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Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Beacon Protocols,Hem - Lymphoma

CSC Hem Inpt/Op R-Hper-CVAD Part (A) And (B) – Lymphoma Ver 8-23-16 (HL 3172)

CSC Hem Inpt/Op R-Hper-CVAD Part (A) And (B) – Lymphoma Ver 8-23-16 (HL 3172) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Lymphoma


CSC HEM INPT/OP R-HYPER-CVAD PART (A) AND (B) - LYMPHOMA VER: 8-23-16 – Properties
Cycle 1 R-Hyper-CVAD (Part A) – 8/23/2016 through 9/12/2016 (21 days), Planned
Day 1 through 4 (Inpatient), Cycle 1 R-Hyper-CVAD (Part A) – Planned for 8/23/2016
Treatment Plan Information
Reference Information (1)
ACUTE LYMPHOBLASTIC LYMPHOMA: Thomas D, et al. Blood. 2004; 104(6):1624-30
Treatment Plan Summary
DISEASE: Acute Lymphoblastic Lymphoma; THERAPY (Part A): dexamethasone 40 mg PO/IV Day 1 through 4 and Day 11 through
14, rituximab 375 mg/m2 IV Day 1, cyclophosphamide 300 mg/m2 IV every 12 hours Day 1, 2 and 3, DOXOrubicin 50 mg/m2 IV
continous infusion over 24 hours starting Day 3, vinCRIStine 2 mg IV Day 4 and 11, methotrexate 12 mg IT Day 2, cytarabine 70 mg
IT Day 8, hydrocortisone 30 mg IT may be given with IT chemotherapy followed by THERAPY (Part B): rituximab 375 mg/m2 IV Day
1, 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, methotrexate 12 mg IT Day 2, cytarabine 70
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 the first 4 cycles (A-B-A-B)
of therapy.
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 lymphoma, patient will receive twice weekly IT chemotherapy with alternating methotrexate and cytarabine until
CSF is negative for two consecutive lumbar punctures then weekly IT chemotherapy with alternating methotrexate and cytarabine for
4 weeks then resume intrathecal chemotherapy prophylactic regimen.
Note to all Staff (3)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
HEPATITIS B CORE AB, TOTAL
Expected-S Approximate, Expires-S+365, Routine
HEPATITIS B SURFACE AG
Expected-S Approximate, Expires-S+365, Routine
HEPATITIS B SURFACE AB
Expected-S Approximate, Expires-S+122, Routine
Pre-Labs (delete all that do not apply)
HEPATITIS B DNA, ULTRA QUANT, PCR
Expected-S Approximate, Expires-S+122, Routine
Draw if Hepatitis B Core AB is positive.
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
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6 months since
last dose. For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
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Zztestonc,Jeff J [2507481]
8/23/2016 8:43:56 AM Page 1 of 41
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org

Monitoring Parameters (1)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with rituximab.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Vital Signs every 15 minutes for the first 60 minutes and then every 30 minutes until rituximab infusion complete. If patient
experiences fever accompanied by chills or rigors, shortness of breath, chest pain, or hypotension, stop infusion and contact MD.
Once the patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
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
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to rituximab.
ondansetron (ZOFRAN) tab 12 mg
12 mg, Oral, EVERY 12 HOURS, 8 doses Starting when released
Give prior to chemotherapy. May give IV if unable to tolerate PO. If DOXOrubicin given over 48 hours, add 2 doses for a total of 10
doses.
ondansetron (ZOFRAN) 12 mg in sodium chloride 0.9 % 50 mL bag
12 mg, Intravenous, EVERY 12 HOURS PRN, For 6 days Starting when released until S+6, nausea/vomiting
Give prior to chemotherapy if patient unable to tolerate PO.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
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
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Zztestonc,Jeff J [2507481]
8/23/2016 8:43:56 AM Page 2 of 41
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: 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.
rituximab (RITUXAN) 750 mg in sodium chloride 0.9 % 500 mL bag
750 mg (375 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity Risk. See Emergency Medications. Administer rituximab prior to any chemotherapy. See Note on MAR for infusion
rates. If patient experiences fever accompanied by chills or rigors, shortness of breath, chest pain or hypotension, contact MD. Once
the patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
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)
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
sodium bicarbonate oral powder
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Zztestonc,Jeff J [2507481]
8/23/2016 8:43:56 AM Page 3 of 41
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2016CCKM@uwhealth.org

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; CHEMOTHERAPY 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 R-Hyper-CVAD (Part A) – Planned for 8/30/2016
Treatment Plan Information
Reference Information (1)
ACUTE LYMPHOBLASTIC LYMPHOMA: Thomas D, et al. Blood. 2004; 104(6):1624-30
Treatment Plan Summary
DISEASE: Acute Lymphoblastic Lymphoma; THERAPY (Part A): dexamethasone 40 mg PO/IV Day 1 through 4 and Day 11 through
14, rituximab 375 mg/m2 IV Day 1, cyclophosphamide 300 mg/m2 IV every 12 hours Day 1, 2 and 3, DOXOrubicin 50 mg/m2 IV
continous infusion over 24 hours starting Day 3, vinCRIStine 2 mg IV Day 4 and 11, methotrexate 12 mg IT Day 2, cytarabine 70 mg
IT Day 8, hydrocortisone 30 mg IT may be given with IT chemotherapy followed by THERAPY (Part B): rituximab 375 mg/m2 IV Day
1, 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, methotrexate 12 mg IT Day 2, cytarabine 70
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 the first 4 cycles (A-B-A-B)
of therapy.
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 lymphoma, patient will receive twice weekly IT chemotherapy with alternating methotrexate and cytarabine until
CSF is negative for two consecutive lumbar punctures then weekly IT chemotherapy with alternating methotrexate and cytarabine for
4 weeks then resume intrathecal chemotherapy prophylactic regimen.
Note to all Staff (3)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
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.
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Zztestonc,Jeff J [2507481]
8/23/2016 8:43:56 AM Page 4 of 41
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2016CCKM@uwhealth.org

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) 70 mg in sodium chloride 0.9 % 1.4 mL intraTHECAL injection
70 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 administered 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 1 R-Hyper-CVAD (Part A) – Planned for 9/2/2016
Treatment Plan Information
Reference Information (1)
ACUTE LYMPHOBLASTIC LYMPHOMA: Thomas D, et al. Blood. 2004; 104(6):1624-30
Treatment Plan Summary
DISEASE: Acute Lymphoblastic Lymphoma; THERAPY (Part A): dexamethasone 40 mg PO/IV Day 1 through 4 and Day 11 through
14, rituximab 375 mg/m2 IV Day 1, cyclophosphamide 300 mg/m2 IV every 12 hours Day 1, 2 and 3, DOXOrubicin 50 mg/m2 IV
continous infusion over 24 hours starting Day 3, vinCRIStine 2 mg IV Day 4 and 11, methotrexate 12 mg IT Day 2, cytarabine 70 mg
IT Day 8, hydrocortisone 30 mg IT may be given with IT chemotherapy followed by THERAPY (Part B): rituximab 375 mg/m2 IV Day
1, 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, methotrexate 12 mg IT Day 2, cytarabine 70
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 the first 4 cycles (A-B-A-B)
of therapy.
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 lymphoma, patient will receive twice weekly IT chemotherapy with alternating methotrexate and cytarabine until
CSF is negative for two consecutive lumbar punctures then weekly IT chemotherapy with alternating methotrexate and cytarabine for
4 weeks then resume intrathecal chemotherapy prophylactic regimen.
Note to all Staff (3)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
IV Access
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Zztestonc,Jeff J [2507481]
8/23/2016 8:43:56 AM Page 5 of 41
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2016CCKM@uwhealth.org

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.
Cycle 2 R-Hyper-CVAD (Part B) – 9/13/2016 through 10/3/2016 (21 days), Planned
Day 1 through 3 (Inpatient), Cycle 2 R-Hyper-CVAD (Part B) – Planned for 9/13/2016
Treatment Plan Information
Reference Information (1)
ACUTE LYMPHOBLASTIC LYMPHOMA: Thomas D, et al. Blood. 2004; 104(6):1624-30
Treatment Plan Summary
DISEASE: Acute Lymphoblastic Lymphoma; THERAPY (Part A): dexamethasone 40 mg PO/IV Day 1 through 4 and Day 11 through
14, rituximab 375 mg/m2 IV Day 1, cyclophosphamide 300 mg/m2 IV every 12 hours Day 1, 2 and 3, DOXOrubicin 50 mg/m2 IV
continous infusion over 24 hours starting Day 3, vinCRIStine 2 mg IV Day 4 and 11, methotrexate 12 mg IT Day 2, cytarabine 70 mg
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Zztestonc,Jeff J [2507481]
8/23/2016 8:43:56 AM Page 6 of 41
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2016CCKM@uwhealth.org

IT Day 8, hydrocortisone 30 mg IT may be given with IT chemotherapy followed by THERAPY (Part B): rituximab 375 mg/m2 IV Day
1, 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, methotrexate 12 mg IT Day 2, cytarabine 70
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 the first 4 cycles (A-B-A-B)
of therapy.
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 lymphoma, patient will receive twice weekly IT chemotherapy with alternating methotrexate and cytarabine until
CSF is negative for two consecutive lumbar punctures then weekly IT chemotherapy with alternating methotrexate and cytarabine for
4 weeks then resume intrathecal chemotherapy prophylactic regimen.
Note to all Staff (3)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
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.
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Zztestonc,Jeff J [2507481]
8/23/2016 8:43:56 AM Page 7 of 41
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2016CCKM@uwhealth.org

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
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6 months since
last dose. For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
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.
Monitoring Parameters (4)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with rituximab.
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.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Vital Signs every 15 minutes for the first 60 minutes and then every 30 minutes until rituximab infusion complete. If patient
experiences fever accompanied by chills or rigors, shortness of breath, chest pain, or hypotension, stop infusion and contact MD.
Once the patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
Flush Venous Access Device per Guidelines
Order details
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Zztestonc,Jeff J [2507481]
8/23/2016 8:43:56 AM Page 8 of 41
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2016CCKM@uwhealth.org

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
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to rituximab.
ondansetron (ZOFRAN) tab 12 mg
12 mg, Oral, EVERY 12 HOURS, 6 doses Starting when released
Give prior to chemotherapy. May give IV if unable to tolerate PO.
ondansetron (ZOFRAN) 12 mg in sodium chloride 0.9 % 50 mL bag
12 mg, Intravenous, EVERY 12 HOURS PRN, For 4 days Starting when released until S+4, nausea/vomiting
Give prior to chemotherapy if patient unable to tolerate PO.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, 1 X DAILY, 3 doses Starting when released
Give prior to chemotherapy. May give IV if unable to tolerate PO.
dexamethasone (DECADRON) 10 MG/ML injection 8 mg
8 mg, Intravenous, 1 X DAILY PRN, For 4 days Starting when released, nausea/vomiting
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.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Intrathecal Procedure Orders
LEUKEMIA/LYMPHOMA SCREEN, CSF
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Zztestonc,Jeff J [2507481]
8/23/2016 8:43:56 AM Page 9 of 41
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2016CCKM@uwhealth.org

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
rituximab (RITUXAN) 750 mg in sodium chloride 0.9 % 500 mL bag
750 mg (375 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity Risk. See Emergency Medications. Administer rituximab prior to any chemotherapy. See Note on MAR for infusion
rates. If patient experiences fever accompanied by chills or rigors, shortness of breath, chest pain or hypotension, contact MD. Once
the patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
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)
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 8:43:56 AM Page 10 of 41
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2016CCKM@uwhealth.org

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 R-Hyper-CVAD (Part B) – Planned for 9/20/2016
Treatment Plan Information
Reference Information (1)
ACUTE LYMPHOBLASTIC LYMPHOMA: Thomas D, et al. Blood. 2004; 104(6):1624-30
Treatment Plan Summary
DISEASE: Acute Lymphoblastic Lymphoma; THERAPY (Part A): dexamethasone 40 mg PO/IV Day 1 through 4 and Day 11 through
14, rituximab 375 mg/m2 IV Day 1, cyclophosphamide 300 mg/m2 IV every 12 hours Day 1, 2 and 3, DOXOrubicin 50 mg/m2 IV
continous infusion over 24 hours starting Day 3, vinCRIStine 2 mg IV Day 4 and 11, methotrexate 12 mg IT Day 2, cytarabine 70 mg
IT Day 8, hydrocortisone 30 mg IT may be given with IT chemotherapy followed by THERAPY (Part B): rituximab 375 mg/m2 IV Day
1, 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, methotrexate 12 mg IT Day 2, cytarabine 70
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 the first 4 cycles (A-B-A-B)
of therapy.
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 lymphoma, patient will receive twice weekly IT chemotherapy with alternating methotrexate and cytarabine until
CSF is negative for two consecutive lumbar punctures then weekly IT chemotherapy with alternating methotrexate and cytarabine for
4 weeks then resume intrathecal chemotherapy prophylactic regimen.
Note to all Staff (3)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Jeff J [2507481]
8/23/2016 8:43:56 AM Page 11 of 41
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2016CCKM@uwhealth.org

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) 70 mg in sodium chloride 0.9 % 1.4 mL intraTHECAL injection
70 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 administered by provider.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 R-Hyper-CVAD (Part A) – 10/4/2016 through 10/24/2016 (21 days), Planned
Day 1 through 4 (Inpatient), Cycle 3 R-Hyper-CVAD (Part A) – Planned for 10/4/2016
Treatment Plan Information
Reference Information (1)
ACUTE LYMPHOBLASTIC LYMPHOMA: Thomas D, et al. Blood. 2004; 104(6):1624-30
Treatment Plan Summary
DISEASE: Acute Lymphoblastic Lymphoma; THERAPY (Part A): dexamethasone 40 mg PO/IV Day 1 through 4 and Day 11 through
14, rituximab 375 mg/m2 IV Day 1, cyclophosphamide 300 mg/m2 IV every 12 hours Day 1, 2 and 3, DOXOrubicin 50 mg/m2 IV
continous infusion over 24 hours starting Day 3, vinCRIStine 2 mg IV Day 4 and 11, methotrexate 12 mg IT Day 2, cytarabine 70 mg
IT Day 8, hydrocortisone 30 mg IT may be given with IT chemotherapy followed by THERAPY (Part B): rituximab 375 mg/m2 IV Day
1, 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, methotrexate 12 mg IT Day 2, cytarabine 70
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 the first 4 cycles (A-B-A-B)
of therapy.
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 lymphoma, patient will receive twice weekly IT chemotherapy with alternating methotrexate and cytarabine until
CSF is negative for two consecutive lumbar punctures then weekly IT chemotherapy with alternating methotrexate and cytarabine for
4 weeks then resume intrathecal chemotherapy prophylactic regimen.
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Zztestonc,Jeff J [2507481]
8/23/2016 8:43:56 AM Page 12 of 41
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 (3)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
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
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6 months since
last dose. For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
Monitoring Parameters (1)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with rituximab.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Vital Signs every 15 minutes for the first 60 minutes and then every 30 minutes until rituximab infusion complete. If patient
experiences fever accompanied by chills or rigors, shortness of breath, chest pain, or hypotension, stop infusion and contact MD.
Once the patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
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
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to rituximab.
ondansetron (ZOFRAN) tab 12 mg
12 mg, Oral, EVERY 12 HOURS, 8 doses Starting when released
Give prior to chemotherapy. May give IV if unable to tolerate PO. If DOXOrubicin given over 48 hours, add 2 doses for a total of 10
doses.
ondansetron (ZOFRAN) 12 mg in sodium chloride 0.9 % 50 mL bag
12 mg, Intravenous, EVERY 12 HOURS PRN, For 6 days Starting when released until S+6, nausea/vomiting
Give prior to chemotherapy if patient unable to tolerate PO.
Emergency Medications
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Zztestonc,Jeff J [2507481]
8/23/2016 8:43:56 AM Page 13 of 41
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2016CCKM@uwhealth.org

diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
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.
rituximab (RITUXAN) 750 mg in sodium chloride 0.9 % 500 mL bag
750 mg (375 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity Risk. See Emergency Medications. Administer rituximab prior to any chemotherapy. See Note on MAR for infusion
rates. If patient experiences fever accompanied by chills or rigors, shortness of breath, chest pain or hypotension, contact MD. Once
the patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
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)
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
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Zztestonc,Jeff J [2507481]
8/23/2016 8:43:56 AM Page 14 of 41
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
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; CHEMOTHERAPY 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 R-Hyper-CVAD (Part A) – Planned for 10/5/2016
Treatment Plan Information
Reference Information (1)
ACUTE LYMPHOBLASTIC LYMPHOMA: Thomas D, et al. Blood. 2004; 104(6):1624-30
Treatment Plan Summary
DISEASE: Acute Lymphoblastic Lymphoma; THERAPY (Part A): dexamethasone 40 mg PO/IV Day 1 through 4 and Day 11 through
14, rituximab 375 mg/m2 IV Day 1, cyclophosphamide 300 mg/m2 IV every 12 hours Day 1, 2 and 3, DOXOrubicin 50 mg/m2 IV
continous infusion over 24 hours starting Day 3, vinCRIStine 2 mg IV Day 4 and 11, methotrexate 12 mg IT Day 2, cytarabine 70 mg
IT Day 8, hydrocortisone 30 mg IT may be given with IT chemotherapy followed by THERAPY (Part B): rituximab 375 mg/m2 IV Day
1, 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, methotrexate 12 mg IT Day 2, cytarabine 70
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 the first 4 cycles (A-B-A-B)
of therapy.
Note to All Staff (1)
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Zztestonc,Jeff J [2507481]
8/23/2016 8:43:56 AM Page 15 of 41
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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 lymphoma, patient will receive twice weekly IT chemotherapy with alternating methotrexate and cytarabine until
CSF is negative for two consecutive lumbar punctures then weekly IT chemotherapy with alternating methotrexate and cytarabine for
4 weeks then resume intrathecal chemotherapy prophylactic regimen.
Note to all Staff (3)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
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) 70 mg in sodium chloride 0.9 % 1.4 mL intraTHECAL injection
70 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 administered 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 R-Hyper-CVAD (Part A) – Planned for 10/14/2016
Treatment Plan Information
Reference Information (1)
ACUTE LYMPHOBLASTIC LYMPHOMA: Thomas D, et al. Blood. 2004; 104(6):1624-30
Treatment Plan Summary
DISEASE: Acute Lymphoblastic Lymphoma; THERAPY (Part A): dexamethasone 40 mg PO/IV Day 1 through 4 and Day 11 through
14, rituximab 375 mg/m2 IV Day 1, cyclophosphamide 300 mg/m2 IV every 12 hours Day 1, 2 and 3, DOXOrubicin 50 mg/m2 IV
continous infusion over 24 hours starting Day 3, vinCRIStine 2 mg IV Day 4 and 11, methotrexate 12 mg IT Day 2, cytarabine 70 mg
IT Day 8, hydrocortisone 30 mg IT may be given with IT chemotherapy followed by THERAPY (Part B): rituximab 375 mg/m2 IV Day
1, 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
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Zztestonc,Jeff J [2507481]
8/23/2016 8:43:56 AM Page 16 of 41
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08/2016CCKM@uwhealth.org

equal to 0.05 uM/L, cytarabine 3000 mg/m2 IV every 12 hours Day 2 and 3, methotrexate 12 mg IT Day 2, cytarabine 70
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 the first 4 cycles (A-B-A-B)
of therapy.
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 lymphoma, patient will receive twice weekly IT chemotherapy with alternating methotrexate and cytarabine until
CSF is negative for two consecutive lumbar punctures then weekly IT chemotherapy with alternating methotrexate and cytarabine for
4 weeks then resume intrathecal chemotherapy prophylactic regimen.
Note to all Staff (3)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
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
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Zztestonc,Jeff J [2507481]
8/23/2016 8:43:56 AM Page 17 of 41
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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.
Cycle 4 R-Hyper-CVAD (Part B) – 10/25/2016 through 11/14/2016 (21 days), Planned
Day 1 through 3 (Inpatient), Cycle 4 R-Hyper-CVAD (Part B) – Planned for 10/25/2016
Treatment Plan Information
Reference Information (1)
ACUTE LYMPHOBLASTIC LYMPHOMA: Thomas D, et al. Blood. 2004; 104(6):1624-30
Treatment Plan Summary
DISEASE: Acute Lymphoblastic Lymphoma; THERAPY (Part A): dexamethasone 40 mg PO/IV Day 1 through 4 and Day 11 through
14, rituximab 375 mg/m2 IV Day 1, cyclophosphamide 300 mg/m2 IV every 12 hours Day 1, 2 and 3, DOXOrubicin 50 mg/m2 IV
continous infusion over 24 hours starting Day 3, vinCRIStine 2 mg IV Day 4 and 11, methotrexate 12 mg IT Day 2, cytarabine 70 mg
IT Day 8, hydrocortisone 30 mg IT may be given with IT chemotherapy followed by THERAPY (Part B): rituximab 375 mg/m2 IV Day
1, 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, methotrexate 12 mg IT Day 2, cytarabine 70
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 the first 4 cycles (A-B-A-B)
of therapy.
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 lymphoma, patient will receive twice weekly IT chemotherapy with alternating methotrexate and cytarabine until
CSF is negative for two consecutive lumbar punctures then weekly IT chemotherapy with alternating methotrexate and cytarabine for
4 weeks then resume intrathecal chemotherapy prophylactic regimen.
Note to all Staff (3)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
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.
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Zztestonc,Jeff J [2507481]
8/23/2016 8:43:56 AM Page 18 of 41
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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
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6 months since
last dose. For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
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 8:43:56 AM Page 19 of 41
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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.
Monitoring Parameters (4)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with rituximab.
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.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Vital Signs every 15 minutes for the first 60 minutes and then every 30 minutes until rituximab infusion complete. If patient
experiences fever accompanied by chills or rigors, shortness of breath, chest pain, or hypotension, stop infusion and contact MD.
Once the patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
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
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to rituximab.
ondansetron (ZOFRAN) tab 12 mg
12 mg, Oral, EVERY 12 HOURS, 6 doses Starting when released
Give prior to chemotherapy. May give IV if unable to tolerate PO.
ondansetron (ZOFRAN) 12 mg in sodium chloride 0.9 % 50 mL bag
12 mg, Intravenous, EVERY 12 HOURS PRN, For 4 days Starting when released until S+4, nausea/vomiting
Give prior to chemotherapy if patient unable to tolerate PO.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, 1 X DAILY, 3 doses Starting when released
Give prior to chemotherapy. May give IV if unable to tolerate PO.
dexamethasone (DECADRON) 10 MG/ML injection 8 mg
8 mg, Intravenous, 1 X DAILY PRN, For 4 days Starting when released, nausea/vomiting
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.
Emergency Medications
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Zztestonc,Jeff J [2507481]
8/23/2016 8:43:56 AM Page 20 of 41
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diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
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
rituximab (RITUXAN) 750 mg in sodium chloride 0.9 % 500 mL bag
750 mg (375 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity Risk. See Emergency Medications. Administer rituximab prior to any chemotherapy. See Note on MAR for infusion
rates. If patient experiences fever accompanied by chills or rigors, shortness of breath, chest pain or hypotension, contact MD. Once
the patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
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)
acyclovir (ZOVIRAX) tab 400 mg
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Zztestonc,Jeff J [2507481]
8/23/2016 8:43:56 AM Page 21 of 41
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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 4 R-Hyper-CVAD (Part B) – Planned for 11/1/2016
Treatment Plan Information
Reference Information (1)
ACUTE LYMPHOBLASTIC LYMPHOMA: Thomas D, et al. Blood. 2004; 104(6):1624-30
Treatment Plan Summary
DISEASE: Acute Lymphoblastic Lymphoma; THERAPY (Part A): dexamethasone 40 mg PO/IV Day 1 through 4 and Day 11 through
14, rituximab 375 mg/m2 IV Day 1, cyclophosphamide 300 mg/m2 IV every 12 hours Day 1, 2 and 3, DOXOrubicin 50 mg/m2 IV
continous infusion over 24 hours starting Day 3, vinCRIStine 2 mg IV Day 4 and 11, methotrexate 12 mg IT Day 2, cytarabine 70 mg
IT Day 8, hydrocortisone 30 mg IT may be given with IT chemotherapy followed by THERAPY (Part B): rituximab 375 mg/m2 IV Day
1, 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, methotrexate 12 mg IT Day 2, cytarabine 70
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Zztestonc,Jeff J [2507481]
8/23/2016 8:43:56 AM Page 22 of 41
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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 the first 4 cycles (A-B-A-B)
of therapy.
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 lymphoma, patient will receive twice weekly IT chemotherapy with alternating methotrexate and cytarabine until
CSF is negative for two consecutive lumbar punctures then weekly IT chemotherapy with alternating methotrexate and cytarabine for
4 weeks then resume intrathecal chemotherapy prophylactic regimen.
Note to all Staff (3)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
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) 70 mg in sodium chloride 0.9 % 1.4 mL intraTHECAL injection
70 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 administered by provider.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 R-Hyper-CVAD (Part A) – 11/15/2016 through 12/5/2016 (21 days), Planned
Day 1 through 4 (Inpatient), Cycle 5 R-Hyper-CVAD (Part A) – Planned for 11/15/2016
Treatment Plan Information
Reference Information (1)
ACUTE LYMPHOBLASTIC LYMPHOMA: Thomas D, et al. Blood. 2004; 104(6):1624-30
Treatment Plan Summary
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Zztestonc,Jeff J [2507481]
8/23/2016 8:43:56 AM Page 23 of 41
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08/2016CCKM@uwhealth.org

DISEASE: Acute Lymphoblastic Lymphoma; THERAPY (Part A): dexamethasone 40 mg PO/IV Day 1 through 4
and Day 11 through 14, rituximab 375 mg/m2 IV Day 1, cyclophosphamide 300 mg/m2 IV every 12 hours Day 1, 2
and 3, DOXOrubicin 50 mg/m2 IV continous infusion over 24 hours starting Day 3, vinCRIStine 2 mg IV Day 4 and
11, methotrexate 12 mg IT Day 2, cytarabine 70 mg IT Day 8, hydrocortisone 30 mg IT may be given with IT
chemotherapy followed by THERAPY (Part B): rituximab 375 mg/m2 IV Day 1, 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, methotrexate 12 mg IT Day
2, cytarabine 70
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
the first 4 cycles (A-B-A-B) of therapy.
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 lymphoma, patient will receive twice weekly IT chemotherapy with alternating methotrexate and cytarabine until
CSF is negative for two consecutive lumbar punctures then weekly IT chemotherapy with alternating methotrexate and cytarabine for
4 weeks then resume intrathecal chemotherapy prophylactic regimen.
Note to all Staff (3)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
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
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6 months since
last dose. For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
Monitoring Parameters (1)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with rituximab.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Vital Signs every 15 minutes for the first 60 minutes and then every 30 minutes until rituximab infusion complete. If patient
experiences fever accompanied by chills or rigors, shortness of breath, chest pain, or hypotension, stop infusion and contact MD.
Once the patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
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 8:43:56 AM Page 24 of 41
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at 100 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to rituximab.
ondansetron (ZOFRAN) tab 12 mg
12 mg, Oral, EVERY 12 HOURS, 8 doses Starting when released
Give prior to chemotherapy. May give IV if unable to tolerate PO. If DOXOrubicin given over 48 hours, add 2 doses for a total of 10
doses.
ondansetron (ZOFRAN) 12 mg in sodium chloride 0.9 % 50 mL bag
12 mg, Intravenous, EVERY 12 HOURS PRN, For 6 days Starting when released until S+6, nausea/vomiting
Give prior to chemotherapy if patient unable to tolerate PO.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
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.
rituximab (RITUXAN) 750 mg in sodium chloride 0.9 % 500 mL bag
750 mg (375 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity Risk. See Emergency Medications. Administer rituximab prior to any chemotherapy. See Note on MAR for infusion
rates. If patient experiences fever accompanied by chills or rigors, shortness of breath, chest pain or hypotension, contact MD. Once
the patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
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)
acyclovir (ZOVIRAX) tab 400 mg
400 mg, Oral, 2 X DAILY Starting when released
fluconazole (DIFLUCAN) tab 400 mg
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Zztestonc,Jeff J [2507481]
8/23/2016 8:43:56 AM Page 25 of 41
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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 11 FOLLOW-UP
LABS: CBC with DIFF; CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine for 30 minutes
DAY 22 FOLLOW-UP
(Day 1 of next cycle) Schedule preadmission to B6/6 for chemotherapy administration.
Day 11 (Outpatient), Cycle 5 R-Hyper-CVAD (Part A) – Planned for 11/25/2016
Treatment Plan Information
Reference Information (1)
ACUTE LYMPHOBLASTIC LYMPHOMA: Thomas D, et al. Blood. 2004; 104(6):1624-30
Treatment Plan Summary
DISEASE: Acute Lymphoblastic Lymphoma; THERAPY (Part A): dexamethasone 40 mg PO/IV Day 1 through 4 and Day 11 through
14, rituximab 375 mg/m2 IV Day 1, cyclophosphamide 300 mg/m2 IV every 12 hours Day 1, 2 and 3, DOXOrubicin 50 mg/m2 IV
continous infusion over 24 hours starting Day 3, vinCRIStine 2 mg IV Day 4 and 11, methotrexate 12 mg IT Day 2, cytarabine 70 mg
IT Day 8, hydrocortisone 30 mg IT may be given with IT chemotherapy followed by THERAPY (Part B): rituximab 375 mg/m2 IV Day
1, 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, methotrexate 12 mg IT Day 2, cytarabine 70
mg IT Day 8, hydrocortisone 30 mg IT may be given with IT chemotherapy; CYCLE LENGTH: 21 days; COURSE: 8 alternating
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Zztestonc,Jeff J [2507481]
8/23/2016 8:43:56 AM Page 26 of 41
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2016CCKM@uwhealth.org

cycles (A-B-A-B-A-B-A-B); NOTE: IT chemotherapy for CNS prophylaxis will be given on Day 2 and 8 of the first 4 cycles (A-B-A-B)
of therapy.
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 lymphoma, patient will receive twice weekly IT chemotherapy with alternating methotrexate and cytarabine until
CSF is negative for two consecutive lumbar punctures then weekly IT chemotherapy with alternating methotrexate and cytarabine for
4 weeks then resume intrathecal chemotherapy prophylactic regimen.
Note to all Staff (3)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
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
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Zztestonc,Jeff J [2507481]
8/23/2016 8:43:56 AM Page 27 of 41
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2016CCKM@uwhealth.org

VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 R-Hyper-CVAD (Part B) – 12/6/2016 through 12/26/2016 (21 days), Planned
Day 1 through 3 (Inpatient), Cycle 6 R-Hyper-CVAD (Part B) – Planned for 12/6/2016
Treatment Plan Information
Reference Information (1)
ACUTE LYMPHOBLASTIC LYMPHOMA: Thomas D, et al. Blood. 2004; 104(6):1624-30
Treatment Plan Summary
DISEASE: Acute Lymphoblastic Lymphoma; THERAPY (Part A): dexamethasone 40 mg PO/IV Day 1 through 4 and Day 11 through
14, rituximab 375 mg/m2 IV Day 1, cyclophosphamide 300 mg/m2 IV every 12 hours Day 1, 2 and 3, DOXOrubicin 50 mg/m2 IV
continous infusion over 24 hours starting Day 3, vinCRIStine 2 mg IV Day 4 and 11, methotrexate 12 mg IT Day 2, cytarabine 70 mg
IT Day 8, hydrocortisone 30 mg IT may be given with IT chemotherapy followed by THERAPY (Part B): rituximab 375 mg/m2 IV Day
1, 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, methotrexate 12 mg IT Day 2, cytarabine 70
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 the first 4 cycles (A-B-A-B)
of therapy.
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 lymphoma, patient will receive twice weekly IT chemotherapy with alternating methotrexate and cytarabine until
CSF is negative for two consecutive lumbar punctures then weekly IT chemotherapy with alternating methotrexate and cytarabine for
4 weeks then resume intrathecal chemotherapy prophylactic regimen.
Note to all Staff (3)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
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)
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Zztestonc,Jeff J [2507481]
8/23/2016 8:43:56 AM Page 28 of 41
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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
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6 months since
last dose. For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
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 8:43:56 AM Page 29 of 41
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
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.
Monitoring Parameters (4)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with rituximab.
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.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Vital Signs every 15 minutes for the first 60 minutes and then every 30 minutes until rituximab infusion complete. If patient
experiences fever accompanied by chills or rigors, shortness of breath, chest pain, or hypotension, stop infusion and contact MD.
Once the patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
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
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to rituximab.
ondansetron (ZOFRAN) tab 12 mg
12 mg, Oral, EVERY 12 HOURS, 6 doses Starting when released
Give prior to chemotherapy. May give IV if unable to tolerate PO.
ondansetron (ZOFRAN) 12 mg in sodium chloride 0.9 % 50 mL bag
12 mg, Intravenous, EVERY 12 HOURS PRN, For 4 days Starting when released until S+4, nausea/vomiting
Give prior to chemotherapy if patient unable to tolerate PO.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, 1 X DAILY, 3 doses Starting when released
Give prior to chemotherapy. May give IV if unable to tolerate PO.
dexamethasone (DECADRON) 10 MG/ML injection 8 mg
8 mg, Intravenous, 1 X DAILY PRN, For 4 days Starting when released, nausea/vomiting
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.
Emergency Medications
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Zztestonc,Jeff J [2507481]
8/23/2016 8:43:56 AM Page 30 of 41
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2016CCKM@uwhealth.org

diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
rituximab (RITUXAN) 750 mg in sodium chloride 0.9 % 500 mL bag
750 mg (375 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity Risk. See Emergency Medications. Administer rituximab prior to any chemotherapy. See Note on MAR for infusion
rates. If patient experiences fever accompanied by chills or rigors, shortness of breath, chest pain or hypotension, contact MD. Once
the patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
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)
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
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Zztestonc,Jeff J [2507481]
8/23/2016 8:43:56 AM Page 31 of 41
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2016CCKM@uwhealth.org

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.
Cycle 7 R-Hyper-CVAD (Part A) – 12/27/2016 through 1/16/2017 (21 days), Planned
Day 1 through 4 (Inpatient), Cycle 7 R-Hyper-CVAD (Part A) – Planned for 12/27/2016
Treatment Plan Information
Reference Information (1)
ACUTE LYMPHOBLASTIC LYMPHOMA: Thomas D, et al. Blood. 2004; 104(6):1624-30
Treatment Plan Summary
DISEASE: Acute Lymphoblastic Lymphoma; THERAPY (Part A): dexamethasone 40 mg PO/IV Day 1 through 4 and Day 11 through
14, rituximab 375 mg/m2 IV Day 1, cyclophosphamide 300 mg/m2 IV every 12 hours Day 1, 2 and 3, DOXOrubicin 50 mg/m2 IV
continous infusion over 24 hours starting Day 3, vinCRIStine 2 mg IV Day 4 and 11, methotrexate 12 mg IT Day 2, cytarabine 70 mg
IT Day 8, hydrocortisone 30 mg IT may be given with IT chemotherapy followed by THERAPY (Part B): rituximab 375 mg/m2 IV Day
1, 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, methotrexate 12 mg IT Day 2, cytarabine 70
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 the first 4 cycles (A-B-A-B)
of therapy.
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 lymphoma, patient will receive twice weekly IT chemotherapy with alternating methotrexate and cytarabine until
CSF is negative for two consecutive lumbar punctures then weekly IT chemotherapy with alternating methotrexate and cytarabine for
4 weeks then resume intrathecal chemotherapy prophylactic regimen.
Note to all Staff (3)
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Zztestonc,Jeff J [2507481]
8/23/2016 8:43:56 AM Page 32 of 41
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2016CCKM@uwhealth.org

Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or
death. Screen patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
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
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6 months since
last dose. For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
Monitoring Parameters (1)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with rituximab.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Vital Signs every 15 minutes for the first 60 minutes and then every 30 minutes until rituximab infusion complete. If patient
experiences fever accompanied by chills or rigors, shortness of breath, chest pain, or hypotension, stop infusion and contact MD.
Once the patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
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
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to rituximab.
ondansetron (ZOFRAN) tab 12 mg
12 mg, Oral, EVERY 12 HOURS, 8 doses Starting when released
Give prior to chemotherapy. May give IV if unable to tolerate PO. If DOXOrubicin given over 48 hours, add 2 doses for a total of 10
doses.
ondansetron (ZOFRAN) 12 mg in sodium chloride 0.9 % 50 mL bag
12 mg, Intravenous, EVERY 12 HOURS PRN, For 6 days Starting when released until S+6, nausea/vomiting
Give prior to chemotherapy if patient unable to tolerate PO.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
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Zztestonc,Jeff J [2507481]
8/23/2016 8:43:56 AM Page 33 of 41
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2016CCKM@uwhealth.org

25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
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.
rituximab (RITUXAN) 750 mg in sodium chloride 0.9 % 500 mL bag
750 mg (375 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity Risk. See Emergency Medications. Administer rituximab prior to any chemotherapy. See Note on MAR for infusion
rates. If patient experiences fever accompanied by chills or rigors, shortness of breath, chest pain or hypotension, contact MD. Once
the patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
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)
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 8:43:56 AM Page 34 of 41
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 11 FOLLOW-UP
LABS: CBC with DIFF; CHEMOTHERAPY ROOM APPOINTMENT: vinCRIStine for 30 minutes
DAY 22 FOLLOW-UP
(Day 1 of next cycle) Schedule preadmission to B6/6 for chemotherapy administration.
Day 11 (Outpatient), Cycle 7 R-Hyper-CVAD (Part A) – Planned for 1/6/2017
Treatment Plan Information
Reference Information (1)
ACUTE LYMPHOBLASTIC LYMPHOMA: Thomas D, et al. Blood. 2004; 104(6):1624-30
Treatment Plan Summary
DISEASE: Acute Lymphoblastic Lymphoma; THERAPY (Part A): dexamethasone 40 mg PO/IV Day 1 through 4 and Day 11 through
14, rituximab 375 mg/m2 IV Day 1, cyclophosphamide 300 mg/m2 IV every 12 hours Day 1, 2 and 3, DOXOrubicin 50 mg/m2 IV
continous infusion over 24 hours starting Day 3, vinCRIStine 2 mg IV Day 4 and 11, methotrexate 12 mg IT Day 2, cytarabine 70 mg
IT Day 8, hydrocortisone 30 mg IT may be given with IT chemotherapy followed by THERAPY (Part B): rituximab 375 mg/m2 IV Day
1, 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, methotrexate 12 mg IT Day 2, cytarabine 70
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 the first 4 cycles (A-B-A-B)
of therapy.
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 lymphoma, patient will receive twice weekly IT chemotherapy with alternating methotrexate and cytarabine until
CSF is negative for two consecutive lumbar punctures then weekly IT chemotherapy with alternating methotrexate and cytarabine for
4 weeks then resume intrathecal chemotherapy prophylactic regimen.
Note to all Staff (3)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
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
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Zztestonc,Jeff J [2507481]
8/23/2016 8:43:56 AM Page 35 of 41
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2016CCKM@uwhealth.org

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.
Cycle 8 R-Hyper-CVAD (Part B) – 1/17/2017 through 2/6/2017 (21 days), Planned
Day 1 through 3 (Inpatient), Cycle 8 R-Hyper-CVAD (Part B) – Planned for 1/17/2017
Treatment Plan Information
Reference Information (1)
ACUTE LYMPHOBLASTIC LYMPHOMA: Thomas D, et al. Blood. 2004; 104(6):1624-30
Treatment Plan Summary
DISEASE: Acute Lymphoblastic Lymphoma; THERAPY (Part A): dexamethasone 40 mg PO/IV Day 1 through 4 and Day 11 through
14, rituximab 375 mg/m2 IV Day 1, cyclophosphamide 300 mg/m2 IV every 12 hours Day 1, 2 and 3, DOXOrubicin 50 mg/m2 IV
continous infusion over 24 hours starting Day 3, vinCRIStine 2 mg IV Day 4 and 11, methotrexate 12 mg IT Day 2, cytarabine 70 mg
IT Day 8, hydrocortisone 30 mg IT may be given with IT chemotherapy followed by THERAPY (Part B): rituximab 375 mg/m2 IV Day
1, 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, methotrexate 12 mg IT Day 2, cytarabine 70
mg IT Day 8, hydrocortisone 30 mg IT may be given with IT chemotherapy; CYCLE LENGTH: 21 days; COURSE: 8 alternating
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Zztestonc,Jeff J [2507481]
8/23/2016 8:43:56 AM Page 36 of 41
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cycles (A-B-A-B-A-B-A-B); NOTE: IT chemotherapy for CNS prophylaxis will be given on Day 2 and 8 of the first 4 cycles (A-B-A-B)
of therapy.
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 lymphoma, patient will receive twice weekly IT chemotherapy with alternating methotrexate and cytarabine until
CSF is negative for two consecutive lumbar punctures then weekly IT chemotherapy with alternating methotrexate and cytarabine for
4 weeks then resume intrathecal chemotherapy prophylactic regimen.
Note to all Staff (3)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
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.
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8/23/2016 8:43:56 AM Page 37 of 41
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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
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6 months since
last dose. For first and second dose patient should be treated in a location to optimize emergency care. See Emergency Meds.
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.
Monitoring Parameters (4)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with rituximab.
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.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Vital Signs every 15 minutes for the first 60 minutes and then every 30 minutes until rituximab infusion complete. If patient
experiences fever accompanied by chills or rigors, shortness of breath, chest pain, or hypotension, stop infusion and contact MD.
Once the patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
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
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Zztestonc,Jeff J [2507481]
8/23/2016 8:43:56 AM Page 38 of 41
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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
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to rituximab.
ondansetron (ZOFRAN) tab 12 mg
12 mg, Oral, EVERY 12 HOURS, 6 doses Starting when released
Give prior to chemotherapy. May give IV if unable to tolerate PO.
ondansetron (ZOFRAN) 12 mg in sodium chloride 0.9 % 50 mL bag
12 mg, Intravenous, EVERY 12 HOURS PRN, For 4 days Starting when released until S+4, nausea/vomiting
Give prior to chemotherapy if patient unable to tolerate PO.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, 1 X DAILY, 3 doses Starting when released
Give prior to chemotherapy. May give IV if unable to tolerate PO.
dexamethasone (DECADRON) 10 MG/ML injection 8 mg
8 mg, Intravenous, 1 X DAILY PRN, For 4 days Starting when released, nausea/vomiting
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.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
rituximab (RITUXAN) 750 mg in sodium chloride 0.9 % 500 mL bag
750 mg (375 mg/m2 × 2 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity Risk. See Emergency Medications. Administer rituximab prior to any chemotherapy. See Note on MAR for infusion
rates. If patient experiences fever accompanied by chills or rigors, shortness of breath, chest pain or hypotension, contact MD. Once
the patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
methotrexate PF 400 mg in dextrose 5 % 250 mL bag
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Zztestonc,Jeff J [2507481]
8/23/2016 8:43:56 AM Page 39 of 41
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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)
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
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Zztestonc,Jeff J [2507481]
8/23/2016 8:43:56 AM Page 40 of 41
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
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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 22 FOLLOW-UP
(Day 1 of next cycle) Schedule preadmission to B6/6 for chemotherapy administration.
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Zztestonc,Jeff J [2507481]
8/23/2016 8:43:56 AM Page 41 of 41
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2016CCKM@uwhealth.org