapy.
Verify Appointments
Verify Day -1 radiology appointment(s) have been scheduled for Total Body Irradiation 200 cGY in one fraction.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to antithymocyte globulin (horse) can occur. See Emergency Medications.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Day -4 through Day -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
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Zztestonc,Edward E [2435061]
7/6/2017 3:31:02 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

EVERY 4 HOURS Starting when released Until Specified
Day -5 through Day -2: Once cyclosphosphamide begins, monitor urine output to assure minimum of 400 mL over 4
hours. If output is less, notify BMT Team.
Hydration
dextrose 5%-NaCl 0.45% with KCl 20 mEq/L infusion
Intravenous, CONTINUOUS Starting when released Until Discontinued
Day -5: Administer at rate of 3 L/m2/24h.
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 -4: Reduce IV rate to 100 mL/h.
Pre-Medications
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Day -5: administer prior to chemotherapy. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Day -5: Give 30 minutes prior to first dose of cyclophosphamide.
dexamethasone (DECADRON) 10 MG/ML injection 8 mg
8 mg, Intravenous, 1 X DAILY PRN Starting when released Until Discontinued, If unable to tolerate PO.
Day -5: Give 30 minutes prior to first dose of cyclophosphamide.
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, EVERY 24 HOURS, 4 doses Starting when released
Day -5 through Day -2: Administer 30 minutes prior to cyclophosphamide.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, EVERY 24 HOURS PRN, For 96 hours Starting when released, nausea/vomiting, if unable to tolerate
PO
Day -5 through Day -2. Administer 30 minutes prior to cyclophosphamide.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, EVERY 24 HOURS, 3 doses Starting S+1 at 0000
Day -4 through Day -2: Administer 30 minutes before antithymocyte globulin (horse). No more than 4 grams
acetaminophen per 24 hours for adults or 15mg/kg per dose for peds <40kg.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, EVERY 24 HOURS, 3 doses Starting S+1 at 0000
Day -4 through Day -2: Administer 30 minutes before antithymocyte globulin (horse).
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, EVERY 24 HOURS PRN, For 72 hours Starting S+1 at 0000, Infusion reaction, if unable to tolerate
PO, Administer over 1 Minutes
Day -4 through Day -2: Administer 30 minutes before antithymocyte globulin (horse).
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, 2 X DAILY (AT MEALTIME), 2 doses Starting S+4 As Scheduled
Day -1: Administer doses 30 minutes prior to radiation treatments.
dexamethasone (DECADRON) 10 MG/ML injection 8 mg
8 mg, Intravenous, 2 X DAILY PRN, For 24 hours Starting S+4 at 0000, If unable to tolerate PO
Day -1: Administer doses 30 minutes prior to radiation treatments.
ondansetron (ZOFRAN) tab 12 mg
12 mg, Oral, 2 X DAILY (AT MEALTIME), 2 doses Starting S+4 As Scheduled
Day -1: Administer doses 30 minutes prior to radiation treatments.
ondansetron (ZOFRAN) 12 mg in sodium chloride 0.9 % 50 mL bag
12 mg, Intravenous, 2 X DAILY PRN, For 24 hours Starting when released, nausea/vomiting, if unable to tolerate PO
Day -1. Administer 30 minutes prior to radiation treatments.
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Zztestonc,Edward E [2435061]
7/6/2017 3:31:02 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

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
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
mesna (MESNEX) 3,840 mg in sodium chloride 0.9 % 1,000 mL bag
3,840 mg (50 mg/kg × 76.8 kg Treatment plan ideal weight), Intravenous, EVERY 24 HOURS, 4 doses Starting when
released
Day -5 through Day -2: Administer each bag as continuous infusion over 24 hours for 4 days.
cyclophosphamide (CYTOXAN) 3,840 mg bag
3,840 mg (50 mg/kg × 76.8 kg Treatment plan ideal weight), Intravenous, EVERY 24 HOURS, 4 doses Starting when
released
Day -5 through Day -2: Administer as undiluted drug.
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, 12 doses Starting S+1
at 0000
Day -4 through Day -2. Schedule first dose prior to Day -4 cyclophosphamide and antithymocyte globulin. Subsequent
doses of glucocorticoids to be determined by signs and symptoms of serum sickness.
antithymocyte globulin EQUINE (ATGAM) 2,382 mg in sodium chloride 0.9 % 1,000 mL bag
2,382 mg (30 mg/kg × 79.4 kg Treatment plan recorded weight), Intravenous, EVERY 24 HOURS, 3 doses Starting S+1 at
0000
Day -4 through Day -2. Hypersensitivity risk. See emergency medications. Administer with 0.2 or 0.22 micron filter.
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, 2 X DAILY (AT MEALTIME), 8 doses Starting S As Scheduled
Day -5 through Day -2: Give at 1 hour and 6 hours after the start of each cyclophosphamide dose. IV push rate 10
mg/minute. IV push rate 10 mg/minute. IV infusion rate 4 mg/minute.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, 2 X DAILY (AT MEALTIME), 6 doses Starting S+1 As Scheduled
Day -4 through Day -2: Give 4 hours and 8 hours after the start of ATG for a total of 3 doses each day of therapy
(premed included). No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose for peds
<40kg.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, 2 X DAILY (AT MEALTIME), 6 doses Starting S+1 As Scheduled
Day -4 through Day -2: Give 4 hours and 8 hours after the start of ATG for a total of 3 doses each day of therapy
(premed included).
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, 2 X DAILY PRN, For 4 days Starting S+1 at 0000, Infusion reaction, if unable to tolerate po.,
Administer over 1 Minutes
Day -4 through Day -2 Give 4 hours and 8 hours after the start of ATG for a total of 3 doses each day of therapy
(premed included).
tacrolimus cap
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Zztestonc,Edward E [2435061]
7/6/2017 3:31:02 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

Oral, EVERY 12 HOURS Starting S+2 at 0000
Day -3: 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+6 at 0000
Day +1: Administer 24 hours after the completion of stem cell infusion. IV push rate 10 mg/minute.
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+8 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+11 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+16 at 0000
Day +11: IV push rate 10 mg/minute. Check with BMT team before administering dose.
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Zztestonc,Edward E [2435061]
7/6/2017 3:31:02 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