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CSC HEM INPT-OP Hyper-CVAD Part (A) and (B) - Leukemia VER 8-23-16 (HL 3087)

CSC HEM INPT-OP Hyper-CVAD Part (A) and (B) - Leukemia VER 8-23-16 (HL 3087) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Leukemia


CSC HEM INPT/OP HYPER-CVAD PART (A) AND (B) - LEUKEMIA VER: 8-23-16 – Properties
Cycle 1 Hyper-CVAD (Part A) – 8/23/2016 through 9/12/2016 (21 days), Planned
Day 1 through 4 (Inpatient), Cycle 1 Hyper-CVAD (Part A) – Planned for 8/23/2016
Treatment Plan Information
Reference Information (1)
ACUTE LYMPHOCYTIC LEUKEMIA: Kantarjian H, et al. J Clin Oncol. 2000; 18(3):547-61
Reference Information (2)
ACUTE LYMPHOCYTIC LEUKEMIA: Thomas D, et al. Blood. 2004; 103(12):4396-4407
Reference Information (3)
ACUTE LYMPHOCYTIC LEUKEMIA: Daver N, et al. Haematologica 2015;100(5):653-61.
Reference Information (4)
ACUTE LYMPHOCYTIC LEUKEMIA: Benjamini O, et al. Am J Hematol 2014;89(3):282-7.
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; THERAPY (Part A): dexamethasone 40 mg by mouth or IV Day 1 through 4 and Day 11
through 14, cyclophosphamide 300 mg/m2 IV every 12 hours Day 1, 2 and 3, doxorubicin 50 mg/m2 IV continuous infusion over 24
hours starting Day 3, vinCRIStine 2 mg IV Day 4 and 11, imatinib 400 mg by mouth once daily Day 1 through 14 (if Philadelphia
chromosome positive disease) OR dasatinib 100 mg by mouth once daily Days 1 through 14 (if Philadelphia chromosome positive
disease), methotrexate 12 mg IT Day 2, cytarabine 100 mg IT Day 8, hydrocortisone 30 mg IT may be given with IT chemotherapy
followed by THERAPY (Part B): methylprednisolone 50mg IV twice daily Day 1 through 3, methotrexate 200 mg/m2 IV over 2 hours
followed by 800 mg/m2 IV continuous infusion over 22 hours starting Day 1, leucovorin 50 mg/m2 IV given 36 hours after start of
methotrexate infusion followed by leucovorin 15 mg/m2 IV every 6 hours until methotrexate level is less than or equal to 0.5 uM/L
followed by leucovorin 15 mg by mouth every 6 hours until methotrexate level is less than or equal to 0.05 uM/L, cytarabine 3000
mg/m2 IV every 12 hours Day 2 and 3, imatinib 400 mg by mouth once daily Day 1 through 14 OR dasatinib 100 mg by mouth once
daily Days 1 through 14 (if Philadelphia chromosome positive disease), methotrexate 12 mg IT Day 2, cytarabine 100 mg IT Day 8,
hydrocortisone 30 mg IT may be given with IT chemotherapy; CYCLE LENGTH: 21 days; COURSE: 8 alternating cycles (A-B-A-B-
A-B-A-B); NOTE: IT chemotherapy for CNS prophylaxis will be given on Day 2 and 8 of Part A and B for a total of 4 doses for low
risk patients, a total of 8 doses for unknown risk patients or a total of 16 doses for high risk patients.
Note to All Staff (1)
If ejection fraction less than 50%, decrease DOXOrubicin to 25 mg/m2/day IV continuous infusion over 24 hours Day 2 and 3 (total
dose = 50 mg/m2 over 48 hours). If age greater than 60 years, consider decreasing cytarabine to 1000 mg/m2 IV every 12 hours
Day 2 and 3.
Note to All Staff (2)
If CSF is positive for leukemia, patient will receive twice weekly IT chemotherapy with alternating methotrexate and cytarabine until
CSF is negative for two consecutive lumbar punctures then resume intrathecal chemotherapy prophylactic regimen.
Consent
Verify Consent
Verify informed consent has been obtained.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total Bilirubin, AST
Treatment Parameters
Hold treatment and notify authorizing prescriber for Total Bilirubin greater than or equal to 2 mg/dL.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
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Zztestonc,Jeff J [2507481]
8/23/2016 8:35:12 AM Page 1 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org

500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 100 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, 1 X DAILY, 4 doses Starting when released
Give prior to chemotherapy. May give IV if unable to tolerate PO. If DOXOrubicin given over 48 hours, add 1 dose for a total of 5
doses.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, EVERY 24 HOURS PRN, For 4 days Starting when released until S+4, nausea/vomiting
Give prior to chemotherapy if patient unable to tolerate PO.
Intrathecal Procedure Orders
LEUKEMIA/LYMPHOMA SCREEN, CSF
Expected-S+1 Approximate, Expires-S+122, Normal, Routine
methotrexate PF 12 mg in sodium chloride 0.9 % 2.4 mL intraTHECAL injection
12 mg, Intrathecal, ONCE, 1 dose Starting S+1 at 0000
Day 2: Dose to be administered by provider.
Intrathecal Procedure Orders (delete all that do not apply)
hydrocortisone sodium succinate PF (SOLU-CORTEF) 30 mg in sodium chloride 0.9 % 3 mL intraTHECAL
injection
30 mg, Intrathecal, ONCE, 1 dose Starting S+1 at 0000
Day 2: Dose to be administered by provider.
Treatment Medications
dexamethasone (DECADRON) tab 40 mg
40 mg, Oral, 1 X DAILY, 4 doses Starting when released
Give prior to chemotherapy. May give IV if patient unable to tolerate PO.
dexamethasone (DECADRON) 40 mg in sodium chloride 0.9 % 50 mL bag
40 mg, Intravenous, 1 X DAILY PRN, For 5 days Starting when released until S+4 at 2359,
Give prior to chemotherapy if patient unable to tolerate PO.
cyclophosphamide (CYTOXAN) 600 mg in sodium chloride 0.9 % 250 mL bag
600 mg (300 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 12 HOURS, 6 doses Starting when
released
doxorubicin CONVENTIONAL (ADRIAMYCIN) 100 mg in sodium chloride 0.9 % 500 mL infusion
100 mg (50 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting S+2 at 0000
Give after completion of last dose of cyclophosphamide. If ejection fraction is less than 50%, decrease dose to 25 mg/m2 IV
continuous infusion over 24 hours on Day 2 and 3 (total dose = 50 mg/m2 over 48 hours).
vinCRIStine (ONCOVIN) 2 mg in sodium chloride 0.9 % 25 mL bag
2 mg, Intravenous, ONCE, 1 dose Starting S+3 at 0000
MUST be administered via gravity through a peripheral IV (not on an infusion pump).
Treatment Medications (delete all that do not apply)
imatinib (GLEEVEC) tab 400 mg
400 mg, Oral, 1 X DAILY, 14 doses Starting when released
Give if patient has Philadelphia chromosome positive disease. Prior to initiating therapy, verify outpatient prescription coverage with
pharmacist.
dasatinib (SPRYCEL) tab 100 mg
100 mg, Oral, 1 X DAILY, 14 doses Starting when released
Give if patient has Philadelphia chromosome positive disease. Prior to initiating therapy, verify outpatient prescription coverage with
pharmacist.
allopurinol (ZYLOPRIM) tab 300 mg
300 mg, Oral, 1 X DAILY, 7 doses Starting when released
acyclovir (ZOVIRAX) tab 400 mg
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Zztestonc,Jeff J [2507481]
8/23/2016 8:35:12 AM Page 2 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org

400 mg, Oral, 2 X DAILY Starting when released
fluconazole (DIFLUCAN) tab 400 mg
400 mg, Oral, 1 X DAILY Starting when released
sulfamethoxazole-trimethoprim (BACTRIM DS) 800-160 MG per tab 1 tab
1 tab, Oral, 2 X DAILY SAT, SUN Starting when released
ranitidine (ZANTAC) tab 150 mg
150 mg, Oral, 2 X DAILY Starting when released
senna-docusate (SENOKOT S) 8.6-50 MG per tab 2 tab
2 tab, Oral, 1 X DAILY (HS) Starting when released
Hold for loose stools
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
If unable to take PO, may give IV.
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting, If unable to tolerate PO.
IV push slowly, max rate 5 mg/minute.
Take Home Medications
sodium bicarbonate oral powder
Mix 1/2 teaspoon sodium bicarbonate oral powder (baking soda) in 6-8 ounces of a non-acidic fluid and drink by mouth at 8 AM, 12
PM, 4 PM, 10 PM the day before methotrexate treatment and at 8 AM the morning of methotrexate treatment., Disp-1 Bottle, R-0,
starting S, No Print
dexamethasone (DECADRON) 4 MG tab
Take 10 tabs by mouth one time daily. Take on Day 11 through 14., 40 mg, Disp-40 tab, R-0, 1 X DAILY starting S
Take Home Medications (delete all that do not apply)
levofloxacin (LEVAQUIN) 500 MG tab
Take 1 tab by mouth one time daily. Begin on Day ***, 500 mg, Disp-10 tab, R-0, 1 X DAILY starting S
TBO-filgrastim (GRANIX) 300 MCG/0.5ML soln prefilled syringe
Inject 300 mcg under skin one time daily in evening. Begin Day ***. Continue until ANC is greater than *** after nadir., 300 mcg,
Disp-10 Syringe, R-5, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
TBO-filgrastim (GRANIX) 480 MCG/0.8ML soln prefilled syringe
Inject 480 mcg under skin one time daily in evening. Begin Day ***. Continue until ANC is greater than *** after nadir., 480 mcg,
Disp-10 Syringe, R-5, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
Follow-Up
DAY 8 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT for intrathecal cytarabine for 60 minutes.
DAY 11 FOLLOW-UP
LABS: CBC with DIFF; CHEMO ROOM APPOINTMENT: vinCRIStine for 30 minutes
DAY 22 FOLLOW-UP
(Day 1 of next cycle) Schedule preadmission to B6/6 for chemotherapy administration.
Day 8 (Outpatient), Cycle 1 Hyper-CVAD (Part A) – Planned for 8/24/2016
Treatment Plan Information
Reference Information (1)
ACUTE LYMPHOCYTIC LEUKEMIA: Kantarjian H, et al. J Clin Oncol. 2000; 18(3):547-61
Reference Information (2)
ACUTE LYMPHOCYTIC LEUKEMIA: Thomas D, et al. Blood. 2004; 103(12):4396-4407
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Zztestonc,Jeff J [2507481]
8/23/2016 8:35:12 AM Page 3 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org

Reference Information (3)
ACUTE LYMPHOCYTIC LEUKEMIA: Daver N, et al. Haematologica 2015;100(5):653-61.
Reference Information (4)
ACUTE LYMPHOCYTIC LEUKEMIA: Benjamini O, et al. Am J Hematol 2014;89(3):282-7.
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; THERAPY (Part A): dexamethasone 40 mg by mouth or IV Day 1 through 4 and Day 11
through 14, cyclophosphamide 300 mg/m2 IV every 12 hours Day 1, 2 and 3, doxorubicin 50 mg/m2 IV continuous infusion over 24
hours starting Day 3, vinCRIStine 2 mg IV Day 4 and 11, imatinib 400 mg by mouth once daily Day 1 through 14 (if Philadelphia
chromosome positive disease) OR dasatinib 100 mg by mouth once daily Days 1 through 14 (if Philadelphia chromosome positive
disease), methotrexate 12 mg IT Day 2, cytarabine 100 mg IT Day 8, hydrocortisone 30 mg IT may be given with IT chemotherapy
followed by THERAPY (Part B): methylprednisolone 50mg IV twice daily Day 1 through 3, methotrexate 200 mg/m2 IV over 2 hours
followed by 800 mg/m2 IV continuous infusion over 22 hours starting Day 1, leucovorin 50 mg/m2 IV given 36 hours after start of
methotrexate infusion followed by leucovorin 15 mg/m2 IV every 6 hours until methotrexate level is less than or equal to 0.5 uM/L
followed by leucovorin 15 mg by mouth every 6 hours until methotrexate level is less than or equal to 0.05 uM/L, cytarabine 3000
mg/m2 IV every 12 hours Day 2 and 3, imatinib 400 mg by mouth once daily Day 1 through 14 OR dasatinib 100 mg by mouth once
daily Days 1 through 14 (if Philadelphia chromosome positive disease), methotrexate 12 mg IT Day 2, cytarabine 100 mg IT Day 8,
hydrocortisone 30 mg IT may be given with IT chemotherapy; CYCLE LENGTH: 21 days; COURSE: 8 alternating cycles (A-B-A-B-
A-B-A-B); NOTE: IT chemotherapy for CNS prophylaxis will be given on Day 2 and 8 of Part A and B for a total of 4 doses for low
risk patients, a total of 8 doses for unknown risk patients or a total of 16 doses for high risk patients.
Note to All Staff (1)
If ejection fraction less than 50%, decrease DOXOrubicin to 25 mg/m2/day IV continuous infusion over 24 hours Day 2 and 3 (total
dose = 50 mg/m2 over 48 hours). If age greater than 60 years, consider decreasing cytarabine to 1000 mg/m2 IV every 12 hours
Day 2 and 3.
Note to All Staff (2)
If CSF is positive for leukemia, patient will receive twice weekly IT chemotherapy with alternating methotrexate and cytarabine until
CSF is negative for two consecutive lumbar punctures then resume intrathecal chemotherapy prophylactic regimen.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Intrathecal Procedure Orders
LEUKEMIA/LYMPHOMA SCREEN, CSF
ONCE Starting when released
cytarabine PF (CYTOSAR) 100 mg in sodium chloride 0.9 % 2 mL intraTHECAL injection
100 mg, Intrathecal, ONCE, 1 dose Starting when released
Dose to be given by provider.
Intrathecal Procedure Orders (delete all that do not apply)
hydrocortisone sodium succinate PF (SOLU-CORTEF) 30 mg in sodium chloride 0.9 % 3 mL intraTHECAL
injection
30 mg, Intrathecal, ONCE, 1 dose Starting when released
Dose to be given by provider.
Follow-Up
VERIFY APPOINTMENTS
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Zztestonc,Jeff J [2507481]
8/23/2016 8:35:12 AM Page 4 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org

Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 11 (Outpatient), Cycle 1 Hyper-CVAD (Part A) – Planned for 9/2/2016
Treatment Plan Information
Reference Information (1)
ACUTE LYMPHOCYTIC LEUKEMIA: Kantarjian H, et al. J Clin Oncol. 2000; 18(3):547-61
Reference Information (2)
ACUTE LYMPHOCYTIC LEUKEMIA: Thomas D, et al. Blood. 2004; 103(12):4396-4407
Reference Information (3)
ACUTE LYMPHOCYTIC LEUKEMIA: Daver N, et al. Haematologica 2015;100(5):653-61.
Reference Information (4)
ACUTE LYMPHOCYTIC LEUKEMIA: Benjamini O, et al. Am J Hematol 2014;89(3):282-7.
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; THERAPY (Part A): dexamethasone 40 mg by mouth or IV Day 1 through 4 and Day 11
through 14, cyclophosphamide 300 mg/m2 IV every 12 hours Day 1, 2 and 3, doxorubicin 50 mg/m2 IV continuous infusion over 24
hours starting Day 3, vinCRIStine 2 mg IV Day 4 and 11, imatinib 400 mg by mouth once daily Day 1 through 14 (if Philadelphia
chromosome positive disease) OR dasatinib 100 mg by mouth once daily Days 1 through 14 (if Philadelphia chromosome positive
disease), methotrexate 12 mg IT Day 2, cytarabine 100 mg IT Day 8, hydrocortisone 30 mg IT may be given with IT chemotherapy
followed by THERAPY (Part B): methylprednisolone 50mg IV twice daily Day 1 through 3, methotrexate 200 mg/m2 IV over 2 hours
followed by 800 mg/m2 IV continuous infusion over 22 hours starting Day 1, leucovorin 50 mg/m2 IV given 36 hours after start of
methotrexate infusion followed by leucovorin 15 mg/m2 IV every 6 hours until methotrexate level is less than or equal to 0.5 uM/L
followed by leucovorin 15 mg by mouth every 6 hours until methotrexate level is less than or equal to 0.05 uM/L, cytarabine 3000
mg/m2 IV every 12 hours Day 2 and 3, imatinib 400 mg by mouth once daily Day 1 through 14 OR dasatinib 100 mg by mouth once
daily Days 1 through 14 (if Philadelphia chromosome positive disease), methotrexate 12 mg IT Day 2, cytarabine 100 mg IT Day 8,
hydrocortisone 30 mg IT may be given with IT chemotherapy; CYCLE LENGTH: 21 days; COURSE: 8 alternating cycles (A-B-A-B-
A-B-A-B); NOTE: IT chemotherapy for CNS prophylaxis will be given on Day 2 and 8 of Part A and B for a total of 4 doses for low
risk patients, a total of 8 doses for unknown risk patients or a total of 16 doses for high risk patients.
Note to All Staff (1)
If ejection fraction less than 50%, decrease DOXOrubicin to 25 mg/m2/day IV continuous infusion over 24 hours Day 2 and 3 (total
dose = 50 mg/m2 over 48 hours). If age greater than 60 years, consider decreasing cytarabine to 1000 mg/m2 IV every 12 hours
Day 2 and 3.
Note to All Staff (2)
If CSF is positive for leukemia, patient will receive twice weekly IT chemotherapy with alternating methotrexate and cytarabine until
CSF is negative for two consecutive lumbar punctures then resume intrathecal chemotherapy prophylactic regimen.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total Bilirubin, AST
Treatment Parameters
Hold treatment and notify authorizing prescriber for Total Bilirubin greater than or equal to 2 mg/dL.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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Zztestonc,Jeff J [2507481]
8/23/2016 8:35:12 AM Page 5 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org

Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Treatment Medications
vinCRIStine (ONCOVIN) 2 mg in sodium chloride 0.9 % 25 mL bag
2 mg, Intravenous, ONCE, 1 dose Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump).
See Take Home Medication(s)
Refer to the Day 1 take home medications section for the following treatment medication(s): dexamethasone
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 Hyper-CVAD (Part B) – 9/13/2016 through 10/3/2016 (21 days), Planned
Day 1 through 3 (Inpatient), Cycle 2 Hyper-CVAD (Part B) – Planned for 9/13/2016
Treatment Plan Information
Reference Information (1)
ACUTE LYMPHOCYTIC LEUKEMIA: Kantarjian H, et al. J Clin Oncol. 2000; 18(3):547-61
Reference Information (2)
ACUTE LYMPHOCYTIC LEUKEMIA: Thomas D, et al. Blood. 2004; 103(12):4396-4407
Reference Information (3)
ACUTE LYMPHOCYTIC LEUKEMIA: Daver N, et al. Haematologica 2015;100(5):653-61.
Reference Information (4)
ACUTE LYMPHOCYTIC LEUKEMIA: Benjamini O, et al. Am J Hematol 2014;89(3):282-7.
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; THERAPY (Part A): dexamethasone 40 mg by mouth or IV Day 1 through 4 and Day 11
through 14, cyclophosphamide 300 mg/m2 IV every 12 hours Day 1, 2 and 3, doxorubicin 50 mg/m2 IV continuous infusion over 24
hours starting Day 3, vinCRIStine 2 mg IV Day 4 and 11, imatinib 400 mg by mouth once daily Day 1 through 14 (if Philadelphia
chromosome positive disease) OR dasatinib 100 mg by mouth once daily Days 1 through 14 (if Philadelphia chromosome positive
disease), methotrexate 12 mg IT Day 2, cytarabine 100 mg IT Day 8, hydrocortisone 30 mg IT may be given with IT chemotherapy
followed by THERAPY (Part B): methylprednisolone 50mg IV twice daily Day 1 through 3, methotrexate 200 mg/m2 IV over 2 hours
followed by 800 mg/m2 IV continuous infusion over 22 hours starting Day 1, leucovorin 50 mg/m2 IV given 36 hours after start of
methotrexate infusion followed by leucovorin 15 mg/m2 IV every 6 hours until methotrexate level is less than or equal to 0.5 uM/L
followed by leucovorin 15 mg by mouth every 6 hours until methotrexate level is less than or equal to 0.05 uM/L, cytarabine 3000
mg/m2 IV every 12 hours Day 2 and 3, imatinib 400 mg by mouth once daily Day 1 through 14 OR dasatinib 100 mg by mouth once
daily Days 1 through 14 (if Philadelphia chromosome positive disease), methotrexate 12 mg IT Day 2, cytarabine 100 mg IT Day 8,
hydrocortisone 30 mg IT may be given with IT chemotherapy; CYCLE LENGTH: 21 days; COURSE: 8 alternating cycles (A-B-A-B-
A-B-A-B); NOTE: IT chemotherapy for CNS prophylaxis will be given on Day 2 and 8 of Part A and B for a total of 4 doses for low
risk patients, a total of 8 doses for unknown risk patients or a total of 16 doses for high risk patients.
Note to All Staff (1)
If ejection fraction less than 50%, decrease DOXOrubicin to 25 mg/m2/day IV continuous infusion over 24 hours Day 2 and 3 (total
dose = 50 mg/m2 over 48 hours). If age greater than 60 years, consider decreasing cytarabine to 1000 mg/m2 IV every 12 hours
Day 2 and 3.
Note to All Staff (2)
If CSF is positive for leukemia, patient will receive twice weekly IT chemotherapy with alternating methotrexate and cytarabine until
CSF is negative for two consecutive lumbar punctures then resume intrathecal chemotherapy prophylactic regimen.
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Zztestonc,Jeff J [2507481]
8/23/2016 8:35:12 AM Page 6 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org

Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
ONCE Starting when released, Routine
CREATININE
ONCE Starting when released, Routine
BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALT/SGPT
ONCE Starting when released
ALKALINE PHOSPHATASE
ONCE Starting when released, Routine
Additional Labs
PH, URINE (METHOTREXATE PROTOCOL)
ONCE Starting when released
Obtain pH, Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 2 HOURS Starting when released for 2 occurrences
Obtain pH, Urine (Methotrexate Protocol) at 2 hours and 4 hours after start of Methotrexate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting when released for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting S+8 at 0000 for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
CONDITIONAL - RN COLLECT Starting when released until S+7 for 7 days
If Urine pH falls below 7, obtain pH, Urine (Methotrexate Protocol) every 2 hours as needed until Urine pH is greater than or equal to
7 for two consecutive occurrences.
METHOTREXATE
ONCE Starting when released
Obtain methotrexate level 24 hours after the start of methotrexate infusion.
METHOTREXATE
NEXT AM Starting S+2 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate levels when
drug level is undetectable.
METHOTREXATE
NEXT AM Starting S+9 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate levels when
drug level is undetectable.
CREATININE
ONCE Starting when released
Obtain creatinine at 24 hours after the start of methotrexate infusion.
CREATININE
NEXT AM Starting S+2 As Scheduled for 7 days
CREATININE
NEXT AM Starting S+9 As Scheduled for 7 days
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Zztestonc,Jeff J [2507481]
8/23/2016 8:35:12 AM Page 7 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase, pH Urine
(Methotrexate Protocol).
Verify Labs (2)
Verify ongoing treatment labs: Creatinine, pH, Urine (Methotrexate Protocol) and Methotrexate levels.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Creatinine greater than 1.5 mg/dL or Creatinine Clearance less than 60 mL/min
or Total Bilirubin greater than or equal to 2 mg/dL or AST greater than 2.5 X ULN or ALT greater than 2.5 X ULN or Alkaline
Phosphatase greater than 2.5 X ULN.
Treatment Parameters (2)
Do not administer methotrexate until urine pH is greater than or equal to 7.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Check pH Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion. If less than 7, give sodium bicarbonate
50 mEq IV. See Conditional Medications.
Monitoring Parameters (2)
Check pH Urine (Methotrexate Protocol) at 2 hours, 4 hours, and 8 hours after start of methotrexate and then every 8 hours until
methotrexate level is undetectable. If less than 7, give sodium bicarbonate 50 mEq IV and check urine pH every 2 hours until urine
pH is greater than or equal to 7. See Conditional Medications and Additional Labs.
Monitoring Parameters (3)
Cytarabine: Perform neuro check prior to each dose. Monitor for cerebellar toxicity (slurred speech or ataxia) and if patient develops
signs of toxicity, hold dose and contact hematology fellow or attending physician.
Nursing Communication
CONTINUOUS Starting when released Until Specified
If sodium bicarbonate bolus given, recheck Urine pH in 2 hours. If two boluses of sodium bicarbonate have been given in 8 hours or
three boluses in 24 hours, notify pharmacy and provider to review IV fluid orders.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium bicarbonate 100 mEq in dextrose 5 % 1,000 mL infusion
Intravenous, CONTINUOUS Starting when released Until Discontinued
Begin 4 hours prior to start of methotrexate. May discontinue when methotrexate level is undetectable. Sodium Bicarbonate infusion
must NOT be interrupted for any reason without an order from the attending physician or fellow.
NOTE:
EVERY 6 HOURS Starting when released
Sodium Bicarbonate infusion must NOT be interrupted for any reason without an order from the attending physician or fellow.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, 1 X DAILY, 3 doses Starting when released
Days 1, 2 and 3. Give prior to chemotherapy. May give IV if unable to tolerate PO.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, EVERY 24 HOURS PRN, For 3 days Starting when released until S+3, nausea/vomiting
Days 1, 2 and 3. Give prior to chemotherapy if patient unable to tolerate PO.
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Zztestonc,Jeff J [2507481]
8/23/2016 8:35:12 AM Page 8 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org

prednisolone (PRED FORTE) 1 % ophthalmic susp 1 drop
1 drop, Eyes (Each), 4 X DAILY, For 2 days Starting S+1 at 0800
Day 2 and 3. Instill one drop into each eye four times daily. First dose prior to chemotherapy on Day 2.
Intrathecal Procedure Orders
LEUKEMIA/LYMPHOMA SCREEN, CSF
Expected-S+1 Approximate, Expires-S+122, Normal, Routine
methotrexate PF 12 mg in sodium chloride 0.9 % 2.4 mL intraTHECAL injection
12 mg, Intrathecal, ONCE, 1 dose Starting S+1 at 0000
Day 2: Dose to be administered by provider.
Intrathecal Procedure Orders (delete all that do not apply)
hydrocortisone sodium succinate PF (SOLU-CORTEF) 30 mg in sodium chloride 0.9 % 3 mL intraTHECAL
injection
30 mg, Intrathecal, ONCE, 1 dose Starting S+1 at 0000
Day 2: Dose to be administered by provider.
Treatment Medications
methylprednisolone sod. succ. in sodium chloride 0.9% (SOLU-MEDROL) injection 50 mg
50 mg, Intravenous, EVERY 12 HOURS, 6 doses Starting when released
methotrexate PF 400 mg in dextrose 5 % 250 mL bag
400 mg (200 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Do not start methotrexate until urine pH greater than or equal to 7.
methotrexate PF 1,600 mg in dextrose 5 % 1,000 mL bag
1,600 mg (800 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give after methotrexate bolus dose.
cytarabine PF (CYTOSAR) 6,000 mg in sodium chloride 0.9 % 250 mL bag
6,000 mg (3,000 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 12 HOURS, 4 doses Starting S+1
at 0000
Begin after completion of methotrexate. Neuro check prior to each dose. Consider decreasing dose to 1000 mg/m2 for patients
greater than 60 years of age.
leucovorin 20 MG/ML injection 100 mg
100 mg (50 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting S+1 at 0000, Administer
over 3 Minutes
Start 36 hours after the start of methotrexate infusion.
leucovorin 20 MG/ML injection 30 mg
30 mg (15 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 6 HOURS Starting S+1 at 0000,
Administer over 3 Minutes
Start 6 hours after IV leucovorin loading dose. Give every 6 hours until the serum methotrexate level is less than or equal to 0.5
µM/L, then give PO leucovorin. See PRN NOTIFY PHARMACY order.
leucovorin tab 15 mg
15 mg, Oral, PRN - NOTIFY PHARMACY WHEN NEEDED Starting S+1 at 0000 Until Discontinued, High Dose Methotrexate
Once methotrexate level is less than or equal to 0.5 µM/L, starting 6 hours after last IV leucovorin dose give 15 mg leucovorin PO
every 6 hours until serum methotrexate level is less than or equal to 0.05 µM/L
Treatment Medications (delete all that do not apply)
imatinib (GLEEVEC) tab 400 mg
400 mg, Oral, 1 X DAILY, 14 doses Starting when released
Give if patient has Philadelphia chromosome positive disease. Prior to initiating therapy, verify outpatient prescription coverage with
pharmacist.
dasatinib (SPRYCEL) tab 100 mg
100 mg, Oral, 1 X DAILY, 14 doses Starting when released
Give if patient has Philadelphia chromosome positive disease. Prior to initiating therapy, verify outpatient prescription coverage with
pharmacist.
acyclovir (ZOVIRAX) tab 400 mg
400 mg, Oral, 2 X DAILY Starting when released
fluconazole (DIFLUCAN) tab 400 mg
400 mg, Oral, 1 X DAILY Starting when released
ranitidine (ZANTAC) tab 150 mg
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Zztestonc,Jeff J [2507481]
8/23/2016 8:35:12 AM Page 9 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org

150 mg, Oral, 2 X DAILY Starting when released
Conditional Orders
sodium bicarbonate 8.4 % injection 50 mEq
50 mEq, Intravenous, EVERY 2 HOURS PRN, For 7 days Starting when released until S+7, For urine pH less than 7, Administer
over 1 Minutes
Administer over 1 to 2 minutes. Give if urine pH is less than 7. May discontinue when methotrexate level is undetectable.
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
If unable to take PO, may give IV.
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting, If unable to tolerate PO.
IV push slowly, max rate 5 mg/minute.
Take Home Medications
leucovorin 15 MG tab
Take 1 tab by mouth every 6 hours. Take until seen in clinic for follow up appt to confirm methotrexate level undetectable, 15 mg,
Disp-16 tab, R-0, EVERY 6 HOURS starting S
sulfamethoxazole-trimethoprim (BACTRIM DS) 800-160 MG per tab
Take 1 tab by mouth 2 times daily Sat,Sun. Begin when methotrexate level is undetectable., 1 tab, Disp-16 tab, R-0, 2 X DAILY
SAT, SUN starting S
Take Home Medications (delete all that do not apply)
levofloxacin (LEVAQUIN) 500 MG tab
Take 1 tab by mouth one time daily. Begin on Day ***, 500 mg, Disp-10 tab, R-0, 1 X DAILY starting S
TBO-filgrastim (GRANIX) 300 MCG/0.5ML soln prefilled syringe
Inject 300 mcg under skin one time daily in evening. Begin Day ***. Continue until ANC is greater than *** after nadir., 300 mcg,
Disp-10 Syringe, R-5, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
TBO-filgrastim (GRANIX) 480 MCG/0.8ML soln prefilled syringe
Inject 480 mcg under skin one time daily in evening. Begin Day ***. Continue until ANC is greater than *** after nadir., 480 mcg,
Disp-10 Syringe, R-5, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
Follow-Up
DAY 8 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT for intrathecal cytarabine for 60 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) Schedule preadmission to B6/6 for chemotherapy administration.
Day 8 (Outpatient), Cycle 2 Hyper-CVAD (Part B) – Planned for 9/14/2016
Treatment Plan Information
Reference Information (1)
ACUTE LYMPHOCYTIC LEUKEMIA: Kantarjian H, et al. J Clin Oncol. 2000; 18(3):547-61
Reference Information (2)
ACUTE LYMPHOCYTIC LEUKEMIA: Thomas D, et al. Blood. 2004; 103(12):4396-4407
Reference Information (3)
ACUTE LYMPHOCYTIC LEUKEMIA: Daver N, et al. Haematologica 2015;100(5):653-61.
Reference Information (4)
ACUTE LYMPHOCYTIC LEUKEMIA: Benjamini O, et al. Am J Hematol 2014;89(3):282-7.
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; THERAPY (Part A): dexamethasone 40 mg by mouth or IV Day 1 through 4 and Day 11
through 14, cyclophosphamide 300 mg/m2 IV every 12 hours Day 1, 2 and 3, doxorubicin 50 mg/m2 IV continuous infusion over 24
hours starting Day 3, vinCRIStine 2 mg IV Day 4 and 11, imatinib 400 mg by mouth once daily Day 1 through 14 (if Philadelphia
chromosome positive disease) OR dasatinib 100 mg by mouth once daily Days 1 through 14 (if Philadelphia chromosome positive
disease), methotrexate 12 mg IT Day 2, cytarabine 100 mg IT Day 8, hydrocortisone 30 mg IT may be given with IT chemotherapy
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Zztestonc,Jeff J [2507481]
8/23/2016 8:35:12 AM Page 10 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org

followed by THERAPY (Part B): methylprednisolone 50mg IV twice daily Day 1 through 3, methotrexate 200 mg/m2 IV over 2 hours
followed by 800 mg/m2 IV continuous infusion over 22 hours starting Day 1, leucovorin 50 mg/m2 IV given 36 hours after start of
methotrexate infusion followed by leucovorin 15 mg/m2 IV every 6 hours until methotrexate level is less than or equal to 0.5 uM/L
followed by leucovorin 15 mg by mouth every 6 hours until methotrexate level is less than or equal to 0.05 uM/L, cytarabine 3000
mg/m2 IV every 12 hours Day 2 and 3, imatinib 400 mg by mouth once daily Day 1 through 14 OR dasatinib 100 mg by mouth once
daily Days 1 through 14 (if Philadelphia chromosome positive disease), methotrexate 12 mg IT Day 2, cytarabine 100 mg IT Day 8,
hydrocortisone 30 mg IT may be given with IT chemotherapy; CYCLE LENGTH: 21 days; COURSE: 8 alternating cycles (A-B-A-B-
A-B-A-B); NOTE: IT chemotherapy for CNS prophylaxis will be given on Day 2 and 8 of Part A and B for a total of 4 doses for low
risk patients, a total of 8 doses for unknown risk patients or a total of 16 doses for high risk patients.
Note to All Staff (1)
If ejection fraction less than 50%, decrease DOXOrubicin to 25 mg/m2/day IV continuous infusion over 24 hours Day 2 and 3 (total
dose = 50 mg/m2 over 48 hours). If age greater than 60 years, consider decreasing cytarabine to 1000 mg/m2 IV every 12 hours
Day 2 and 3.
Note to All Staff (2)
If CSF is positive for leukemia, patient will receive twice weekly IT chemotherapy with alternating methotrexate and cytarabine until
CSF is negative for two consecutive lumbar punctures then resume intrathecal chemotherapy prophylactic regimen.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Intrathecal Procedure Orders
LEUKEMIA/LYMPHOMA SCREEN, CSF
ONCE Starting when released
cytarabine PF (CYTOSAR) 100 mg in sodium chloride 0.9 % 2 mL intraTHECAL injection
100 mg, Intrathecal, ONCE, 1 dose Starting when released
Dose to be given by provider.
Intrathecal Procedure Orders (delete all that do not apply)
hydrocortisone sodium succinate PF (SOLU-CORTEF) 30 mg in sodium chloride 0.9 % 3 mL intraTHECAL
injection
30 mg, Intrathecal, ONCE, 1 dose Starting when released
Dose to be given by provider.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 Hyper-CVAD (Part A) – 10/4/2016 through 10/24/2016 (21 days), Planned
Day 1 through 4 (Inpatient), Cycle 3 Hyper-CVAD (Part A) – Planned for 10/4/2016
Treatment Plan Information
Reference Information (1)
ACUTE LYMPHOCYTIC LEUKEMIA: Kantarjian H, et al. J Clin Oncol. 2000; 18(3):547-61
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Zztestonc,Jeff J [2507481]
8/23/2016 8:35:12 AM Page 11 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org

Reference Information (2)
ACUTE LYMPHOCYTIC LEUKEMIA: Thomas D, et al. Blood. 2004; 103(12):4396-4407
Reference Information (3)
ACUTE LYMPHOCYTIC LEUKEMIA: Daver N, et al. Haematologica 2015;100(5):653-61.
Reference Information (4)
ACUTE LYMPHOCYTIC LEUKEMIA: Benjamini O, et al. Am J Hematol 2014;89(3):282-7.
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; THERAPY (Part A): dexamethasone 40 mg by mouth or IV Day 1 through 4 and Day 11
through 14, cyclophosphamide 300 mg/m2 IV every 12 hours Day 1, 2 and 3, doxorubicin 50 mg/m2 IV continuous infusion over 24
hours starting Day 3, vinCRIStine 2 mg IV Day 4 and 11, imatinib 400 mg by mouth once daily Day 1 through 14 (if Philadelphia
chromosome positive disease) OR dasatinib 100 mg by mouth once daily Days 1 through 14 (if Philadelphia chromosome positive
disease), methotrexate 12 mg IT Day 2, cytarabine 100 mg IT Day 8, hydrocortisone 30 mg IT may be given with IT chemotherapy
followed by THERAPY (Part B): methylprednisolone 50mg IV twice daily Day 1 through 3, methotrexate 200 mg/m2 IV over 2 hours
followed by 800 mg/m2 IV continuous infusion over 22 hours starting Day 1, leucovorin 50 mg/m2 IV given 36 hours after start of
methotrexate infusion followed by leucovorin 15 mg/m2 IV every 6 hours until methotrexate level is less than or equal to 0.5 uM/L
followed by leucovorin 15 mg by mouth every 6 hours until methotrexate level is less than or equal to 0.05 uM/L, cytarabine 3000
mg/m2 IV every 12 hours Day 2 and 3, imatinib 400 mg by mouth once daily Day 1 through 14 OR dasatinib 100 mg by mouth once
daily Days 1 through 14 (if Philadelphia chromosome positive disease), methotrexate 12 mg IT Day 2, cytarabine 100 mg IT Day 8,
hydrocortisone 30 mg IT may be given with IT chemotherapy; CYCLE LENGTH: 21 days; COURSE: 8 alternating cycles (A-B-A-B-
A-B-A-B); NOTE: IT chemotherapy for CNS prophylaxis will be given on Day 2 and 8 of Part A and B for a total of 4 doses for low
risk patients, a total of 8 doses for unknown risk patients or a total of 16 doses for high risk patients.
Note to All Staff (1)
If ejection fraction less than 50%, decrease DOXOrubicin to 25 mg/m2/day IV continuous infusion over 24 hours Day 2 and 3 (total
dose = 50 mg/m2 over 48 hours). If age greater than 60 years, consider decreasing cytarabine to 1000 mg/m2 IV every 12 hours
Day 2 and 3.
Note to All Staff (2)
If CSF is positive for leukemia, patient will receive twice weekly IT chemotherapy with alternating methotrexate and cytarabine until
CSF is negative for two consecutive lumbar punctures then resume intrathecal chemotherapy prophylactic regimen.
Consent
Verify Consent
Verify informed consent has been obtained.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total Bilirubin, AST
Treatment Parameters
Hold treatment and notify authorizing prescriber for Total Bilirubin greater than or equal to 2 mg/dL.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 100 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
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Zztestonc,Jeff J [2507481]
8/23/2016 8:35:12 AM Page 12 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org

16 mg, Oral, 1 X DAILY, 4 doses Starting when released
Give prior to chemotherapy. May give IV if unable to tolerate PO. If DOXOrubicin given over 48 hours, add 1 dose for a total of 5
doses.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, EVERY 24 HOURS PRN, For 4 days Starting when released until S+4, nausea/vomiting
Give prior to chemotherapy if patient unable to tolerate PO.
Intrathecal Procedure Orders
LEUKEMIA/LYMPHOMA SCREEN, CSF
Expected-S+1 Approximate, Expires-S+122, Normal, Routine
methotrexate PF 12 mg in sodium chloride 0.9 % 2.4 mL intraTHECAL injection
12 mg, Intrathecal, ONCE, 1 dose Starting S+1 at 0000
Day 2: Dose to be administered by provider.
Intrathecal Procedure Orders (delete all that do not apply)
hydrocortisone sodium succinate PF (SOLU-CORTEF) 30 mg in sodium chloride 0.9 % 3 mL intraTHECAL
injection
30 mg, Intrathecal, ONCE, 1 dose Starting S+1 at 0000
Day 2: Dose to be administered by provider.
Treatment Medications
dexamethasone (DECADRON) tab 40 mg
40 mg, Oral, 1 X DAILY, 4 doses Starting when released
Give prior to chemotherapy. May give IV if patient unable to tolerate PO.
dexamethasone (DECADRON) 40 mg in sodium chloride 0.9 % 50 mL bag
40 mg, Intravenous, 1 X DAILY PRN, For 5 days Starting when released until S+4 at 2359,
Give prior to chemotherapy if patient unable to tolerate PO.
cyclophosphamide (CYTOXAN) 600 mg in sodium chloride 0.9 % 250 mL bag
600 mg (300 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 12 HOURS, 6 doses Starting when
released
doxorubicin CONVENTIONAL (ADRIAMYCIN) 100 mg in sodium chloride 0.9 % 500 mL infusion
100 mg (50 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting S+2 at 0000
Give after completion of last dose of cyclophosphamide. If ejection fraction is less than 50%, decrease dose to 25 mg/m2 IV
continuous infusion over 24 hours on Day 2 and 3 (total dose = 50 mg/m2 over 48 hours).
vinCRIStine (ONCOVIN) 2 mg in sodium chloride 0.9 % 25 mL bag
2 mg, Intravenous, ONCE, 1 dose Starting S+3 at 0000
MUST be administered via gravity through a peripheral IV (not on an infusion pump).
Treatment Medications (delete all that do not apply)
imatinib (GLEEVEC) tab 400 mg
400 mg, Oral, 1 X DAILY, 14 doses Starting when released
Give if patient has Philadelphia chromosome positive disease. Prior to initiating therapy, verify outpatient prescription coverage with
pharmacist.
dasatinib (SPRYCEL) tab 100 mg
100 mg, Oral, 1 X DAILY, 14 doses Starting when released
Give if patient has Philadelphia chromosome positive disease. Prior to initiating therapy, verify outpatient prescription coverage with
pharmacist.
acyclovir (ZOVIRAX) tab 400 mg
400 mg, Oral, 2 X DAILY Starting when released
fluconazole (DIFLUCAN) tab 400 mg
400 mg, Oral, 1 X DAILY Starting when released
sulfamethoxazole-trimethoprim (BACTRIM DS) 800-160 MG per tab 1 tab
1 tab, Oral, 2 X DAILY SAT, SUN Starting when released
ranitidine (ZANTAC) tab 150 mg
150 mg, Oral, 2 X DAILY Starting when released
senna-docusate (SENOKOT S) 8.6-50 MG per tab 2 tab
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Zztestonc,Jeff J [2507481]
8/23/2016 8:35:12 AM Page 13 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org

2 tab, Oral, 1 X DAILY (HS) Starting when released
Hold for loose stools
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
If unable to take PO, may give IV.
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting, If unable to tolerate PO.
IV push slowly, max rate 5 mg/minute.
Take Home Medications
sodium bicarbonate oral powder
Mix 1/2 teaspoon sodium bicarbonate oral powder (baking soda) in 6-8 ounces of a non-acidic fluid and drink by mouth at 8 AM, 12
PM, 4 PM, 10 PM the day before methotrexate treatment and at 8 AM the morning of methotrexate treatment., Disp-1 Bottle, R-0,
starting S, No Print
dexamethasone (DECADRON) 4 MG tab
Take 10 tabs by mouth one time daily. Take on Day 11 through 14., 40 mg, Disp-40 tab, R-0, 1 X DAILY starting S
Take Home Medications (delete all that do not apply)
levofloxacin (LEVAQUIN) 500 MG tab
Take 1 tab by mouth one time daily. Begin on Day ***, 500 mg, Disp-10 tab, R-0, 1 X DAILY starting S
TBO-filgrastim (GRANIX) 300 MCG/0.5ML soln prefilled syringe
Inject 300 mcg under skin one time daily in evening. Begin Day ***. Continue until ANC is greater than *** after nadir., 300 mcg,
Disp-10 Syringe, R-5, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
TBO-filgrastim (GRANIX) 480 MCG/0.8ML soln prefilled syringe
Inject 480 mcg under skin one time daily in evening. Begin Day ***. Continue until ANC is greater than *** after nadir., 480 mcg,
Disp-10 Syringe, R-5, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
Follow-Up
DAY 8 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT for intrathecal cytarabine for 60 minutes.
DAY 11 FOLLOW-UP
LABS: CBC with DIFF; CHEMO ROOM APPOINTMENT: vinCRIStine for 30 minutes
DAY 22 FOLLOW-UP
(Day 1 of next cycle) Schedule preadmission to B6/6 for chemotherapy administration.
Day 8 (Outpatient), Cycle 3 Hyper-CVAD (Part A) – Planned for 10/5/2016
Treatment Plan Information
Reference Information (1)
ACUTE LYMPHOCYTIC LEUKEMIA: Kantarjian H, et al. J Clin Oncol. 2000; 18(3):547-61
Reference Information (2)
ACUTE LYMPHOCYTIC LEUKEMIA: Thomas D, et al. Blood. 2004; 103(12):4396-4407
Reference Information (3)
ACUTE LYMPHOCYTIC LEUKEMIA: Daver N, et al. Haematologica 2015;100(5):653-61.
Reference Information (4)
ACUTE LYMPHOCYTIC LEUKEMIA: Benjamini O, et al. Am J Hematol 2014;89(3):282-7.
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; THERAPY (Part A): dexamethasone 40 mg by mouth or IV Day 1 through 4 and Day 11
through 14, cyclophosphamide 300 mg/m2 IV every 12 hours Day 1, 2 and 3, doxorubicin 50 mg/m2 IV continuous infusion over 24
hours starting Day 3, vinCRIStine 2 mg IV Day 4 and 11, imatinib 400 mg by mouth once daily Day 1 through 14 (if Philadelphia
chromosome positive disease) OR dasatinib 100 mg by mouth once daily Days 1 through 14 (if Philadelphia chromosome positive
disease), methotrexate 12 mg IT Day 2, cytarabine 100 mg IT Day 8, hydrocortisone 30 mg IT may be given with IT chemotherapy
followed by THERAPY (Part B): methylprednisolone 50mg IV twice daily Day 1 through 3, methotrexate 200 mg/m2 IV over 2 hours
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Zztestonc,Jeff J [2507481]
8/23/2016 8:35:12 AM Page 14 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org

followed by 800 mg/m2 IV continuous infusion over 22 hours starting Day 1, leucovorin 50 mg/m2 IV given 36 hours after start of
methotrexate infusion followed by leucovorin 15 mg/m2 IV every 6 hours until methotrexate level is less than or equal to 0.5 uM/L
followed by leucovorin 15 mg by mouth every 6 hours until methotrexate level is less than or equal to 0.05 uM/L, cytarabine 3000
mg/m2 IV every 12 hours Day 2 and 3, imatinib 400 mg by mouth once daily Day 1 through 14 OR dasatinib 100 mg by mouth once
daily Days 1 through 14 (if Philadelphia chromosome positive disease), methotrexate 12 mg IT Day 2, cytarabine 100 mg IT Day 8,
hydrocortisone 30 mg IT may be given with IT chemotherapy; CYCLE LENGTH: 21 days; COURSE: 8 alternating cycles (A-B-A-B-
A-B-A-B); NOTE: IT chemotherapy for CNS prophylaxis will be given on Day 2 and 8 of Part A and B for a total of 4 doses for low
risk patients, a total of 8 doses for unknown risk patients or a total of 16 doses for high risk patients.
Note to All Staff (1)
If ejection fraction less than 50%, decrease DOXOrubicin to 25 mg/m2/day IV continuous infusion over 24 hours Day 2 and 3 (total
dose = 50 mg/m2 over 48 hours). If age greater than 60 years, consider decreasing cytarabine to 1000 mg/m2 IV every 12 hours
Day 2 and 3.
Note to All Staff (2)
If CSF is positive for leukemia, patient will receive twice weekly IT chemotherapy with alternating methotrexate and cytarabine until
CSF is negative for two consecutive lumbar punctures then resume intrathecal chemotherapy prophylactic regimen.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Intrathecal Procedure Orders
LEUKEMIA/LYMPHOMA SCREEN, CSF
ONCE Starting when released
cytarabine PF (CYTOSAR) 100 mg in sodium chloride 0.9 % 2 mL intraTHECAL injection
100 mg, Intrathecal, ONCE, 1 dose Starting when released
Dose to be given by provider.
Intrathecal Procedure Orders (delete all that do not apply)
hydrocortisone sodium succinate PF (SOLU-CORTEF) 30 mg in sodium chloride 0.9 % 3 mL intraTHECAL
injection
30 mg, Intrathecal, ONCE, 1 dose Starting when released
Dose to be given by provider.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 11 (Outpatient), Cycle 3 Hyper-CVAD (Part A) – Planned for 10/14/2016
Treatment Plan Information
Reference Information (1)
ACUTE LYMPHOCYTIC LEUKEMIA: Kantarjian H, et al. J Clin Oncol. 2000; 18(3):547-61
Reference Information (2)
ACUTE LYMPHOCYTIC LEUKEMIA: Thomas D, et al. Blood. 2004; 103(12):4396-4407
Reference Information (3)
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Zztestonc,Jeff J [2507481]
8/23/2016 8:35:12 AM Page 15 of 44
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org

ACUTE LYMPHOCYTIC LEUKEMIA: Daver N, et al. Haematologica 2015;100(5):653-61.
Reference Information (4)
ACUTE LYMPHOCYTIC LEUKEMIA: Benjamini O, et al. Am J Hematol 2014;89(3):282-7.
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; THERAPY (Part A): dexamethasone 40 mg by mouth or IV Day 1 through 4 and Day 11
through 14, cyclophosphamide 300 mg/m2 IV every 12 hours Day 1, 2 and 3, doxorubicin 50 mg/m2 IV continuous infusion over 24
hours starting Day 3, vinCRIStine 2 mg IV Day 4 and 11, imatinib 400 mg by mouth once daily Day 1 through 14 (if Philadelphia
chromosome positive disease) OR dasatinib 100 mg by mouth once daily Days 1 through 14 (if Philadelphia chromosome positive
disease), methotrexate 12 mg IT Day 2, cytarabine 100 mg IT Day 8, hydrocortisone 30 mg IT may be given with IT chemotherapy
followed by THERAPY (Part B): methylprednisolone 50mg IV twice daily Day 1 through 3, methotrexate 200 mg/m2 IV over 2 hours
followed by 800 mg/m2 IV continuous infusion over 22 hours starting Day 1, leucovorin 50 mg/m2 IV given 36 hours after start of
methotrexate infusion followed by leucovorin 15 mg/m2 IV every 6 hours until methotrexate level is less than or equal to 0.5 uM/L
followed by leucovorin 15 mg by mouth every 6 hours until methotrexate level is less than or equal to 0.05 uM/L, cytarabine 3000
mg/m2 IV every 12 hours Day 2 and 3, imatinib 400 mg by mouth once daily Day 1 through 14 OR dasatinib 100 mg by mouth once
daily Days 1 through 14 (if Philadelphia chromosome positive disease), methotrexate 12 mg IT Day 2, cytarabine 100 mg IT Day 8,
hydrocortisone 30 mg IT may be given with IT chemotherapy; CYCLE LENGTH: 21 days; COURSE: 8 alternating cycles (A-B-A-B-
A-B-A-B); NOTE: IT chemotherapy for CNS prophylaxis will be given on Day 2 and 8 of Part A and B for a total of 4 doses for low
risk patients, a total of 8 doses for unknown risk patients or a total of 16 doses for high risk patients.
Note to All Staff (1)
If ejection fraction less than 50%, decrease DOXOrubicin to 25 mg/m2/day IV continuous infusion over 24 hours Day 2 and 3 (total
dose = 50 mg/m2 over 48 hours). If age greater than 60 years, consider decreasing cytarabine to 1000 mg/m2 IV every 12 hours
Day 2 and 3.
Note to All Staff (2)
If CSF is positive for leukemia, patient will receive twice weekly IT chemotherapy with alternating methotrexate and cytarabine until
CSF is negative for two consecutive lumbar punctures then resume intrathecal chemotherapy prophylactic regimen.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total Bilirubin, AST
Treatment Parameters
Hold treatment and notify authorizing prescriber for Total Bilirubin greater than or equal to 2 mg/dL.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
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Zztestonc,Jeff J [2507481]
8/23/2016 8:35:12 AM Page 16 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org

at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Treatment Medications
vinCRIStine (ONCOVIN) 2 mg in sodium chloride 0.9 % 25 mL bag
2 mg, Intravenous, ONCE, 1 dose Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump).
See Take Home Medication(s)
Refer to the Day 1 take home medications section for the following treatment medication(s): dexamethasone
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 Hyper-CVAD (Part B) – 10/25/2016 through 11/14/2016 (21 days), Planned
Day 1 through 3 (Inpatient), Cycle 4 Hyper-CVAD (Part B) – Planned for 10/25/2016
Treatment Plan Information
Reference Information (1)
ACUTE LYMPHOCYTIC LEUKEMIA: Kantarjian H, et al. J Clin Oncol. 2000; 18(3):547-61
Reference Information (2)
ACUTE LYMPHOCYTIC LEUKEMIA: Thomas D, et al. Blood. 2004; 103(12):4396-4407
Reference Information (3)
ACUTE LYMPHOCYTIC LEUKEMIA: Daver N, et al. Haematologica 2015;100(5):653-61.
Reference Information (4)
ACUTE LYMPHOCYTIC LEUKEMIA: Benjamini O, et al. Am J Hematol 2014;89(3):282-7.
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; THERAPY (Part A): dexamethasone 40 mg by mouth or IV Day 1 through 4 and Day 11
through 14, cyclophosphamide 300 mg/m2 IV every 12 hours Day 1, 2 and 3, doxorubicin 50 mg/m2 IV continuous infusion over 24
hours starting Day 3, vinCRIStine 2 mg IV Day 4 and 11, imatinib 400 mg by mouth once daily Day 1 through 14 (if Philadelphia
chromosome positive disease) OR dasatinib 100 mg by mouth once daily Days 1 through 14 (if Philadelphia chromosome positive
disease), methotrexate 12 mg IT Day 2, cytarabine 100 mg IT Day 8, hydrocortisone 30 mg IT may be given with IT chemotherapy
followed by THERAPY (Part B): methylprednisolone 50mg IV twice daily Day 1 through 3, methotrexate 200 mg/m2 IV over 2 hours
followed by 800 mg/m2 IV continuous infusion over 22 hours starting Day 1, leucovorin 50 mg/m2 IV given 36 hours after start of
methotrexate infusion followed by leucovorin 15 mg/m2 IV every 6 hours until methotrexate level is less than or equal to 0.5 uM/L
followed by leucovorin 15 mg by mouth every 6 hours until methotrexate level is less than or equal to 0.05 uM/L, cytarabine 3000
mg/m2 IV every 12 hours Day 2 and 3, imatinib 400 mg by mouth once daily Day 1 through 14 OR dasatinib 100 mg by mouth once
daily Days 1 through 14 (if Philadelphia chromosome positive disease), methotrexate 12 mg IT Day 2, cytarabine 100 mg IT Day 8,
hydrocortisone 30 mg IT may be given with IT chemotherapy; CYCLE LENGTH: 21 days; COURSE: 8 alternating cycles (A-B-A-B-
A-B-A-B); NOTE: IT chemotherapy for CNS prophylaxis will be given on Day 2 and 8 of Part A and B for a total of 4 doses for low
risk patients, a total of 8 doses for unknown risk patients or a total of 16 doses for high risk patients.
Note to All Staff (1)
If ejection fraction less than 50%, decrease DOXOrubicin to 25 mg/m2/day IV continuous infusion over 24 hours Day 2 and 3 (total
dose = 50 mg/m2 over 48 hours). If age greater than 60 years, consider decreasing cytarabine to 1000 mg/m2 IV every 12 hours
Day 2 and 3.
Note to All Staff (2)
If CSF is positive for leukemia, patient will receive twice weekly IT chemotherapy with alternating methotrexate and cytarabine until
CSF is negative for two consecutive lumbar punctures then resume intrathecal chemotherapy prophylactic regimen.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
ONCE Starting when released, Routine
CREATININE
ONCE Starting when released, Routine
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Zztestonc,Jeff J [2507481]
8/23/2016 8:35:12 AM Page 17 of 44
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org

BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALT/SGPT
ONCE Starting when released
ALKALINE PHOSPHATASE
ONCE Starting when released, Routine
Additional Labs
PH, URINE (METHOTREXATE PROTOCOL)
ONCE Starting when released
Obtain pH, Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 2 HOURS Starting when released for 2 occurrences
Obtain pH, Urine (Methotrexate Protocol) at 2 hours and 4 hours after start of Methotrexate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting when released for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting S+8 at 0000 for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
CONDITIONAL - RN COLLECT Starting when released until S+7 for 7 days
If Urine pH falls below 7, obtain pH, Urine (Methotrexate Protocol) every 2 hours as needed until Urine pH is greater than or equal to
7 for two consecutive occurrences.
METHOTREXATE
ONCE Starting when released
Obtain methotrexate level 24 hours after the start of methotrexate infusion.
METHOTREXATE
NEXT AM Starting S+2 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate levels when
drug level is undetectable.
METHOTREXATE
NEXT AM Starting S+9 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate levels when
drug level is undetectable.
CREATININE
ONCE Starting when released
Obtain creatinine at 24 hours after the start of methotrexate infusion.
CREATININE
NEXT AM Starting S+2 As Scheduled for 7 days
CREATININE
NEXT AM Starting S+9 As Scheduled for 7 days
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase, pH Urine
(Methotrexate Protocol).
Verify Labs (2)
Verify ongoing treatment labs: Creatinine, pH, Urine (Methotrexate Protocol) and Methotrexate levels.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Creatinine greater than 1.5 mg/dL or Creatinine Clearance less than 60 mL/min
or Total Bilirubin greater than or equal to 2 mg/dL or AST greater than 2.5 X ULN or ALT greater than 2.5 X ULN or Alkaline
Phosphatase greater than 2.5 X ULN.
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Zztestonc,Jeff J [2507481]
8/23/2016 8:35:12 AM Page 18 of 44
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org

Treatment Parameters (2)
Do not administer methotrexate until urine pH is greater than or equal to 7.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Check pH Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion. If less than 7, give sodium bicarbonate
50 mEq IV. See Conditional Medications.
Monitoring Parameters (2)
Check pH Urine (Methotrexate Protocol) at 2 hours, 4 hours, and 8 hours after start of methotrexate and then every 8 hours until
methotrexate level is undetectable. If less than 7, give sodium bicarbonate 50 mEq IV and check urine pH every 2 hours until urine
pH is greater than or equal to 7. See Conditional Medications and Additional Labs.
Monitoring Parameters (3)
Cytarabine: Perform neuro check prior to each dose. Monitor for cerebellar toxicity (slurred speech or ataxia) and if patient develops
signs of toxicity, hold dose and contact hematology fellow or attending physician.
Nursing Communication
CONTINUOUS Starting when released Until Specified
If sodium bicarbonate bolus given, recheck Urine pH in 2 hours. If two boluses of sodium bicarbonate have been given in 8 hours or
three boluses in 24 hours, notify pharmacy and provider to review IV fluid orders.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium bicarbonate 100 mEq in dextrose 5 % 1,000 mL infusion
Intravenous, CONTINUOUS Starting when released Until Discontinued
Begin 4 hours prior to start of methotrexate. May discontinue when methotrexate level is undetectable. Sodium Bicarbonate infusion
must NOT be interrupted for any reason without an order from the attending physician or fellow.
NOTE:
EVERY 6 HOURS Starting when released
Sodium Bicarbonate infusion must NOT be interrupted for any reason without an order from the attending physician or fellow.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, 1 X DAILY, 3 doses Starting when released
Days 1, 2 and 3. Give prior to chemotherapy. May give IV if unable to tolerate PO.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, EVERY 24 HOURS PRN, For 3 days Starting when released until S+3, nausea/vomiting
Days 1, 2 and 3. Give prior to chemotherapy if patient unable to tolerate PO.
prednisolone (PRED FORTE) 1 % ophthalmic susp 1 drop
1 drop, Eyes (Each), 4 X DAILY, For 2 days Starting S+1 at 0800
Day 2 and 3. Instill one drop into each eye four times daily. First dose prior to chemotherapy on Day 2.
Intrathecal Procedure Orders
LEUKEMIA/LYMPHOMA SCREEN, CSF
Expected-S+1 Approximate, Expires-S+122, Normal, Routine
methotrexate PF 12 mg in sodium chloride 0.9 % 2.4 mL intraTHECAL injection
12 mg, Intrathecal, ONCE, 1 dose Starting S+1 at 0000
Day 2: Dose to be administered by provider.
Intrathecal Procedure Orders (delete all that do not apply)
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8/23/2016 8:35:12 AM Page 19 of 44
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org

hydrocortisone sodium succinate PF (SOLU-CORTEF) 30 mg in sodium chloride 0.9 % 3 mL intraTHECAL
injection
30 mg, Intrathecal, ONCE, 1 dose Starting S+1 at 0000
Day 2: Dose to be administered by provider.
Treatment Medications
methylprednisolone sod. succ. in sodium chloride 0.9% (SOLU-MEDROL) injection 50 mg
50 mg, Intravenous, EVERY 12 HOURS, 6 doses Starting when released
methotrexate PF 400 mg in dextrose 5 % 250 mL bag
400 mg (200 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Do not start methotrexate until urine pH greater than or equal to 7.
methotrexate PF 1,600 mg in dextrose 5 % 1,000 mL bag
1,600 mg (800 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give after methotrexate bolus dose.
cytarabine PF (CYTOSAR) 6,000 mg in sodium chloride 0.9 % 250 mL bag
6,000 mg (3,000 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 12 HOURS, 4 doses Starting S+1
at 0000
Begin after completion of methotrexate. Neuro check prior to each dose. Consider decreasing dose to 1000 mg/m2 for patients
greater than 60 years of age.
leucovorin 20 MG/ML injection 100 mg
100 mg (50 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting S+1 at 0000, Administer
over 3 Minutes
Start 36 hours after the start of methotrexate infusion.
leucovorin 20 MG/ML injection 30 mg
30 mg (15 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 6 HOURS Starting S+1 at 0000,
Administer over 3 Minutes
Start 6 hours after IV leucovorin loading dose. Give every 6 hours until the serum methotrexate level is less than or equal to 0.5
µM/L, then give PO leucovorin. See PRN NOTIFY PHARMACY order.
leucovorin tab 15 mg
15 mg, Oral, PRN - NOTIFY PHARMACY WHEN NEEDED Starting S+1 at 0000 Until Discontinued, High Dose Methotrexate
Once methotrexate level is less than or equal to 0.5 µM/L, starting 6 hours after last IV leucovorin dose give 15 mg leucovorin PO
every 6 hours until serum methotrexate level is less than or equal to 0.05 µM/L
Treatment Medications (delete all that do not apply)
imatinib (GLEEVEC) tab 400 mg
400 mg, Oral, 1 X DAILY, 14 doses Starting when released
Give if patient has Philadelphia chromosome positive disease. Prior to initiating therapy, verify outpatient prescription coverage with
pharmacist.
dasatinib (SPRYCEL) tab 100 mg
100 mg, Oral, 1 X DAILY, 14 doses Starting when released
Give if patient has Philadelphia chromosome positive disease. Prior to initiating therapy, verify outpatient prescription coverage with
pharmacist.
acyclovir (ZOVIRAX) tab 400 mg
400 mg, Oral, 2 X DAILY Starting when released
fluconazole (DIFLUCAN) tab 400 mg
400 mg, Oral, 1 X DAILY Starting when released
ranitidine (ZANTAC) tab 150 mg
150 mg, Oral, 2 X DAILY Starting when released
Conditional Orders
sodium bicarbonate 8.4 % injection 50 mEq
50 mEq, Intravenous, EVERY 2 HOURS PRN, For 7 days Starting when released until S+7, For urine pH less than 7, Administer
over 1 Minutes
Administer over 1 to 2 minutes. Give if urine pH is less than 7. May discontinue when methotrexate level is undetectable.
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
If unable to take PO, may give IV.
prochlorperazine (COMPAZINE) injection 10 mg
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Zztestonc,Jeff J [2507481]
8/23/2016 8:35:12 AM Page 20 of 44
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10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting, If unable to tolerate PO.
IV push slowly, max rate 5 mg/minute.
Take Home Medications
leucovorin 15 MG tab
Take 1 tab by mouth every 6 hours. Take until seen in clinic for follow up appt to confirm methotrexate level undetectable, 15 mg,
Disp-16 tab, R-0, EVERY 6 HOURS starting S
sulfamethoxazole-trimethoprim (BACTRIM DS) 800-160 MG per tab
Take 1 tab by mouth 2 times daily Sat,Sun. Begin when methotrexate level is undetectable., 1 tab, Disp-16 tab, R-0, 2 X DAILY
SAT, SUN starting S
Take Home Medications (delete all that do not apply)
levofloxacin (LEVAQUIN) 500 MG tab
Take 1 tab by mouth one time daily. Begin on Day ***, 500 mg, Disp-10 tab, R-0, 1 X DAILY starting S
TBO-filgrastim (GRANIX) 300 MCG/0.5ML soln prefilled syringe
Inject 300 mcg under skin one time daily in evening. Begin Day ***. Continue until ANC is greater than *** after nadir., 300 mcg,
Disp-10 Syringe, R-5, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
TBO-filgrastim (GRANIX) 480 MCG/0.8ML soln prefilled syringe
Inject 480 mcg under skin one time daily in evening. Begin Day ***. Continue until ANC is greater than *** after nadir., 480 mcg,
Disp-10 Syringe, R-5, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
Follow-Up
DAY 8 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT for intrathecal cytarabine for 60 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) Schedule preadmission to B6/6 for chemotherapy administration.
Day 8 (Outpatient), Cycle 4 Hyper-CVAD (Part B) – Planned for 10/26/2016
Treatment Plan Information
Reference Information (1)
ACUTE LYMPHOCYTIC LEUKEMIA: Kantarjian H, et al. J Clin Oncol. 2000; 18(3):547-61
Reference Information (2)
ACUTE LYMPHOCYTIC LEUKEMIA: Thomas D, et al. Blood. 2004; 103(12):4396-4407
Reference Information (3)
ACUTE LYMPHOCYTIC LEUKEMIA: Daver N, et al. Haematologica 2015;100(5):653-61.
Reference Information (4)
ACUTE LYMPHOCYTIC LEUKEMIA: Benjamini O, et al. Am J Hematol 2014;89(3):282-7.
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; THERAPY (Part A): dexamethasone 40 mg by mouth or IV Day 1 through 4 and Day 11
through 14, cyclophosphamide 300 mg/m2 IV every 12 hours Day 1, 2 and 3, doxorubicin 50 mg/m2 IV continuous infusion over 24
hours starting Day 3, vinCRIStine 2 mg IV Day 4 and 11, imatinib 400 mg by mouth once daily Day 1 through 14 (if Philadelphia
chromosome positive disease) OR dasatinib 100 mg by mouth once daily Days 1 through 14 (if Philadelphia chromosome positive
disease), methotrexate 12 mg IT Day 2, cytarabine 100 mg IT Day 8, hydrocortisone 30 mg IT may be given with IT chemotherapy
followed by THERAPY (Part B): methylprednisolone 50mg IV twice daily Day 1 through 3, methotrexate 200 mg/m2 IV over 2 hours
followed by 800 mg/m2 IV continuous infusion over 22 hours starting Day 1, leucovorin 50 mg/m2 IV given 36 hours after start of
methotrexate infusion followed by leucovorin 15 mg/m2 IV every 6 hours until methotrexate level is less than or equal to 0.5 uM/L
followed by leucovorin 15 mg by mouth every 6 hours until methotrexate level is less than or equal to 0.05 uM/L, cytarabine 3000
mg/m2 IV every 12 hours Day 2 and 3, imatinib 400 mg by mouth once daily Day 1 through 14 OR dasatinib 100 mg by mouth once
daily Days 1 through 14 (if Philadelphia chromosome positive disease), methotrexate 12 mg IT Day 2, cytarabine 100 mg IT Day 8,
hydrocortisone 30 mg IT may be given with IT chemotherapy; CYCLE LENGTH: 21 days; COURSE: 8 alternating cycles (A-B-A-B-
A-B-A-B); NOTE: IT chemotherapy for CNS prophylaxis will be given on Day 2 and 8 of Part A and B for a total of 4 doses for low
risk patients, a total of 8 doses for unknown risk patients or a total of 16 doses for high risk patients.
Note to All Staff (1)
If ejection fraction less than 50%, decrease DOXOrubicin to 25 mg/m2/day IV continuous infusion over 24 hours Day 2 and 3 (total
dose = 50 mg/m2 over 48 hours). If age greater than 60 years, consider decreasing cytarabine to 1000 mg/m2 IV every 12 hours
Day 2 and 3.
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Zztestonc,Jeff J [2507481]
8/23/2016 8:35:12 AM Page 21 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org

Note to All Staff (2)
If CSF is positive for leukemia, patient will receive twice weekly IT chemotherapy with alternating methotrexate and
cytarabine until CSF is negative for two consecutive lumbar punctures then resume intrathecal chemotherapy
prophylactic regimen.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Intrathecal Procedure Orders
LEUKEMIA/LYMPHOMA SCREEN, CSF
ONCE Starting when released
cytarabine PF (CYTOSAR) 100 mg in sodium chloride 0.9 % 2 mL intraTHECAL injection
100 mg, Intrathecal, ONCE, 1 dose Starting when released
Dose to be given by provider.
Intrathecal Procedure Orders (delete all that do not apply)
hydrocortisone sodium succinate PF (SOLU-CORTEF) 30 mg in sodium chloride 0.9 % 3 mL intraTHECAL
injection
30 mg, Intrathecal, ONCE, 1 dose Starting when released
Dose to be given by provider.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 Hyper-CVAD (Part A) – 11/15/2016 through 12/5/2016 (21 days), Planned
Day 1 through 4 (Inpatient), Cycle 5 Hyper-CVAD (Part A) – Planned for 11/15/2016
Treatment Plan Information
Reference Information (1)
ACUTE LYMPHOCYTIC LEUKEMIA: Kantarjian H, et al. J Clin Oncol. 2000; 18(3):547-61
Reference Information (2)
ACUTE LYMPHOCYTIC LEUKEMIA: Thomas D, et al. Blood. 2004; 103(12):4396-4407
Reference Information (3)
ACUTE LYMPHOCYTIC LEUKEMIA: Daver N, et al. Haematologica 2015;100(5):653-61.
Reference Information (4)
ACUTE LYMPHOCYTIC LEUKEMIA: Benjamini O, et al. Am J Hematol 2014;89(3):282-7.
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; THERAPY (Part A): dexamethasone 40 mg by mouth or IV Day 1 through 4 and Day 11
through 14, cyclophosphamide 300 mg/m2 IV every 12 hours Day 1, 2 and 3, doxorubicin 50 mg/m2 IV continuous infusion over 24
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Zztestonc,Jeff J [2507481]
8/23/2016 8:35:12 AM Page 22 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org

hours starting Day 3, vinCRIStine 2 mg IV Day 4 and 11, imatinib 400 mg by mouth once daily Day 1 through 14 (if Philadelphia
chromosome positive disease) OR dasatinib 100 mg by mouth once daily Days 1 through 14 (if Philadelphia chromosome positive
disease), methotrexate 12 mg IT Day 2, cytarabine 100 mg IT Day 8, hydrocortisone 30 mg IT may be given with IT chemotherapy
followed by THERAPY (Part B): methylprednisolone 50mg IV twice daily Day 1 through 3, methotrexate 200 mg/m2 IV over 2 hours
followed by 800 mg/m2 IV continuous infusion over 22 hours starting Day 1, leucovorin 50 mg/m2 IV given 36 hours after start of
methotrexate infusion followed by leucovorin 15 mg/m2 IV every 6 hours until methotrexate level is less than or equal to 0.5 uM/L
followed by leucovorin 15 mg by mouth every 6 hours until methotrexate level is less than or equal to 0.05 uM/L, cytarabine 3000
mg/m2 IV every 12 hours Day 2 and 3, imatinib 400 mg by mouth once daily Day 1 through 14 OR dasatinib 100 mg by mouth once
daily Days 1 through 14 (if Philadelphia chromosome positive disease), methotrexate 12 mg IT Day 2, cytarabine 100 mg IT Day 8,
hydrocortisone 30 mg IT may be given with IT chemotherapy; CYCLE LENGTH: 21 days; COURSE: 8 alternating cycles (A-B-A-B-
A-B-A-B); NOTE: IT chemotherapy for CNS prophylaxis will be given on Day 2 and 8 of Part A and B for a total of 4 doses for low
risk patients, a total of 8 doses for unknown risk patients or a total of 16 doses for high risk patients.
Note to All Staff (1)
If ejection fraction less than 50%, decrease DOXOrubicin to 25 mg/m2/day IV continuous infusion over 24 hours Day 2 and 3 (total
dose = 50 mg/m2 over 48 hours). If age greater than 60 years, consider decreasing cytarabine to 1000 mg/m2 IV every 12 hours
Day 2 and 3.
Note to All Staff (2)
If CSF is positive for leukemia, patient will receive twice weekly IT chemotherapy with alternating methotrexate and cytarabine until
CSF is negative for two consecutive lumbar punctures then resume intrathecal chemotherapy prophylactic regimen.
Consent
Verify Consent
Verify informed consent has been obtained.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total Bilirubin, AST
Treatment Parameters
Hold treatment and notify authorizing prescriber for Total Bilirubin greater than or equal to 2 mg/dL.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 100 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, 1 X DAILY, 4 doses Starting when released
Give prior to chemotherapy. May give IV if unable to tolerate PO. If DOXOrubicin given over 48 hours, add 1 dose for a total of 5
doses.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, EVERY 24 HOURS PRN, For 4 days Starting when released until S+4, nausea/vomiting
Give prior to chemotherapy if patient unable to tolerate PO.
Intrathecal Procedure Orders (delete all that do not apply)
LEUKEMIA/LYMPHOMA SCREEN, CSF
Expected-S+1 Approximate, Expires-S+122, Normal, Routine
methotrexate PF 12 mg in sodium chloride 0.9 % 2.4 mL intraTHECAL injection
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Zztestonc,Jeff J [2507481]
8/23/2016 8:35:12 AM Page 23 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org

12 mg, Intrathecal, ONCE, 1 dose Starting S+1 at 0000
Day 2: Only give if patient is HIGH RISK. Dose to be administered by provider.
hydrocortisone sodium succinate PF (SOLU-CORTEF) 30 mg in sodium chloride 0.9 % 3 mL intraTHECAL
injection
30 mg, Intrathecal, ONCE, 1 dose Starting S+1 at 0000
Day 2: Only give if patient is HIGH RISK. Dose to be administered by provider.
Treatment Medications
dexamethasone (DECADRON) tab 40 mg
40 mg, Oral, 1 X DAILY, 4 doses Starting when released
Give prior to chemotherapy. May give IV if patient unable to tolerate PO.
dexamethasone (DECADRON) 40 mg in sodium chloride 0.9 % 50 mL bag
40 mg, Intravenous, 1 X DAILY PRN, For 5 days Starting when released until S+4 at 2359,
Give prior to chemotherapy if patient unable to tolerate PO.
cyclophosphamide (CYTOXAN) 600 mg in sodium chloride 0.9 % 250 mL bag
600 mg (300 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 12 HOURS, 6 doses Starting when
released
doxorubicin CONVENTIONAL (ADRIAMYCIN) 100 mg in sodium chloride 0.9 % 500 mL infusion
100 mg (50 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting S+2 at 0000
Give after completion of last dose of cyclophosphamide. If ejection fraction is less than 50%, decrease dose to 25 mg/m2 IV
continuous infusion over 24 hours on Day 2 and 3 (total dose = 50 mg/m2 over 48 hours).
vinCRIStine (ONCOVIN) 2 mg in sodium chloride 0.9 % 25 mL bag
2 mg, Intravenous, ONCE, 1 dose Starting S+3 at 0000
MUST be administered via gravity through a peripheral IV (not on an infusion pump).
Treatment Medications (delete all that do not apply)
imatinib (GLEEVEC) tab 400 mg
400 mg, Oral, 1 X DAILY, 14 doses Starting when released
Give if patient has Philadelphia chromosome positive disease. Prior to initiating therapy, verify outpatient prescription coverage with
pharmacist.
dasatinib (SPRYCEL) tab 100 mg
100 mg, Oral, 1 X DAILY, 14 doses Starting when released
Give if patient has Philadelphia chromosome positive disease. Prior to initiating therapy, verify outpatient prescription coverage with
pharmacist.
allopurinol (ZYLOPRIM) tab 300 mg
300 mg, Oral, 1 X DAILY, 7 doses Starting when released
acyclovir (ZOVIRAX) tab 400 mg
400 mg, Oral, 2 X DAILY Starting when released
fluconazole (DIFLUCAN) tab 400 mg
400 mg, Oral, 1 X DAILY Starting when released
sulfamethoxazole-trimethoprim (BACTRIM DS) 800-160 MG per tab 1 tab
1 tab, Oral, 2 X DAILY SAT, SUN Starting when released
ranitidine (ZANTAC) tab 150 mg
150 mg, Oral, 2 X DAILY Starting when released
senna-docusate (SENOKOT S) 8.6-50 MG per tab 2 tab
2 tab, Oral, 1 X DAILY (HS) Starting when released
Hold for loose stools
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
If unable to take PO, may give IV.
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting, If unable to tolerate PO.
IV push slowly, max rate 5 mg/minute.
Take Home Medications
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Zztestonc,Jeff J [2507481]
8/23/2016 8:35:12 AM Page 24 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org

sodium bicarbonate oral powder
Mix 1/2 teaspoon sodium bicarbonate oral powder (baking soda) in 6-8 ounces of a non-acidic fluid and drink by mouth at 8 AM, 12
PM, 4 PM, 10 PM the day before methotrexate treatment and at 8 AM the morning of methotrexate treatment., Disp-1 Bottle, R-0,
starting S, No Print
dexamethasone (DECADRON) 4 MG tab
Take 10 tabs by mouth one time daily. Take on Day 11 through 14., 40 mg, Disp-40 tab, R-0, 1 X DAILY starting S
Take Home Medications (delete all that do not apply)
levofloxacin (LEVAQUIN) 500 MG tab
Take 1 tab by mouth one time daily. Begin on Day ***, 500 mg, Disp-10 tab, R-0, 1 X DAILY starting S
TBO-filgrastim (GRANIX) 300 MCG/0.5ML soln prefilled syringe
Inject 300 mcg under skin one time daily in evening. Begin Day ***. Continue until ANC is greater than *** after nadir., 300 mcg,
Disp-10 Syringe, R-5, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
TBO-filgrastim (GRANIX) 480 MCG/0.8ML soln prefilled syringe
Inject 480 mcg under skin one time daily in evening. Begin Day ***. Continue until ANC is greater than *** after nadir., 480 mcg,
Disp-10 Syringe, R-5, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
Follow-Up
DAY 8 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT for intrathecal cytarabine for 60 minutes.
DAY 11 FOLLOW-UP
LABS: CBC with DIFF; CHEMO ROOM APPOINTMENT: vinCRIStine for 30 minutes
DAY 22 FOLLOW-UP
(Day 1 of next cycle) Schedule preadmission to B6/6 for chemotherapy administration.
Day 8 (Outpatient), Cycle 5 Hyper-CVAD (Part A) – Planned for 11/16/2016
Treatment Plan Information
Reference Information (1)
ACUTE LYMPHOCYTIC LEUKEMIA: Kantarjian H, et al. J Clin Oncol. 2000; 18(3):547-61
Reference Information (2)
ACUTE LYMPHOCYTIC LEUKEMIA: Thomas D, et al. Blood. 2004; 103(12):4396-4407
Reference Information (3)
ACUTE LYMPHOCYTIC LEUKEMIA: Daver N, et al. Haematologica 2015;100(5):653-61.
Reference Information (4)
ACUTE LYMPHOCYTIC LEUKEMIA: Benjamini O, et al. Am J Hematol 2014;89(3):282-7.
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; THERAPY (Part A): dexamethasone 40 mg by mouth or IV Day 1 through 4 and Day 11
through 14, cyclophosphamide 300 mg/m2 IV every 12 hours Day 1, 2 and 3, doxorubicin 50 mg/m2 IV continuous infusion over 24
hours starting Day 3, vinCRIStine 2 mg IV Day 4 and 11, imatinib 400 mg by mouth once daily Day 1 through 14 (if Philadelphia
chromosome positive disease) OR dasatinib 100 mg by mouth once daily Days 1 through 14 (if Philadelphia chromosome positive
disease), methotrexate 12 mg IT Day 2, cytarabine 100 mg IT Day 8, hydrocortisone 30 mg IT may be given with IT chemotherapy
followed by THERAPY (Part B): methylprednisolone 50mg IV twice daily Day 1 through 3, methotrexate 200 mg/m2 IV over 2 hours
followed by 800 mg/m2 IV continuous infusion over 22 hours starting Day 1, leucovorin 50 mg/m2 IV given 36 hours after start of
methotrexate infusion followed by leucovorin 15 mg/m2 IV every 6 hours until methotrexate level is less than or equal to 0.5 uM/L
followed by leucovorin 15 mg by mouth every 6 hours until methotrexate level is less than or equal to 0.05 uM/L, cytarabine 3000
mg/m2 IV every 12 hours Day 2 and 3, imatinib 400 mg by mouth once daily Day 1 through 14 OR dasatinib 100 mg by mouth once
daily Days 1 through 14 (if Philadelphia chromosome positive disease), methotrexate 12 mg IT Day 2, cytarabine 100 mg IT Day 8,
hydrocortisone 30 mg IT may be given with IT chemotherapy; CYCLE LENGTH: 21 days; COURSE: 8 alternating cycles (A-B-A-B-
A-B-A-B); NOTE: IT chemotherapy for CNS prophylaxis will be given on Day 2 and 8 of Part A and B for a total of 4 doses for low
risk patients, a total of 8 doses for unknown risk patients or a total of 16 doses for high risk patients.
Note to All Staff (1)
If ejection fraction less than 50%, decrease DOXOrubicin to 25 mg/m2/day IV continuous infusion over 24 hours Day 2 and 3 (total
dose = 50 mg/m2 over 48 hours). If age greater than 60 years, consider decreasing cytarabine to 1000 mg/m2 IV every 12 hours
Day 2 and 3.
Note to All Staff (2)
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Zztestonc,Jeff J [2507481]
8/23/2016 8:35:12 AM Page 25 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org

If CSF is positive for leukemia, patient will receive twice weekly IT chemotherapy with alternating methotrexate and cytarabine until
CSF is negative for two consecutive lumbar punctures then resume intrathecal chemotherapy prophylactic regimen.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Intrathecal Procedure Orders (delete all that do not apply)
LEUKEMIA/LYMPHOMA SCREEN, CSF
ONCE Starting when released
cytarabine PF (CYTOSAR) 100 mg in sodium chloride 0.9 % 2 mL intraTHECAL injection
100 mg, Intrathecal, ONCE, 1 dose Starting when released
Only give if patient is HIGH RISK. Dose to be given by provider.
hydrocortisone sodium succinate PF (SOLU-CORTEF) 30 mg in sodium chloride 0.9 % 3 mL intraTHECAL
injection
30 mg, Intrathecal, ONCE, 1 dose Starting when released
Only give if patient is HIGH RISK. Dose to be given by provider.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 11 (Outpatient), Cycle 5 Hyper-CVAD (Part A) – Planned for 11/25/2016
Treatment Plan Information
Reference Information (1)
ACUTE LYMPHOCYTIC LEUKEMIA: Kantarjian H, et al. J Clin Oncol. 2000; 18(3):547-61
Reference Information (2)
ACUTE LYMPHOCYTIC LEUKEMIA: Thomas D, et al. Blood. 2004; 103(12):4396-4407
Reference Information (3)
ACUTE LYMPHOCYTIC LEUKEMIA: Daver N, et al. Haematologica 2015;100(5):653-61.
Reference Information (4)
ACUTE LYMPHOCYTIC LEUKEMIA: Benjamini O, et al. Am J Hematol 2014;89(3):282-7.
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; THERAPY (Part A): dexamethasone 40 mg by mouth or IV Day 1 through 4 and Day 11
through 14, cyclophosphamide 300 mg/m2 IV every 12 hours Day 1, 2 and 3, doxorubicin 50 mg/m2 IV continuous infusion over 24
hours starting Day 3, vinCRIStine 2 mg IV Day 4 and 11, imatinib 400 mg by mouth once daily Day 1 through 14 (if Philadelphia
chromosome positive disease) OR dasatinib 100 mg by mouth once daily Days 1 through 14 (if Philadelphia chromosome positive
disease), methotrexate 12 mg IT Day 2, cytarabine 100 mg IT Day 8, hydrocortisone 30 mg IT may be given with IT chemotherapy
followed by THERAPY (Part B): methylprednisolone 50mg IV twice daily Day 1 through 3, methotrexate 200 mg/m2 IV over 2 hours
followed by 800 mg/m2 IV continuous infusion over 22 hours starting Day 1, leucovorin 50 mg/m2 IV given 36 hours after start of
methotrexate infusion followed by leucovorin 15 mg/m2 IV every 6 hours until methotrexate level is less than or equal to 0.5 uM/L
followed by leucovorin 15 mg by mouth every 6 hours until methotrexate level is less than or equal to 0.05 uM/L, cytarabine 3000
mg/m2 IV every 12 hours Day 2 and 3, imatinib 400 mg by mouth once daily Day 1 through 14 OR dasatinib 100 mg by mouth once
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Zztestonc,Jeff J [2507481]
8/23/2016 8:35:12 AM Page 26 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org

daily Days 1 through 14 (if Philadelphia chromosome positive disease), methotrexate 12 mg IT Day 2, cytarabine 100 mg IT Day 8,
hydrocortisone 30 mg IT may be given with IT chemotherapy; CYCLE LENGTH: 21 days; COURSE: 8 alternating cycles (A-B-A-B-
A-B-A-B); NOTE: IT chemotherapy for CNS prophylaxis will be given on Day 2 and 8 of Part A and B for a total of 4 doses for low
risk patients, a total of 8 doses for unknown risk patients or a total of 16 doses for high risk patients.
Note to All Staff (1)
If ejection fraction less than 50%, decrease DOXOrubicin to 25 mg/m2/day IV continuous infusion over 24 hours Day 2 and 3 (total
dose = 50 mg/m2 over 48 hours). If age greater than 60 years, consider decreasing cytarabine to 1000 mg/m2 IV every 12 hours
Day 2 and 3.
Note to All Staff (2)
If CSF is positive for leukemia, patient will receive twice weekly IT chemotherapy with alternating methotrexate and cytarabine until
CSF is negative for two consecutive lumbar punctures then resume intrathecal chemotherapy prophylactic regimen.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total Bilirubin, AST
Treatment Parameters
Hold treatment and notify authorizing prescriber for Total Bilirubin greater than or equal to 2 mg/dL.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Treatment Medications
vinCRIStine (ONCOVIN) 2 mg in sodium chloride 0.9 % 25 mL bag
2 mg, Intravenous, ONCE, 1 dose Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump).
See Take Home Medication(s)
Refer to the Day 1 take home medications section for the following treatment medication(s): dexamethasone
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Jeff J [2507481]
8/23/2016 8:35:12 AM Page 27 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org

Cycle 6 Hyper-CVAD (Part B) – 12/6/2016 through 12/26/2016 (21 days), Planned
Day 1 through 3 (Inpatient), Cycle 6 Hyper-CVAD (Part B) – Planned for 12/6/2016
Treatment Plan Information
Reference Information (1)
ACUTE LYMPHOCYTIC LEUKEMIA: Kantarjian H, et al. J Clin Oncol. 2000; 18(3):547-61
Reference Information (2)
ACUTE LYMPHOCYTIC LEUKEMIA: Thomas D, et al. Blood. 2004; 103(12):4396-4407
Reference Information (3)
ACUTE LYMPHOCYTIC LEUKEMIA: Daver N, et al. Haematologica 2015;100(5):653-61.
Reference Information (4)
ACUTE LYMPHOCYTIC LEUKEMIA: Benjamini O, et al. Am J Hematol 2014;89(3):282-7.
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; THERAPY (Part A): dexamethasone 40 mg by mouth or IV Day 1 through 4 and Day 11
through 14, cyclophosphamide 300 mg/m2 IV every 12 hours Day 1, 2 and 3, doxorubicin 50 mg/m2 IV continuous infusion over 24
hours starting Day 3, vinCRIStine 2 mg IV Day 4 and 11, imatinib 400 mg by mouth once daily Day 1 through 14 (if Philadelphia
chromosome positive disease) OR dasatinib 100 mg by mouth once daily Days 1 through 14 (if Philadelphia chromosome positive
disease), methotrexate 12 mg IT Day 2, cytarabine 100 mg IT Day 8, hydrocortisone 30 mg IT may be given with IT chemotherapy
followed by THERAPY (Part B): methylprednisolone 50mg IV twice daily Day 1 through 3, methotrexate 200 mg/m2 IV over 2 hours
followed by 800 mg/m2 IV continuous infusion over 22 hours starting Day 1, leucovorin 50 mg/m2 IV given 36 hours after start of
methotrexate infusion followed by leucovorin 15 mg/m2 IV every 6 hours until methotrexate level is less than or equal to 0.5 uM/L
followed by leucovorin 15 mg by mouth every 6 hours until methotrexate level is less than or equal to 0.05 uM/L, cytarabine 3000
mg/m2 IV every 12 hours Day 2 and 3, imatinib 400 mg by mouth once daily Day 1 through 14 OR dasatinib 100 mg by mouth once
daily Days 1 through 14 (if Philadelphia chromosome positive disease), methotrexate 12 mg IT Day 2, cytarabine 100 mg IT Day 8,
hydrocortisone 30 mg IT may be given with IT chemotherapy; CYCLE LENGTH: 21 days; COURSE: 8 alternating cycles (A-B-A-B-
A-B-A-B); NOTE: IT chemotherapy for CNS prophylaxis will be given on Day 2 and 8 of Part A and B for a total of 4 doses for low
risk patients, a total of 8 doses for unknown risk patients or a total of 16 doses for high risk patients.
Note to All Staff (1)
If ejection fraction less than 50%, decrease DOXOrubicin to 25 mg/m2/day IV continuous infusion over 24 hours Day 2 and 3 (total
dose = 50 mg/m2 over 48 hours). If age greater than 60 years, consider decreasing cytarabine to 1000 mg/m2 IV every 12 hours
Day 2 and 3.
Note to All Staff (2)
If CSF is positive for leukemia, patient will receive twice weekly IT chemotherapy with alternating methotrexate and cytarabine until
CSF is negative for two consecutive lumbar punctures then resume intrathecal chemotherapy prophylactic regimen.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
ONCE Starting when released, Routine
CREATININE
ONCE Starting when released, Routine
BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALT/SGPT
ONCE Starting when released
ALKALINE PHOSPHATASE
ONCE Starting when released, Routine
Additional Labs
PH, URINE (METHOTREXATE PROTOCOL)
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Zztestonc,Jeff J [2507481]
8/23/2016 8:35:12 AM Page 28 of 44
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ONCE Starting when released
Obtain pH, Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 2 HOURS Starting when released for 2 occurrences
Obtain pH, Urine (Methotrexate Protocol) at 2 hours and 4 hours after start of Methotrexate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting when released for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting S+8 at 0000 for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
CONDITIONAL - RN COLLECT Starting when released until S+7 for 7 days
If Urine pH falls below 7, obtain pH, Urine (Methotrexate Protocol) every 2 hours as needed until Urine pH is greater than or equal to
7 for two consecutive occurrences.
METHOTREXATE
ONCE Starting when released
Obtain methotrexate level 24 hours after the start of methotrexate infusion.
METHOTREXATE
NEXT AM Starting S+2 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate levels when
drug level is undetectable.
METHOTREXATE
NEXT AM Starting S+9 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate levels when
drug level is undetectable.
CREATININE
ONCE Starting when released
Obtain creatinine at 24 hours after the start of methotrexate infusion.
CREATININE
NEXT AM Starting S+2 As Scheduled for 7 days
CREATININE
NEXT AM Starting S+9 As Scheduled for 7 days
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase, pH Urine
(Methotrexate Protocol).
Verify Labs (2)
Verify ongoing treatment labs: Creatinine, pH, Urine (Methotrexate Protocol) and Methotrexate levels.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Creatinine greater than 1.5 mg/dL or Creatinine Clearance less than 60 mL/min
or Total Bilirubin greater than or equal to 2 mg/dL or AST greater than 2.5 X ULN or ALT greater than 2.5 X ULN or Alkaline
Phosphatase greater than 2.5 X ULN.
Treatment Parameters (2)
Do not administer methotrexate until urine pH is greater than or equal to 7.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Check pH Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion. If less than 7, give sodium bicarbonate
50 mEq IV. See Conditional Medications.
Monitoring Parameters (2)
Check pH Urine (Methotrexate Protocol) at 2 hours, 4 hours, and 8 hours after start of methotrexate and then every 8 hours until
methotrexate level is undetectable. If less than 7, give sodium bicarbonate 50 mEq IV and check urine pH every 2 hours until urine
pH is greater than or equal to 7. See Conditional Medications and Additional Labs.
Monitoring Parameters (3)
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Zztestonc,Jeff J [2507481]
8/23/2016 8:35:12 AM Page 29 of 44
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org

Cytarabine: Perform neuro check prior to each dose. Monitor for cerebellar toxicity (slurred speech or ataxia) and if patient develops
signs of toxicity, hold dose and contact hematology fellow or attending physician.
Nursing Communication
CONTINUOUS Starting when released Until Specified
If sodium bicarbonate bolus given, recheck Urine pH in 2 hours. If two boluses of sodium bicarbonate have been given in 8 hours or
three boluses in 24 hours, notify pharmacy and provider to review IV fluid orders.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium bicarbonate 100 mEq in dextrose 5 % 1,000 mL infusion
Intravenous, CONTINUOUS Starting when released Until Discontinued
Begin 4 hours prior to start of methotrexate. May discontinue when methotrexate level is undetectable. Sodium Bicarbonate infusion
must NOT be interrupted for any reason without an order from the attending physician or fellow.
NOTE:
EVERY 6 HOURS Starting when released
Sodium Bicarbonate infusion must NOT be interrupted for any reason without an order from the attending physician or fellow.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, 1 X DAILY, 3 doses Starting when released
Days 1, 2 and 3. Give prior to chemotherapy. May give IV if unable to tolerate PO.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, EVERY 24 HOURS PRN, For 3 days Starting when released until S+3, nausea/vomiting
Days 1, 2 and 3. Give prior to chemotherapy if patient unable to tolerate PO.
prednisolone (PRED FORTE) 1 % ophthalmic susp 1 drop
1 drop, Eyes (Each), 4 X DAILY, For 2 days Starting S+1 at 0800
Day 2 and 3. Instill one drop into each eye four times daily. First dose prior to chemotherapy on Day 2.
Intrathecal Procedure Orders (delete all that do not apply)
LEUKEMIA/LYMPHOMA SCREEN, CSF
Expected-S+1 Approximate, Expires-S+122, Normal, Routine
methotrexate PF 12 mg in sodium chloride 0.9 % 2.4 mL intraTHECAL injection
12 mg, Intrathecal, ONCE, 1 dose Starting S+1 at 0000
Day 2: Only give if patient is HIGH RISK. Dose to be administered by provider.
hydrocortisone sodium succinate PF (SOLU-CORTEF) 30 mg in sodium chloride 0.9 % 3 mL intraTHECAL
injection
30 mg, Intrathecal, ONCE, 1 dose Starting S+1 at 0000
Day 2: Only give if patient is HIGH RISK. Dose to be administered by provider.
Treatment Medications
methylprednisolone sod. succ. in sodium chloride 0.9% (SOLU-MEDROL) injection 50 mg
50 mg, Intravenous, EVERY 12 HOURS, 6 doses Starting when released
methotrexate PF 400 mg in dextrose 5 % 250 mL bag
400 mg (200 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Do not start methotrexate until urine pH greater than or equal to 7.
methotrexate PF 1,600 mg in dextrose 5 % 1,000 mL bag
1,600 mg (800 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give after methotrexate bolus dose.
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Zztestonc,Jeff J [2507481]
8/23/2016 8:35:12 AM Page 30 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org

cytarabine PF (CYTOSAR) 6,000 mg in sodium chloride 0.9 % 250 mL bag
6,000 mg (3,000 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 12 HOURS, 4 doses Starting S+1
at 0000
Begin after completion of methotrexate. Neuro check prior to each dose. Consider decreasing dose to 1000 mg/m2 for patients
greater than 60 years of age.
leucovorin 20 MG/ML injection 100 mg
100 mg (50 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting S+1 at 0000, Administer
over 3 Minutes
Start 36 hours after the start of methotrexate infusion.
leucovorin 20 MG/ML injection 30 mg
30 mg (15 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 6 HOURS Starting S+1 at 0000,
Administer over 3 Minutes
Start 6 hours after IV leucovorin loading dose. Give every 6 hours until the serum methotrexate level is less than or equal to 0.5
µM/L, then give PO leucovorin. See PRN NOTIFY PHARMACY order.
leucovorin tab 15 mg
15 mg, Oral, PRN - NOTIFY PHARMACY WHEN NEEDED Starting S+1 at 0000 Until Discontinued, High Dose Methotrexate
Once methotrexate level is less than or equal to 0.5 µM/L, starting 6 hours after last IV leucovorin dose give 15 mg leucovorin PO
every 6 hours until serum methotrexate level is less than or equal to 0.05 µM/L
Treatment Medications (delete all that do not apply)
imatinib (GLEEVEC) tab 400 mg
400 mg, Oral, 1 X DAILY, 14 doses Starting when released
Give if patient has Philadelphia chromosome positive disease. Prior to initiating therapy, verify outpatient prescription coverage with
pharmacist.
dasatinib (SPRYCEL) tab 100 mg
100 mg, Oral, 1 X DAILY, 14 doses Starting when released
Give if patient has Philadelphia chromosome positive disease. Prior to initiating therapy, verify outpatient prescription coverage with
pharmacist.
acyclovir (ZOVIRAX) tab 400 mg
400 mg, Oral, 2 X DAILY Starting when released
fluconazole (DIFLUCAN) tab 400 mg
400 mg, Oral, 1 X DAILY Starting when released
ranitidine (ZANTAC) tab 150 mg
150 mg, Oral, 2 X DAILY Starting when released
Conditional Orders
sodium bicarbonate 8.4 % injection 50 mEq
50 mEq, Intravenous, EVERY 2 HOURS PRN, For 7 days Starting when released until S+7, For urine pH less than 7, Administer
over 1 Minutes
Administer over 1 to 2 minutes. Give if urine pH is less than 7. May discontinue when methotrexate level is undetectable.
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
If unable to take PO, may give IV.
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting, If unable to tolerate PO.
IV push slowly, max rate 5 mg/minute.
Take Home Medications
leucovorin 15 MG tab
Take 1 tab by mouth every 6 hours. Take until seen in clinic for follow up appt to confirm methotrexate level undetectable, 15 mg,
Disp-16 tab, R-0, EVERY 6 HOURS starting S
sulfamethoxazole-trimethoprim (BACTRIM DS) 800-160 MG per tab
Take 1 tab by mouth 2 times daily Sat,Sun. Begin when methotrexate level is undetectable., 1 tab, Disp-16 tab, R-0, 2 X DAILY
SAT, SUN starting S
Take Home Medications (delete all that do not apply)
levofloxacin (LEVAQUIN) 500 MG tab
Take 1 tab by mouth one time daily. Begin on Day ***, 500 mg, Disp-10 tab, R-0, 1 X DAILY starting S
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Zztestonc,Jeff J [2507481]
8/23/2016 8:35:12 AM Page 31 of 44
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org

TBO-filgrastim (GRANIX) 300 MCG/0.5ML soln prefilled syringe
Inject 300 mcg under skin one time daily in evening. Begin Day ***. Continue until ANC is greater than *** after
nadir., 300 mcg, Disp-10 Syringe, R-5, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
TBO-filgrastim (GRANIX) 480 MCG/0.8ML soln prefilled syringe
Inject 480 mcg under skin one time daily in evening. Begin Day ***. Continue until ANC is greater than *** after nadir., 480 mcg,
Disp-10 Syringe, R-5, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
Follow-Up
DAY 8 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT for intrathecal cytarabine for 60 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) Schedule preadmission to B6/6 for chemotherapy administration.
Day 8 (Outpatient), Cycle 6 Hyper-CVAD (Part B) – Planned for 12/7/2016
Treatment Plan Information
Reference Information (1)
ACUTE LYMPHOCYTIC LEUKEMIA: Kantarjian H, et al. J Clin Oncol. 2000; 18(3):547-61
Reference Information (2)
ACUTE LYMPHOCYTIC LEUKEMIA: Thomas D, et al. Blood. 2004; 103(12):4396-4407
Reference Information (3)
ACUTE LYMPHOCYTIC LEUKEMIA: Daver N, et al. Haematologica 2015;100(5):653-61.
Reference Information (4)
ACUTE LYMPHOCYTIC LEUKEMIA: Benjamini O, et al. Am J Hematol 2014;89(3):282-7.
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; THERAPY (Part A): dexamethasone 40 mg by mouth or IV Day 1 through 4 and Day 11
through 14, cyclophosphamide 300 mg/m2 IV every 12 hours Day 1, 2 and 3, doxorubicin 50 mg/m2 IV continuous infusion over 24
hours starting Day 3, vinCRIStine 2 mg IV Day 4 and 11, imatinib 400 mg by mouth once daily Day 1 through 14 (if Philadelphia
chromosome positive disease) OR dasatinib 100 mg by mouth once daily Days 1 through 14 (if Philadelphia chromosome positive
disease), methotrexate 12 mg IT Day 2, cytarabine 100 mg IT Day 8, hydrocortisone 30 mg IT may be given with IT chemotherapy
followed by THERAPY (Part B): methylprednisolone 50mg IV twice daily Day 1 through 3, methotrexate 200 mg/m2 IV over 2 hours
followed by 800 mg/m2 IV continuous infusion over 22 hours starting Day 1, leucovorin 50 mg/m2 IV given 36 hours after start of
methotrexate infusion followed by leucovorin 15 mg/m2 IV every 6 hours until methotrexate level is less than or equal to 0.5 uM/L
followed by leucovorin 15 mg by mouth every 6 hours until methotrexate level is less than or equal to 0.05 uM/L, cytarabine 3000
mg/m2 IV every 12 hours Day 2 and 3, imatinib 400 mg by mouth once daily Day 1 through 14 OR dasatinib 100 mg by mouth once
daily Days 1 through 14 (if Philadelphia chromosome positive disease), methotrexate 12 mg IT Day 2, cytarabine 100 mg IT Day 8,
hydrocortisone 30 mg IT may be given with IT chemotherapy; CYCLE LENGTH: 21 days; COURSE: 8 alternating cycles (A-B-A-B-
A-B-A-B); NOTE: IT chemotherapy for CNS prophylaxis will be given on Day 2 and 8 of Part A and B for a total of 4 doses for low
risk patients, a total of 8 doses for unknown risk patients or a total of 16 doses for high risk patients.
Note to All Staff (1)
If ejection fraction less than 50%, decrease DOXOrubicin to 25 mg/m2/day IV continuous infusion over 24 hours Day 2 and 3 (total
dose = 50 mg/m2 over 48 hours). If age greater than 60 years, consider decreasing cytarabine to 1000 mg/m2 IV every 12 hours
Day 2 and 3.
Note to All Staff (2)
If CSF is positive for leukemia, patient will receive twice weekly IT chemotherapy with alternating methotrexate and cytarabine until
CSF is negative for two consecutive lumbar punctures then resume intrathecal chemotherapy prophylactic regimen.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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Zztestonc,Jeff J [2507481]
8/23/2016 8:35:12 AM Page 32 of 44
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org

Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Intrathecal Procedure Orders (delete all that do not apply)
LEUKEMIA/LYMPHOMA SCREEN, CSF
ONCE Starting when released
cytarabine PF (CYTOSAR) 100 mg in sodium chloride 0.9 % 2 mL intraTHECAL injection
100 mg, Intrathecal, ONCE, 1 dose Starting when released
Only give if patient is HIGH RISK. Dose to be given by provider.
hydrocortisone sodium succinate PF (SOLU-CORTEF) 30 mg in sodium chloride 0.9 % 3 mL intraTHECAL
injection
30 mg, Intrathecal, ONCE, 1 dose Starting when released
Only give if patient is HIGH RISK. Dose to be given by provider.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 7 Hyper-CVAD (Part A) – 12/27/2016 through 1/16/2017 (21 days), Planned
Day 1 through 4 (Inpatient), Cycle 7 Hyper-CVAD (Part A) – Planned for 12/27/2016
Treatment Plan Information
Reference Information (1)
ACUTE LYMPHOCYTIC LEUKEMIA: Kantarjian H, et al. J Clin Oncol. 2000; 18(3):547-61
Reference Information (2)
ACUTE LYMPHOCYTIC LEUKEMIA: Thomas D, et al. Blood. 2004; 103(12):4396-4407
Reference Information (3)
ACUTE LYMPHOCYTIC LEUKEMIA: Daver N, et al. Haematologica 2015;100(5):653-61.
Reference Information (4)
ACUTE LYMPHOCYTIC LEUKEMIA: Benjamini O, et al. Am J Hematol 2014;89(3):282-7.
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; THERAPY (Part A): dexamethasone 40 mg by mouth or IV Day 1 through 4 and Day 11
through 14, cyclophosphamide 300 mg/m2 IV every 12 hours Day 1, 2 and 3, doxorubicin 50 mg/m2 IV continuous infusion over 24
hours starting Day 3, vinCRIStine 2 mg IV Day 4 and 11, imatinib 400 mg by mouth once daily Day 1 through 14 (if Philadelphia
chromosome positive disease) OR dasatinib 100 mg by mouth once daily Days 1 through 14 (if Philadelphia chromosome positive
disease), methotrexate 12 mg IT Day 2, cytarabine 100 mg IT Day 8, hydrocortisone 30 mg IT may be given with IT chemotherapy
followed by THERAPY (Part B): methylprednisolone 50mg IV twice daily Day 1 through 3, methotrexate 200 mg/m2 IV over 2 hours
followed by 800 mg/m2 IV continuous infusion over 22 hours starting Day 1, leucovorin 50 mg/m2 IV given 36 hours after start of
methotrexate infusion followed by leucovorin 15 mg/m2 IV every 6 hours until methotrexate level is less than or equal to 0.5 uM/L
followed by leucovorin 15 mg by mouth every 6 hours until methotrexate level is less than or equal to 0.05 uM/L, cytarabine 3000
mg/m2 IV every 12 hours Day 2 and 3, imatinib 400 mg by mouth once daily Day 1 through 14 OR dasatinib 100 mg by mouth once
daily Days 1 through 14 (if Philadelphia chromosome positive disease), methotrexate 12 mg IT Day 2, cytarabine 100 mg IT Day 8,
hydrocortisone 30 mg IT may be given with IT chemotherapy; CYCLE LENGTH: 21 days; COURSE: 8 alternating cycles (A-B-A-B-
A-B-A-B); NOTE: IT chemotherapy for CNS prophylaxis will be given on Day 2 and 8 of Part A and B for a total of 4 doses for low
risk patients, a total of 8 doses for unknown risk patients or a total of 16 doses for high risk patients.
Note to All Staff (1)
If ejection fraction less than 50%, decrease DOXOrubicin to 25 mg/m2/day IV continuous infusion over 24 hours Day 2 and 3 (total
dose = 50 mg/m2 over 48 hours). If age greater than 60 years, consider decreasing cytarabine to 1000 mg/m2 IV every 12 hours
Day 2 and 3.
Note to All Staff (2)
If CSF is positive for leukemia, patient will receive twice weekly IT chemotherapy with alternating methotrexate and cytarabine until
CSF is negative for two consecutive lumbar punctures then resume intrathecal chemotherapy prophylactic regimen.
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Zztestonc,Jeff J [2507481]
8/23/2016 8:35:12 AM Page 33 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org

Consent
Verify Consent
Verify informed consent has been obtained.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total Bilirubin, AST
Treatment Parameters
Hold treatment and notify authorizing prescriber for Total Bilirubin greater than or equal to 2 mg/dL.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 100 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, 1 X DAILY, 4 doses Starting when released
Give prior to chemotherapy. May give IV if unable to tolerate PO. If DOXOrubicin given over 48 hours, add 1 dose for a total of 5
doses.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, EVERY 24 HOURS PRN, For 4 days Starting when released until S+4, nausea/vomiting
Give prior to chemotherapy if patient unable to tolerate PO.
Intrathecal Procedure Orders (delete all that do not apply)
LEUKEMIA/LYMPHOMA SCREEN, CSF
Expected-S+1 Approximate, Expires-S+122, Normal, Routine
methotrexate PF 12 mg in sodium chloride 0.9 % 2.4 mL intraTHECAL injection
12 mg, Intrathecal, ONCE, 1 dose Starting S+1 at 0000
Day 2: Only give if patient is HIGH RISK. Dose to be administered by provider.
hydrocortisone sodium succinate PF (SOLU-CORTEF) 30 mg in sodium chloride 0.9 % 3 mL intraTHECAL
injection
30 mg, Intrathecal, ONCE, 1 dose Starting S+1 at 0000
Day 2: Only give if patient is HIGH RISK. Dose to be administered by provider.
Treatment Medications
dexamethasone (DECADRON) tab 40 mg
40 mg, Oral, 1 X DAILY, 4 doses Starting when released
Give prior to chemotherapy. May give IV if patient unable to tolerate PO.
dexamethasone (DECADRON) 40 mg in sodium chloride 0.9 % 50 mL bag
40 mg, Intravenous, 1 X DAILY PRN, For 5 days Starting when released until S+4 at 2359,
Give prior to chemotherapy if patient unable to tolerate PO.
cyclophosphamide (CYTOXAN) 600 mg in sodium chloride 0.9 % 250 mL bag
600 mg (300 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 12 HOURS, 6 doses Starting when
released
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Zztestonc,Jeff J [2507481]
8/23/2016 8:35:12 AM Page 34 of 44
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org

doxorubicin CONVENTIONAL (ADRIAMYCIN) 100 mg in sodium chloride 0.9 % 500 mL infusion
100 mg (50 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting S+2 at 0000
Give after completion of last dose of cyclophosphamide. If ejection fraction is less than 50%, decrease dose to 25 mg/m2 IV
continuous infusion over 24 hours on Day 2 and 3 (total dose = 50 mg/m2 over 48 hours).
vinCRIStine (ONCOVIN) 2 mg in sodium chloride 0.9 % 25 mL bag
2 mg, Intravenous, ONCE, 1 dose Starting S+3 at 0000
MUST be administered via gravity through a peripheral IV (not on an infusion pump).
Treatment Medications (delete all that do not apply)
imatinib (GLEEVEC) tab 400 mg
400 mg, Oral, 1 X DAILY, 14 doses Starting when released
Give if patient has Philadelphia chromosome positive disease. Prior to initiating therapy, verify outpatient prescription coverage with
pharmacist.
dasatinib (SPRYCEL) tab 100 mg
100 mg, Oral, 1 X DAILY, 14 doses Starting when released
Give if patient has Philadelphia chromosome positive disease. Prior to initiating therapy, verify outpatient prescription coverage with
pharmacist.
acyclovir (ZOVIRAX) tab 400 mg
400 mg, Oral, 2 X DAILY Starting when released
fluconazole (DIFLUCAN) tab 400 mg
400 mg, Oral, 1 X DAILY Starting when released
sulfamethoxazole-trimethoprim (BACTRIM DS) 800-160 MG per tab 1 tab
1 tab, Oral, 2 X DAILY SAT, SUN Starting when released
ranitidine (ZANTAC) tab 150 mg
150 mg, Oral, 2 X DAILY Starting when released
senna-docusate (SENOKOT S) 8.6-50 MG per tab 2 tab
2 tab, Oral, 1 X DAILY (HS) Starting when released
Hold for loose stools
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
If unable to take PO, may give IV.
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting, If unable to tolerate PO.
IV push slowly, max rate 5 mg/minute.
Take Home Medications
sodium bicarbonate oral powder
Mix 1/2 teaspoon sodium bicarbonate oral powder (baking soda) in 6-8 ounces of a non-acidic fluid and drink by mouth at 8 AM, 12
PM, 4 PM, 10 PM the day before methotrexate treatment and at 8 AM the morning of methotrexate treatment., Disp-1 Bottle, R-0,
starting S, No Print
dexamethasone (DECADRON) 4 MG tab
Take 10 tabs by mouth one time daily. Take on Day 11 through 14., 40 mg, Disp-40 tab, R-0, 1 X DAILY starting S
Take Home Medications (delete all that do not apply)
levofloxacin (LEVAQUIN) 500 MG tab
Take 1 tab by mouth one time daily. Begin on Day ***, 500 mg, Disp-10 tab, R-0, 1 X DAILY starting S
TBO-filgrastim (GRANIX) 300 MCG/0.5ML soln prefilled syringe
Inject 300 mcg under skin one time daily in evening. Begin Day ***. Continue until ANC is greater than *** after nadir., 300 mcg,
Disp-10 Syringe, R-5, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
TBO-filgrastim (GRANIX) 480 MCG/0.8ML soln prefilled syringe
Inject 480 mcg under skin one time daily in evening. Begin Day ***. Continue until ANC is greater than *** after nadir., 480 mcg,
Disp-10 Syringe, R-5, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
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Zztestonc,Jeff J [2507481]
8/23/2016 8:35:12 AM Page 35 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org

Follow-Up
DAY 8 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT for intrathecal cytarabine for 60 minutes.
DAY 11 FOLLOW-UP
LABS: CBC with DIFF; CHEMO ROOM APPOINTMENT: vinCRIStine for 30 minutes
DAY 22 FOLLOW-UP
(Day 1 of next cycle) Schedule preadmission to B6/6 for chemotherapy administration.
Day 8 (Outpatient), Cycle 7 Hyper-CVAD (Part A) – Planned for 12/28/2016
Treatment Plan Information
Reference Information (1)
ACUTE LYMPHOCYTIC LEUKEMIA: Kantarjian H, et al. J Clin Oncol. 2000; 18(3):547-61
Reference Information (2)
ACUTE LYMPHOCYTIC LEUKEMIA: Thomas D, et al. Blood. 2004; 103(12):4396-4407
Reference Information (3)
ACUTE LYMPHOCYTIC LEUKEMIA: Daver N, et al. Haematologica 2015;100(5):653-61.
Reference Information (4)
ACUTE LYMPHOCYTIC LEUKEMIA: Benjamini O, et al. Am J Hematol 2014;89(3):282-7.
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; THERAPY (Part A): dexamethasone 40 mg by mouth or IV Day 1 through 4 and Day 11
through 14, cyclophosphamide 300 mg/m2 IV every 12 hours Day 1, 2 and 3, doxorubicin 50 mg/m2 IV continuous infusion over 24
hours starting Day 3, vinCRIStine 2 mg IV Day 4 and 11, imatinib 400 mg by mouth once daily Day 1 through 14 (if Philadelphia
chromosome positive disease) OR dasatinib 100 mg by mouth once daily Days 1 through 14 (if Philadelphia chromosome positive
disease), methotrexate 12 mg IT Day 2, cytarabine 100 mg IT Day 8, hydrocortisone 30 mg IT may be given with IT chemotherapy
followed by THERAPY (Part B): methylprednisolone 50mg IV twice daily Day 1 through 3, methotrexate 200 mg/m2 IV over 2 hours
followed by 800 mg/m2 IV continuous infusion over 22 hours starting Day 1, leucovorin 50 mg/m2 IV given 36 hours after start of
methotrexate infusion followed by leucovorin 15 mg/m2 IV every 6 hours until methotrexate level is less than or equal to 0.5 uM/L
followed by leucovorin 15 mg by mouth every 6 hours until methotrexate level is less than or equal to 0.05 uM/L, cytarabine 3000
mg/m2 IV every 12 hours Day 2 and 3, imatinib 400 mg by mouth once daily Day 1 through 14 OR dasatinib 100 mg by mouth once
daily Days 1 through 14 (if Philadelphia chromosome positive disease), methotrexate 12 mg IT Day 2, cytarabine 100 mg IT Day 8,
hydrocortisone 30 mg IT may be given with IT chemotherapy; CYCLE LENGTH: 21 days; COURSE: 8 alternating cycles (A-B-A-B-
A-B-A-B); NOTE: IT chemotherapy for CNS prophylaxis will be given on Day 2 and 8 of Part A and B for a total of 4 doses for low
risk patients, a total of 8 doses for unknown risk patients or a total of 16 doses for high risk patients.
Note to All Staff (1)
If ejection fraction less than 50%, decrease DOXOrubicin to 25 mg/m2/day IV continuous infusion over 24 hours Day 2 and 3 (total
dose = 50 mg/m2 over 48 hours). If age greater than 60 years, consider decreasing cytarabine to 1000 mg/m2 IV every 12 hours
Day 2 and 3.
Note to All Staff (2)
If CSF is positive for leukemia, patient will receive twice weekly IT chemotherapy with alternating methotrexate and cytarabine until
CSF is negative for two consecutive lumbar punctures then resume intrathecal chemotherapy prophylactic regimen.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
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Zztestonc,Jeff J [2507481]
8/23/2016 8:35:12 AM Page 36 of 44
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org

500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Intrathecal Procedure Orders (delete all that do not apply)
LEUKEMIA/LYMPHOMA SCREEN, CSF
ONCE Starting when released
cytarabine PF (CYTOSAR) 100 mg in sodium chloride 0.9 % 2 mL intraTHECAL injection
100 mg, Intrathecal, ONCE, 1 dose Starting when released
Only give if patient is HIGH RISK. Dose to be given by provider.
hydrocortisone sodium succinate PF (SOLU-CORTEF) 30 mg in sodium chloride 0.9 % 3 mL intraTHECAL
injection
30 mg, Intrathecal, ONCE, 1 dose Starting when released
Only give if patient is HIGH RISK. Dose to be given by provider.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 11 (Outpatient), Cycle 7 Hyper-CVAD (Part A) – Planned for 1/6/2017
Treatment Plan Information
Reference Information (1)
ACUTE LYMPHOCYTIC LEUKEMIA: Kantarjian H, et al. J Clin Oncol. 2000; 18(3):547-61
Reference Information (2)
ACUTE LYMPHOCYTIC LEUKEMIA: Thomas D, et al. Blood. 2004; 103(12):4396-4407
Reference Information (3)
ACUTE LYMPHOCYTIC LEUKEMIA: Daver N, et al. Haematologica 2015;100(5):653-61.
Reference Information (4)
ACUTE LYMPHOCYTIC LEUKEMIA: Benjamini O, et al. Am J Hematol 2014;89(3):282-7.
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; THERAPY (Part A): dexamethasone 40 mg by mouth or IV Day 1 through 4 and Day 11
through 14, cyclophosphamide 300 mg/m2 IV every 12 hours Day 1, 2 and 3, doxorubicin 50 mg/m2 IV continuous infusion over 24
hours starting Day 3, vinCRIStine 2 mg IV Day 4 and 11, imatinib 400 mg by mouth once daily Day 1 through 14 (if Philadelphia
chromosome positive disease) OR dasatinib 100 mg by mouth once daily Days 1 through 14 (if Philadelphia chromosome positive
disease), methotrexate 12 mg IT Day 2, cytarabine 100 mg IT Day 8, hydrocortisone 30 mg IT may be given with IT chemotherapy
followed by THERAPY (Part B): methylprednisolone 50mg IV twice daily Day 1 through 3, methotrexate 200 mg/m2 IV over 2 hours
followed by 800 mg/m2 IV continuous infusion over 22 hours starting Day 1, leucovorin 50 mg/m2 IV given 36 hours after start of
methotrexate infusion followed by leucovorin 15 mg/m2 IV every 6 hours until methotrexate level is less than or equal to 0.5 uM/L
followed by leucovorin 15 mg by mouth every 6 hours until methotrexate level is less than or equal to 0.05 uM/L, cytarabine 3000
mg/m2 IV every 12 hours Day 2 and 3, imatinib 400 mg by mouth once daily Day 1 through 14 OR dasatinib 100 mg by mouth once
daily Days 1 through 14 (if Philadelphia chromosome positive disease), methotrexate 12 mg IT Day 2, cytarabine 100 mg IT Day 8,
hydrocortisone 30 mg IT may be given with IT chemotherapy; CYCLE LENGTH: 21 days; COURSE: 8 alternating cycles (A-B-A-B-
A-B-A-B); NOTE: IT chemotherapy for CNS prophylaxis will be given on Day 2 and 8 of Part A and B for a total of 4 doses for low
risk patients, a total of 8 doses for unknown risk patients or a total of 16 doses for high risk patients.
Note to All Staff (1)
If ejection fraction less than 50%, decrease DOXOrubicin to 25 mg/m2/day IV continuous infusion over 24 hours Day 2 and 3 (total
dose = 50 mg/m2 over 48 hours). If age greater than 60 years, consider decreasing cytarabine to 1000 mg/m2 IV every 12 hours
Day 2 and 3.
Note to All Staff (2)
If CSF is positive for leukemia, patient will receive twice weekly IT chemotherapy with alternating methotrexate and cytarabine until
CSF is negative for two consecutive lumbar punctures then resume intrathecal chemotherapy prophylactic regimen.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Normal, Routine
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Zztestonc,Jeff J [2507481]
8/23/2016 8:35:12 AM Page 37 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org

AST/SGOT
Expected-S Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total Bilirubin, AST
Treatment Parameters
Hold treatment and notify authorizing prescriber for Total Bilirubin greater than or equal to 2 mg/dL.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Treatment Medications
vinCRIStine (ONCOVIN) 2 mg in sodium chloride 0.9 % 25 mL bag
2 mg, Intravenous, ONCE, 1 dose Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump).
See Take Home Medication(s)
Refer to the Day 1 take home medications section for the following treatment medication(s): dexamethasone
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 8 Hyper-CVAD (Part B) – 1/17/2017 through 2/6/2017 (21 days), Planned
Day 1 through 3 (Inpatient), Cycle 8 Hyper-CVAD (Part B) – Planned for 1/17/2017
Treatment Plan Information
Reference Information (1)
ACUTE LYMPHOCYTIC LEUKEMIA: Kantarjian H, et al. J Clin Oncol. 2000; 18(3):547-61
Reference Information (2)
ACUTE LYMPHOCYTIC LEUKEMIA: Thomas D, et al. Blood. 2004; 103(12):4396-4407
Reference Information (3)
ACUTE LYMPHOCYTIC LEUKEMIA: Daver N, et al. Haematologica 2015;100(5):653-61.
Reference Information (4)
ACUTE LYMPHOCYTIC LEUKEMIA: Benjamini O, et al. Am J Hematol 2014;89(3):282-7.
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; THERAPY (Part A): dexamethasone 40 mg by mouth or IV Day 1 through 4 and Day 11
through 14, cyclophosphamide 300 mg/m2 IV every 12 hours Day 1, 2 and 3, doxorubicin 50 mg/m2 IV continuous infusion over 24
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Zztestonc,Jeff J [2507481]
8/23/2016 8:35:12 AM Page 38 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org

hours starting Day 3, vinCRIStine 2 mg IV Day 4 and 11, imatinib 400 mg by mouth once daily Day 1 through 14 (if Philadelphia
chromosome positive disease) OR dasatinib 100 mg by mouth once daily Days 1 through 14 (if Philadelphia chromosome positive
disease), methotrexate 12 mg IT Day 2, cytarabine 100 mg IT Day 8, hydrocortisone 30 mg IT may be given with IT chemotherapy
followed by THERAPY (Part B): methylprednisolone 50mg IV twice daily Day 1 through 3, methotrexate 200 mg/m2 IV over 2 hours
followed by 800 mg/m2 IV continuous infusion over 22 hours starting Day 1, leucovorin 50 mg/m2 IV given 36 hours after start of
methotrexate infusion followed by leucovorin 15 mg/m2 IV every 6 hours until methotrexate level is less than or equal to 0.5 uM/L
followed by leucovorin 15 mg by mouth every 6 hours until methotrexate level is less than or equal to 0.05 uM/L, cytarabine 3000
mg/m2 IV every 12 hours Day 2 and 3, imatinib 400 mg by mouth once daily Day 1 through 14 OR dasatinib 100 mg by mouth once
daily Days 1 through 14 (if Philadelphia chromosome positive disease), methotrexate 12 mg IT Day 2, cytarabine 100 mg IT Day 8,
hydrocortisone 30 mg IT may be given with IT chemotherapy; CYCLE LENGTH: 21 days; COURSE: 8 alternating cycles (A-B-A-B-
A-B-A-B); NOTE: IT chemotherapy for CNS prophylaxis will be given on Day 2 and 8 of Part A and B for a total of 4 doses for low
risk patients, a total of 8 doses for unknown risk patients or a total of 16 doses for high risk patients.
Note to All Staff (1)
If ejection fraction less than 50%, decrease DOXOrubicin to 25 mg/m2/day IV continuous infusion over 24 hours Day 2 and 3 (total
dose = 50 mg/m2 over 48 hours). If age greater than 60 years, consider decreasing cytarabine to 1000 mg/m2 IV every 12 hours
Day 2 and 3.
Note to All Staff (2)
If CSF is positive for leukemia, patient will receive twice weekly IT chemotherapy with alternating methotrexate and cytarabine until
CSF is negative for two consecutive lumbar punctures then resume intrathecal chemotherapy prophylactic regimen.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
ONCE Starting when released, Routine
CREATININE
ONCE Starting when released, Routine
BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALT/SGPT
ONCE Starting when released
ALKALINE PHOSPHATASE
ONCE Starting when released, Routine
Additional Labs
PH, URINE (METHOTREXATE PROTOCOL)
ONCE Starting when released
Obtain pH, Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 2 HOURS Starting when released for 2 occurrences
Obtain pH, Urine (Methotrexate Protocol) at 2 hours and 4 hours after start of Methotrexate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting when released for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting S+8 at 0000 for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
CONDITIONAL - RN COLLECT Starting when released until S+7 for 7 days
If Urine pH falls below 7, obtain pH, Urine (Methotrexate Protocol) every 2 hours as needed until Urine pH is greater than or equal to
7 for two consecutive occurrences.
METHOTREXATE
ONCE Starting when released
Obtain methotrexate level 24 hours after the start of methotrexate infusion.
METHOTREXATE
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Zztestonc,Jeff J [2507481]
8/23/2016 8:35:12 AM Page 39 of 44
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NEXT AM Starting S+2 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily
methotrexate levels when drug level is undetectable.
METHOTREXATE
NEXT AM Starting S+9 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate levels when
drug level is undetectable.
CREATININE
ONCE Starting when released
Obtain creatinine at 24 hours after the start of methotrexate infusion.
CREATININE
NEXT AM Starting S+2 As Scheduled for 7 days
CREATININE
NEXT AM Starting S+9 As Scheduled for 7 days
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase, pH Urine
(Methotrexate Protocol).
Verify Labs (2)
Verify ongoing treatment labs: Creatinine, pH, Urine (Methotrexate Protocol) and Methotrexate levels.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Creatinine greater than 1.5 mg/dL or Creatinine Clearance less than 60 mL/min
or Total Bilirubin greater than or equal to 2 mg/dL or AST greater than 2.5 X ULN or ALT greater than 2.5 X ULN or Alkaline
Phosphatase greater than 2.5 X ULN.
Treatment Parameters (2)
Do not administer methotrexate until urine pH is greater than or equal to 7.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Check pH Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion. If less than 7, give sodium bicarbonate
50 mEq IV. See Conditional Medications.
Monitoring Parameters (2)
Check pH Urine (Methotrexate Protocol) at 2 hours, 4 hours, and 8 hours after start of methotrexate and then every 8 hours until
methotrexate level is undetectable. If less than 7, give sodium bicarbonate 50 mEq IV and check urine pH every 2 hours until urine
pH is greater than or equal to 7. See Conditional Medications and Additional Labs.
Monitoring Parameters (3)
Cytarabine: Perform neuro check prior to each dose. Monitor for cerebellar toxicity (slurred speech or ataxia) and if patient develops
signs of toxicity, hold dose and contact hematology fellow or attending physician.
Nursing Communication
CONTINUOUS Starting when released Until Specified
If sodium bicarbonate bolus given, recheck Urine pH in 2 hours. If two boluses of sodium bicarbonate have been given in 8 hours or
three boluses in 24 hours, notify pharmacy and provider to review IV fluid orders.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
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Zztestonc,Jeff J [2507481]
8/23/2016 8:35:12 AM Page 40 of 44
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org

sodium bicarbonate 100 mEq in dextrose 5 % 1,000 mL infusion
Intravenous, CONTINUOUS Starting when released Until Discontinued
Begin 4 hours prior to start of methotrexate. May discontinue when methotrexate level is undetectable. Sodium
Bicarbonate infusion must NOT be interrupted for any reason without an order from the attending physician or
fellow.
NOTE:
EVERY 6 HOURS Starting when released
Sodium Bicarbonate infusion must NOT be interrupted for any reason without an order from the attending physician or fellow.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, 1 X DAILY, 3 doses Starting when released
Days 1, 2 and 3. Give prior to chemotherapy. May give IV if unable to tolerate PO.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, EVERY 24 HOURS PRN, For 3 days Starting when released until S+3, nausea/vomiting
Days 1, 2 and 3. Give prior to chemotherapy if patient unable to tolerate PO.
prednisolone (PRED FORTE) 1 % ophthalmic susp 1 drop
1 drop, Eyes (Each), 4 X DAILY, For 2 days Starting S+1 at 0800
Day 2 and 3. Instill one drop into each eye four times daily. First dose prior to chemotherapy on Day 2.
Intrathecal Procedure Orders (delete all that do not apply)
LEUKEMIA/LYMPHOMA SCREEN, CSF
Expected-S+1 Approximate, Expires-S+122, Normal, Routine
methotrexate PF 12 mg in sodium chloride 0.9 % 2.4 mL intraTHECAL injection
12 mg, Intrathecal, ONCE, 1 dose Starting S+1 at 0000
Day 2: Only give if patient is HIGH RISK. Dose to be administered by provider.
hydrocortisone sodium succinate PF (SOLU-CORTEF) 30 mg in sodium chloride 0.9 % 3 mL intraTHECAL
injection
30 mg, Intrathecal, ONCE, 1 dose Starting S+1 at 0000
Day 2: Only give if patient is HIGH RISK. Dose to be administered by provider.
Treatment Medications
methylprednisolone sod. succ. in sodium chloride 0.9% (SOLU-MEDROL) injection 50 mg
50 mg, Intravenous, EVERY 12 HOURS, 6 doses Starting when released
methotrexate PF 400 mg in dextrose 5 % 250 mL bag
400 mg (200 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Do not start methotrexate until urine pH greater than or equal to 7.
methotrexate PF 1,600 mg in dextrose 5 % 1,000 mL bag
1,600 mg (800 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Give after methotrexate bolus dose.
cytarabine PF (CYTOSAR) 6,000 mg in sodium chloride 0.9 % 250 mL bag
6,000 mg (3,000 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 12 HOURS, 4 doses Starting S+1
at 0000
Begin after completion of methotrexate. Neuro check prior to each dose. Consider decreasing dose to 1000 mg/m2 for patients
greater than 60 years of age.
leucovorin 20 MG/ML injection 100 mg
100 mg (50 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting S+1 at 0000, Administer
over 3 Minutes
Start 36 hours after the start of methotrexate infusion.
leucovorin 20 MG/ML injection 30 mg
30 mg (15 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 6 HOURS Starting S+1 at 0000,
Administer over 3 Minutes
Start 6 hours after IV leucovorin loading dose. Give every 6 hours until the serum methotrexate level is less than or equal to 0.5
µM/L, then give PO leucovorin. See PRN NOTIFY PHARMACY order.
leucovorin tab 15 mg
15 mg, Oral, PRN - NOTIFY PHARMACY WHEN NEEDED Starting S+1 at 0000 Until Discontinued, High Dose Methotrexate
Once methotrexate level is less than or equal to 0.5 µM/L, starting 6 hours after last IV leucovorin dose give 15 mg leucovorin PO
every 6 hours until serum methotrexate level is less than or equal to 0.05 µM/L
Treatment Medications (delete all that do not apply)
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Zztestonc,Jeff J [2507481]
8/23/2016 8:35:12 AM Page 41 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org

imatinib (GLEEVEC) tab 400 mg
400 mg, Oral, 1 X DAILY, 14 doses Starting when released
Give if patient has Philadelphia chromosome positive disease. Prior to initiating therapy, verify outpatient prescription coverage with
pharmacist.
dasatinib (SPRYCEL) tab 100 mg
100 mg, Oral, 1 X DAILY, 14 doses Starting when released
Give if patient has Philadelphia chromosome positive disease. Prior to initiating therapy, verify outpatient prescription coverage with
pharmacist.
acyclovir (ZOVIRAX) tab 400 mg
400 mg, Oral, 2 X DAILY Starting when released
fluconazole (DIFLUCAN) tab 400 mg
400 mg, Oral, 1 X DAILY Starting when released
ranitidine (ZANTAC) tab 150 mg
150 mg, Oral, 2 X DAILY Starting when released
Conditional Orders
sodium bicarbonate 8.4 % injection 50 mEq
50 mEq, Intravenous, EVERY 2 HOURS PRN, For 7 days Starting when released until S+7, For urine pH less than 7, Administer
over 1 Minutes
Administer over 1 to 2 minutes. Give if urine pH is less than 7. May discontinue when methotrexate level is undetectable.
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
If unable to take PO, may give IV.
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting, If unable to tolerate PO.
IV push slowly, max rate 5 mg/minute.
Take Home Medications
leucovorin 15 MG tab
Take 1 tab by mouth every 6 hours. Take until seen in clinic for follow up appt to confirm methotrexate level undetectable, 15 mg,
Disp-16 tab, R-0, EVERY 6 HOURS starting S
sulfamethoxazole-trimethoprim (BACTRIM DS) 800-160 MG per tab
Take 1 tab by mouth 2 times daily Sat,Sun. Begin when methotrexate level is undetectable., 1 tab, Disp-16 tab, R-0, 2 X DAILY
SAT, SUN starting S
Take Home Medications (delete all that do not apply)
levofloxacin (LEVAQUIN) 500 MG tab
Take 1 tab by mouth one time daily. Begin on Day ***, 500 mg, Disp-10 tab, R-0, 1 X DAILY starting S
TBO-filgrastim (GRANIX) 300 MCG/0.5ML soln prefilled syringe
Inject 300 mcg under skin one time daily in evening. Begin Day ***. Continue until ANC is greater than *** after nadir., 300 mcg,
Disp-10 Syringe, R-5, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
TBO-filgrastim (GRANIX) 480 MCG/0.8ML soln prefilled syringe
Inject 480 mcg under skin one time daily in evening. Begin Day ***. Continue until ANC is greater than *** after nadir., 480 mcg,
Disp-10 Syringe, R-5, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
Follow-Up
DAY 8 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT for intrathecal cytarabine for 60 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) Schedule preadmission to B6/6 for chemotherapy administration.
Day 8 (Outpatient), Cycle 8 Hyper-CVAD (Part B) – Planned for 1/18/2017
Treatment Plan Information
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Zztestonc,Jeff J [2507481]
8/23/2016 8:35:12 AM Page 42 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org

Reference Information (1)
ACUTE LYMPHOCYTIC LEUKEMIA: Kantarjian H, et al. J Clin Oncol. 2000; 18(3):547-61
Reference Information (2)
ACUTE LYMPHOCYTIC LEUKEMIA: Thomas D, et al. Blood. 2004; 103(12):4396-4407
Reference Information (3)
ACUTE LYMPHOCYTIC LEUKEMIA: Daver N, et al. Haematologica 2015;100(5):653-61.
Reference Information (4)
ACUTE LYMPHOCYTIC LEUKEMIA: Benjamini O, et al. Am J Hematol 2014;89(3):282-7.
Treatment Plan Summary
DISEASE: Acute Lymphocytic Leukemia; THERAPY (Part A): dexamethasone 40 mg by mouth or IV Day 1 through 4 and Day 11
through 14, cyclophosphamide 300 mg/m2 IV every 12 hours Day 1, 2 and 3, doxorubicin 50 mg/m2 IV continuous infusion over 24
hours starting Day 3, vinCRIStine 2 mg IV Day 4 and 11, imatinib 400 mg by mouth once daily Day 1 through 14 (if Philadelphia
chromosome positive disease) OR dasatinib 100 mg by mouth once daily Days 1 through 14 (if Philadelphia chromosome positive
disease), methotrexate 12 mg IT Day 2, cytarabine 100 mg IT Day 8, hydrocortisone 30 mg IT may be given with IT chemotherapy
followed by THERAPY (Part B): methylprednisolone 50mg IV twice daily Day 1 through 3, methotrexate 200 mg/m2 IV over 2 hours
followed by 800 mg/m2 IV continuous infusion over 22 hours starting Day 1, leucovorin 50 mg/m2 IV given 36 hours after start of
methotrexate infusion followed by leucovorin 15 mg/m2 IV every 6 hours until methotrexate level is less than or equal to 0.5 uM/L
followed by leucovorin 15 mg by mouth every 6 hours until methotrexate level is less than or equal to 0.05 uM/L, cytarabine 3000
mg/m2 IV every 12 hours Day 2 and 3, imatinib 400 mg by mouth once daily Day 1 through 14 OR dasatinib 100 mg by mouth once
daily Days 1 through 14 (if Philadelphia chromosome positive disease), methotrexate 12 mg IT Day 2, cytarabine 100 mg IT Day 8,
hydrocortisone 30 mg IT may be given with IT chemotherapy; CYCLE LENGTH: 21 days; COURSE: 8 alternating cycles (A-B-A-B-
A-B-A-B); NOTE: IT chemotherapy for CNS prophylaxis will be given on Day 2 and 8 of Part A and B for a total of 4 doses for low
risk patients, a total of 8 doses for unknown risk patients or a total of 16 doses for high risk patients.
Note to All Staff (1)
If ejection fraction less than 50%, decrease DOXOrubicin to 25 mg/m2/day IV continuous infusion over 24 hours Day 2 and 3 (total
dose = 50 mg/m2 over 48 hours). If age greater than 60 years, consider decreasing cytarabine to 1000 mg/m2 IV every 12 hours
Day 2 and 3.
Note to All Staff (2)
If CSF is positive for leukemia, patient will receive twice weekly IT chemotherapy with alternating methotrexate and cytarabine until
CSF is negative for two consecutive lumbar punctures then resume intrathecal chemotherapy prophylactic regimen.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Intrathecal Procedure Orders (delete all that do not apply)
LEUKEMIA/LYMPHOMA SCREEN, CSF
ONCE Starting when released
cytarabine PF (CYTOSAR) 100 mg in sodium chloride 0.9 % 2 mL intraTHECAL injection
100 mg, Intrathecal, ONCE, 1 dose Starting when released
Only give if patient is HIGH RISK. Dose to be given by provider.
hydrocortisone sodium succinate PF (SOLU-CORTEF) 30 mg in sodium chloride 0.9 % 3 mL intraTHECAL
injection
30 mg, Intrathecal, ONCE, 1 dose Starting when released
Only give if patient is HIGH RISK. Dose to be given by provider.
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Zztestonc,Jeff J [2507481]
8/23/2016 8:35:12 AM Page 43 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org

Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Jeff J [2507481]
8/23/2016 8:35:12 AM Page 44 of 44
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org