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CSC BMT Myeloablative Busulfan (ORAL)-Cyclophosphamide-Fludarabine (HLA - Mismatched Donor) VER 4-11-17 (HL 5743)

CSC BMT Myeloablative Busulfan (ORAL)-Cyclophosphamide-Fludarabine (HLA - Mismatched Donor) VER 4-11-17 (HL 5743) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, BMT


CSC BMT MYELOABLATIVE BUSULFAN (ORAL)/CYCLOPHOSPHAMIDE/FLUDARABINE (HLA - MISMATCHED DONOR) VER:
4-11-17 – Properties
Myeloablative Regimen for Allogeneic Transplant – 4/11/2017 through 4/22/2017 (12 days), Planned
Treatment Orders for Day -6 through Day +5, Myeloablative Regimen for Allogeneic
Transplant – Planned for 4/11/2017
Treatment Plan Information
Reference Information (1)
BMT: Bashey A, et al. J Clin Oncol 2013;31(10):1310-16.
Reference Information (2)
BMT: Kanakry CG, et al. J Clin Oncol 2014;32(31):3497-505.
Reference Information (3)
BMT: Di Stasi A, et al. Biol Blood Marrow Transplant 2014;20(12):1975-81.
Reference Information (4)
BMT: Bashey A, et al. Bone Marrow Transplant 2014;49(8):999-1008.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia (AML), Chronic Myeloid Leukemia (CML), Myelodysplastic Syndrome (MDS),
Myeloproliferative Neoplasms (MPN); THERAPY: fludarabine 40 mg/m2 IV daily Days -5, -4, -3, -2, busulfan 1 mg/kg by mouth
every 6 hours Days -5, -4, -3, -2; GRAFT VS. HOST DISEASE PROPHYLAXIS: mesna 40 mg/kg IV daily (given in 4 divided doses)
Days +3 and +4, cyclophosphamide 50 mg/kg IV daily Days +3 and +4, mycophenolate mofetil 15 mg/kg by mouth three times daily
(max dose = 3000 mg/day) beginning Day +5 and continuing through Day +35, tacrolimus 0.06 mg/kg by mouth twice daily
beginning Day +5 and continuing through Day +180; TREATMENT LENGTH: 12 days; COURSE: 1 cycle.
Consent
Verify Consent
Verify informed consent has been obtained.
Pharmacokinetic Sampling
Pharmacokinetic Sample
Obtain busulfan level after the initial dose per UWHC Standard Operating Policy and Procedure B3.440. BMT coordinator to make
necessary arrangements. Busulfan pharmacokinetics will be done to target a steady state concentration of 900 ng/mL.
Treatment Conditions
Treatment Parameters
Hold treatment and notify authorizing prescriber for Creatinine Clearance less than 70 mL/min.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken ursodiol for approximately 2 weeks prior to admission and document start date in a progress
note. Notify authorizing prescriber if patient has not taken medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Nursing Communication
ONCE Starting when released
Administer busulfan on an empty stomach, nothing by mouth 1 hour prior to and 1 hour after each dose. May administer with water
or clear soda. For suspension formulation: if emesis occurs within 30 minutes of busulfan dose, re-administer dose. For tablet
formulation: if emesis occurs within 1 hour of busulfan dose, count tablets, and re-administer number of tablets counted in the
emesis.
Measure Intake And Output
EVERY 4 HOURS Starting S+9 at 0000 Until Specified
Day 3: Once cyclophosphamide administration begins monitor urine output to assure minimum of 400 mL over 4 hours. If urine
output less than 400 mL over 4 hours, notify BMT team.
Hydration
dextrose 5%-NaCl 0.45% with KCl 20 mEq/L infusion
at 100 mL/hr, Intravenous, CONTINUOUS, For 9 days Starting when released until S+9
Day -6 through Day +3. Adjust rate as needed.
sodium chloride 0.9 % infusion
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ZZtestonc,Andrew [2428787]
4/11/2017 3:41:37 PM Page 1 of 3
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Intravenous, CONTINUOUS Starting S+9 at 0000 Until Discontinued
Day +3 and Day +4: Start infusion 2 hours prior to the start of cyclophosphamide on Day +3 and continue until 8 hours after
cyclophosphamide on Day +4. Dose = 2 mL/kg/hour.
Pre-Medications
olanzapine (ZYPREXA) tab 10 mg
10 mg, Oral, 1 X DAILY (HS), 5 doses Starting when released
Days -6, -5, -4, -3, -2.
ondansetron (ZOFRAN) tab 4 mg
4 mg, Oral, EVERY 6 HOURS, 16 doses Starting S+1 at 0000
Day -5, -4, -3, and -2: Administer 60 minutes prior to busulfan. May give IV if PO not tolerated.
ondansetron (ZOFRAN) injection 4 mg
4 mg, Intravenous, EVERY 6 HOURS PRN, For 120 hours Starting S+1 at 0000, nausea/vomiting, Administer over 3 Minutes
Days -5, -4, -3, and -2: Administer 60 minutes prior to busulfan. May give IV if PO not tolerated.
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting S+9 at 0000
Day +3: Administer prior to chemotherapy. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, EVERY 24 HOURS, 2 doses Starting S+9 at 0000
Day +3 and +4: Administer prior to cyclophosphamide. May give IV if PO not tolerated.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, EVERY 24 HOURS PRN, For 72 hours Starting S+9 at 0000, nausea/vomiting
Day +3 and +4: Administer prior to cyclophosphamide. May give IV if PO not tolerated.
NOTE:
EVERY 24 HOURS, For 5 days Starting S+6 at 0000
Corticosteroids may not be used as an antiemetic agent beginning Day 0 and should not be administered until Day +5 (24 hours
after the completion of post-transplantation cyclophosphamide), unless used for adrenal support or during a medical emergency
(e.g. treatment of anaphylaxis).
Treatment Medications
fludarabine (FLUDARA) 40 mg/m2 in sodium chloride 0.9 % 100 mL bag
40 mg/m2, Intravenous, EVERY 24 HOURS, 4 doses Starting S+1 at 0000
Days -5, -4, -3, and -2: 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 -5, -4, -3 and -2, dose will remain
the same.
busulfan (MYLERAN) 2 MG/ML susp 1 mg/kg (Adjusted)
1 mg/kg, Oral, 4 X DAILY, 16 doses Starting S+1 As Scheduled
Days -5, -4, -3, and -2: Shake Well. Administer on empty stomach, nothing by mouth 1 hour prior to and 1 hour after dose. May
administer with water or clear soda. If emesis within 30 minutes of busulfan dose, re-administer dose.
mesna (MESNEX) 10 mg/kg in dextrose 5 % 50 mL bag
10 mg/kg, Intravenous, 4 X DAILY, 8 doses Starting S+9 As Scheduled
Days +3 and +4: Administer 30 minutes prior to start of cyclophosphamide and 3 hours, 6 hours, and 8 hours after the start of
cyclophosphamide.
cyclophosphamide (CYTOXAN) 50 mg/kg bag
50 mg/kg, Intravenous, EVERY 24 HOURS, 2 doses Starting S+9 at 0000
Day +3 and +4: Administer over 120 minutes. Day +3 dose must be given between 60 and 72 hours after bone marrow infusion. Day
+4 dose should be given 24 hours after Day +3 dose.
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, EVERY 5 HOURS, 2 doses Starting S+9 at 0000
Day +3: Administer at 1 hour and 6 hours after the start of each cyclophosphamide dose to promote diuresis. IV push rate 10
mg/minute.
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, EVERY 5 HOURS, 2 doses Starting S+10 at 0000
Day +4: Administer at 1 hour and 6 hours after the start of each cyclophosphamide dose to promote diuresis. IV push rate 10
mg/minute.
mycophenolate mofetil (CELLCEPT) cap 15 mg/kg
15 mg/kg, Oral, 3 X DAILY Starting S+11 As Scheduled
Day +5. Begin at least 24 hours after completion of cyclophosphamide. Max dose = 3000 mg/day. Dosing based on actual body
weight. Round up to nearest tablet size. Continue through Day +35.
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ZZtestonc,Andrew [2428787]
4/11/2017 3:41:37 PM Page 2 of 3
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

tacrolimus cap
Oral, EVERY 12 HOURS Starting S+11 at 0000
Day +5: Begin at least 24 hours after completion of cyclophosphamide. Dose = 0.06 mg/kg every 12 hours based
on Treatment Plan Actual Weight. Round to nearest 0.5 mg. Continue until Day +180. NOTE: Dose may be made
up of more than one capsule strength.
Conditional Orders
diphenhydramine (BENADRYL) cap RANGE 25-50 mg
25-50 mg, Oral, EVERY 6 HOURS PRN, For 48 hours Starting S+9 at 0000, For nasal burning during cyclophosphamide
administration. May give IV if unable to tolerate PO.
Day +3 and +4.
diphenhydramine (BENADRYL) injection RANGE 25-50 mg
25-50 mg, Intravenous, EVERY 6 HOURS PRN, For 48 hours Starting S+9 at 0000, For nasal burning during cyclophosphamide
administration. May give IV if unable to tolerate PO., Administer over 1 Minutes
Day +3 and +4.
Supportive Care Medications
ursodiol (ACTIGALL) cap 300 mg
300 mg, Oral, 2 X DAILY (AT MEALTIME) Starting when released
Continue until Day +30.
levetiracetam (KEPPRA) tab 500 mg
500 mg, Oral, 2 X DAILY, 14 doses Starting when released
Day -6 through Day 0.
TBO-filgrastim (GRANIX) 300 MCG/0.5ML soln prefilled syringe
Subcutaneous, 1 X DAILY (PM) Starting S+11 As Scheduled
Start on Day +5. Discontinue when ANC is greater than 500/µL for 2 consecutive days.
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ZZtestonc,Andrew [2428787]
4/11/2017 3:41:37 PM Page 3 of 3
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org