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201605136

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UWHC,UWMF,

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

CSC Hem Inpt Dose Adjusted EPOCH Plus Rituximab Ver 2-2-16 (HL 4418)

CSC Hem Inpt Dose Adjusted EPOCH Plus Rituximab Ver 2-2-16 (HL 4418) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Lymphoma


CSC HEM INPT DOSE ADJUSTED EPOCH PLUS RITUXIMAB VER: 2-2-16 – Properties
Cycle 1 – 2/4/2016 through 2/24/2016 (21 days), Planned
Days 1 through 6 (Inpatient) , Cycle 1 – Planned for 2/4/2016 through 2/9/2016
Treatment Plan Information
Reference Information (1)
NON-HODGKIN LYMPHOMA: Purroy N, et al. Br J Haematol 2015;169(2):188-98.
Reference Information (2)
NON-HODGKIN LYMPHOMA: Petrich AM, et al. Blood 2014;124(15):2354-61.
Reference Information (3)
NON-HODGKIN LYMPHOMA: Howlett C, et al. Br J Haematol;170(4):504-14.
Reference Information (4)
BURKITTS LYMPHOMA: Dunleavy K, et al. N Eng J Med 2013;369(20):1915-20.
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma/ Burkitts Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1,
prednisone 60 mg/m2 by mouth twice daily Day 1 through 5, etoposide 50 mg/m2/day IV continuous infusion over 24
hours Day 1 through 4 (infuse over 96 hours: Total dose = 200 mg/m2), vinCRIStine 0.4 mg/m2/day IV continous
infusion over 24 hours Day 1 through 4 (infuse over 96 hours: Total dose = 1.6 mg/m2), doxorubicin 10 mg/m2/day IV
continuous infusion over 24 hours Day 1 through 4 (infuse over 96 hours: Total dose = 40 mg/m2), cyclophosphamide
750 mg/m2 IV Day 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 4 to 8 cycles. Note: CSF
negative patients receive methotrexate 12 mg IT Days 1 and 5 of Cycles 3, 4, 5 and 6.
NOTE : Doses listed above are for cycle 1. For subsequent cycles of doxorubicin, etoposide, and cyclophosphamide see
dose calculation instructions below. Doses are not adjusted per protocol for prednisone, rituximab and vinCRIStine.
Note to All Staff (1)
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.
Dose Calculation Instructions
All patients will be started on dose level 1 for cycle 1. If ANC nadir is greater than or equal to 500/uL
increase one dose level. If ANC nadir less than 500/uL for 1 or 2 measurements maintain the same dose level. If ANC
nadir less than 500/uL on at least 3 measurements decrease one dose level. OR if the platelet count is less than 25/uL
on one measurement decrease one dose level
Dose Calculation Instructions
Doxorubicin dose adjustment: Dose Level (Dose): -3(10 mg/m2/day), -2(10 mg/m2/day), -1(10
mg/m2/day), 1(10 mg/m2/day), 2(12 mg/m2/day), 3(14.4 mg/m2/day), 4(17.3 mg/m2/day), 5(20.7 mg/m2/day), 6
(24.8 mg/m2/day), 7(29.8 mg/m2/day),
Dose Calculation Instructions
Etoposide dose adjustment: Dose Level (Dose): -3(50 mg/m2/day), -2(50 mg/m2/day), -1(50
mg/m2/day), 1(50 mg/m2/day), 2(60 mg/m2/day), 3(72 mg/m2/day), 4(86.4 mg/m2/day), 5(103.7 mg/m2/day), 6
(124.4 mg/m2/day), 7(149.3 mg/m2/day),
Dose Calculation Instructions
Cyclophosphamide dose adjustment: Dose Level (Dose): -3(384 mg/m2), -2(480 mg/m2), -1(600
mg/m2), 1(750 mg/m2), 2(900 mg/m2), 3(1080 mg/m2), 4(1296 mg/m2), 5(1555 mg/m2), 6(1866 mg/m2), 7
(2239 mg/m2),
Dose Per Protocol
Dose level for current cycle *** . Date of current cycle ***. DO NOT PROPAGATE THIS ORDER.
Consent
Verify Consent
Verify informed consent has been obtained.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:17:04 PM Page 1 of 30
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Pre-Labs
CBC WITH DIFFERENTIAL
ONCE Starting when released, Routine
CREATININE
ONCE Starting when released, Routine
BILIRUBIN, TOTAL
ONCE Starting when released
POTASSIUM
EVERY MONDAY AND THURSDAY Starting S As Scheduled for 2 occurrences
URIC ACID
EVERY MONDAY AND THURSDAY Starting S As Scheduled for 2 occurrences
LD, TOTAL
EVERY MONDAY AND THURSDAY Starting S As Scheduled for 2 occurrences
HEPATITIS B CORE AB, TOTAL
ONCE Starting when released
HEPATITIS B SURFACE AG
ONCE Starting when released
HEPATITIS B SURFACE AB
ONCE Starting when released
Pre-Labs (delete all that do not apply)
HEPATITIS B DNA, ULTRA QUANT, PCR
ONCE Starting when released
Draw if Hepatitis B Core AB is positive.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin, Uric Acid,
Potassium, LDH.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (2)
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.
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.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:17:04 PM Page 2 of 30
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

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
Days 1 through 6: Administer at 100 mL/hr continuously. When chemotherapy starts, keep TOTAL IV fluids at 100 mL/hr.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, EVERY 24 HOURS, 5 doses Starting when released
Days 1 through 5: Administer first dose prior to start of chemotherapy. May give IV if PO not tolerated.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, nausea/vomiting, if unable to tolerate PO
Days 1 through 5: Administer first dose prior to start of chemotherapy. May give IV if PO not tolerated.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 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
prednisone (DELTASONE) tab 125.5 mg
125.5 mg (rounded from 125.4 mg = 60 mg/m2 × 2.09 m2 Treatment plan actual BSA), Oral, 2 X DAILY,
For 5 days Starting when released
Days 1 through 5: Administer first dose 30 to 60 minutes prior to start of chemotherapy.
rituximab (RITUXAN) 784 mg in sodium chloride 0.9 % 500 mL bag
784 mg (rounded from 783.75 mg = 375 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous,
ONCE, 1 dose Starting when released
Day 1: 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.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:17:04 PM Page 3 of 30
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

etoposide (VEPESID) 105 mg, vinCRIStine (ONCOVIN) 0.8 mg, doxorubicin CONVENTIONAL (ADRIAMYCIN)
21 mg, sodium chloride 0.9 % 1,000 mL bag
Intravenous, EVERY 24 HOURS, 4 doses Starting when released
Day 1-4: Continuous infusion over 24 hours days 1 through 4 for a total of 96 hour. (etoposide Total dose =
200mg/m2/96 hours, vinCRIStine Total dose = 1.6 mg/m2/96 hours, doxorubicin Total dose = 40 mg/m2/96hours.).
cyclophosphamide (CYTOXAN) 1,567.6 mg in sodium chloride 0.9 % 250 mL bag
1,567.6 mg (rounded from 1,567.5 mg = 750 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous
Day 5.
Cyclophosphamide dose less than 2000 mg infuse IV over 30 minutes.
Cyclophosphamide dose 2000 mg to 3999 mg infuse IV over 90 minutes.
Cyclophosphamide dose greater than 4000 mg infuse IV over 120 minutes.
Supportive Care Medications (delete all that do not apply)
allopurinol (ZYLOPRIM) tab 300 mg
300 mg, Oral, 1 X DAILY, 10 doses Starting S As Scheduled
Day 1-10: Administer daily during Cycle 1.
acyclovir (ZOVIRAX) tab 400 mg
400 mg, Oral, 2 X DAILY Starting S As Scheduled
fluconazole (DIFLUCAN) tab 400 mg
400 mg, Oral, 1 X DAILY Starting when released
ranitidine (ZANTAC) tab 150 mg
150 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 Include Now
senna-docusate (SENOKOT S) 8.6-50 MG per tab 2 tab
2 tab, Oral, 1 X DAILY (HS) Starting S As Scheduled
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
Take Home Medications (delete all that do not apply)
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
MULTIPLE DAY FOLLOW-UP (1)
INTERIM LAB APPOINTMENTS: CBC with DIFF every Monday and Thursday starting *** for all
cycles and Creatinine, Potassium, Uric Acid, LDH twice weekly for one week only during Cycle 1 starting ***.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF,
Creatinine, Total Bilirubin; NOTE: Admit to B6/6 through clinic for next Cycle
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:17:04 PM Page 4 of 30
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Cycle 2 – 2/25/2016 through 3/16/2016 (21 days), Planned
Days 1 through 6 (Inpatient) , Cycle 2 – Planned for 2/25/2016 through 3/1/2016
Treatment Plan Information
Reference Information (1)
NON-HODGKIN LYMPHOMA: Purroy N, et al. Br J Haematol 2015;169(2):188-98.
Reference Information (2)
NON-HODGKIN LYMPHOMA: Petrich AM, et al. Blood 2014;124(15):2354-61.
Reference Information (3)
NON-HODGKIN LYMPHOMA: Howlett C, et al. Br J Haematol;170(4):504-14.
Reference Information (4)
BURKITTS LYMPHOMA: Dunleavy K, et al. N Eng J Med 2013;369(20):1915-20.
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma/ Burkitts Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1,
prednisone 60 mg/m2 by mouth twice daily Day 1 through 5, etoposide 50 mg/m2/day IV continuous infusion over 24
hours Day 1 through 4 (infuse over 96 hours: Total dose = 200 mg/m2), vinCRIStine 0.4 mg/m2/day IV continous
infusion over 24 hours Day 1 through 4 (infuse over 96 hours: Total dose = 1.6 mg/m2), doxorubicin 10 mg/m2/day IV
continuous infusion over 24 hours Day 1 through 4 (infuse over 96 hours: Total dose = 40 mg/m2), cyclophosphamide
750 mg/m2 IV Day 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 4 to 8 cycles. Note: CSF
negative patients receive methotrexate 12 mg IT Days 1 and 5 of Cycles 3, 4, 5 and 6.
NOTE : Doses listed above are for cycle 1. For subsequent cycles of doxorubicin, etoposide, and cyclophosphamide see
dose calculation instructions below. Doses are not adjusted per protocol for prednisone, rituximab and vinCRIStine.
Note to All Staff (1)
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.
Dose Calculation Instructions
All patients will be started on dose level 1 for cycle 1. If ANC nadir is greater than or equal to 500/uL
increase one dose level. If ANC nadir less than 500/uL for 1 or 2 measurements maintain the same dose level. If ANC
nadir less than 500/uL on at least 3 measurements decrease one dose level. OR if the platelet count is less than 25/uL
on one measurement decrease one dose level
Dose Calculation Instructions
Doxorubicin dose adjustment: Dose Level (Dose): -3(10 mg/m2/day), -2(10 mg/m2/day), -1(10
mg/m2/day), 1(10 mg/m2/day), 2(12 mg/m2/day), 3(14.4 mg/m2/day), 4(17.3 mg/m2/day), 5(20.7 mg/m2/day), 6
(24.8 mg/m2/day), 7(29.8 mg/m2/day),
Dose Calculation Instructions
Etoposide dose adjustment: Dose Level (Dose): -3(50 mg/m2/day), -2(50 mg/m2/day), -1(50
mg/m2/day), 1(50 mg/m2/day), 2(60 mg/m2/day), 3(72 mg/m2/day), 4(86.4 mg/m2/day), 5(103.7 mg/m2/day), 6
(124.4 mg/m2/day), 7(149.3 mg/m2/day),
Dose Calculation Instructions
Cyclophosphamide dose adjustment: Dose Level (Dose): -3(384 mg/m2), -2(480 mg/m2), -1(600
mg/m2), 1(750 mg/m2), 2(900 mg/m2), 3(1080 mg/m2), 4(1296 mg/m2), 5(1555 mg/m2), 6(1866 mg/m2), 7
(2239 mg/m2),
Dose Per Protocol
Dose level for current cycle *** . Date of current cycle ***. DO NOT PROPAGATE THIS ORDER.
Consent
Verify Consent
Verify informed consent has been obtained.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:17:04 PM Page 5 of 30
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (2)
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.
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
Days 1 through 6: Administer at 100 mL/hr continuously. When chemotherapy starts, keep TOTAL IV fluids at 100 mL/hr.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:17:04 PM Page 6 of 30
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, EVERY 24 HOURS, 5 doses Starting when released
Days 1 through 5: Administer first dose prior to start of chemotherapy. May give IV if PO not tolerated.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, nausea/vomiting, if unable to tolerate PO
Days 1 through 5: Administer first dose prior to start of chemotherapy. May give IV if PO not tolerated.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 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
prednisone (DELTASONE) tab 125.5 mg
125.5 mg (rounded from 125.4 mg = 60 mg/m2 × 2.09 m2 Treatment plan actual BSA), Oral, 2 X DAILY,
For 5 days Starting when released
Days 1 through 5: Administer first dose 30 to 60 minutes prior to start of chemotherapy.
rituximab (RITUXAN) 784 mg in sodium chloride 0.9 % 500 mL bag
784 mg (rounded from 783.75 mg = 375 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous,
ONCE, 1 dose Starting when released
Day 1: 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.
etoposide (VEPESID) 105 mg, vinCRIStine (ONCOVIN) 0.8 mg, doxorubicin CONVENTIONAL (ADRIAMYCIN)
21 mg, sodium chloride 0.9 % 1,000 mL bag
Intravenous, EVERY 24 HOURS, 4 doses Starting when released
Day 1, 2, 3 and 4: Continuous infusion over 24 hours days 1 through 4 for a total of 96 hour. (etoposide Total dose =
***mg/m2/96 hours, vinCRIStine Total dose = ***mg/m2/96 hours, doxorubicin Total dose = ***mg/m2/96 hours.).
cyclophosphamide (CYTOXAN) in sodium chloride 0.9 % 250 mL bag
Intravenous
Day 5:
Cyclophosphamide dose less than 2000 mg infuse IV over 30 minutes.
Cyclophosphamide dose 2000 mg to 3999 mg infuse IV over 90 minutes.
Cyclophosphamide dose greater than 4000 mg infuse IV over 120 minutes.
Supportive Care Medications (delete all that do not apply)
acyclovir (ZOVIRAX) tab 400 mg
400 mg, Oral, 2 X DAILY Starting S As Scheduled
fluconazole (DIFLUCAN) tab 400 mg
400 mg, Oral, 1 X DAILY Starting when released
ranitidine (ZANTAC) tab 150 mg
150 mg, Oral, 1 X DAILY Starting when released
sulfamethoxazole-trimethoprim (BACTRIM DS) 800-160 MG per tab 1 tab
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:17:04 PM Page 7 of 30
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

1 tab, Oral, 2 X DAILY SAT, SUN Include Now
senna-docusate (SENOKOT S) 8.6-50 MG per tab 2 tab
2 tab, Oral, 1 X DAILY (HS) Starting S As Scheduled
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
Take Home Medications (delete all that do not apply)
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
MULTIPLE DAY FOLLOW-UP (1)
INTERIM LAB APPOINTMENTS: CBC with DIFF every Monday and Thursday starting ***
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF,
Creatinine, Total Bilirubin; NOTE: Admit to B6/6 through clinic for next Cycle
Cycle 3 – 3/17/2016 through 4/6/2016 (21 days), Planned
Days 1 through 6 (Inpatient) , Cycle 3 – Planned for 3/17/2016 through 3/22/2016
Treatment Plan Information
Reference Information (1)
NON-HODGKIN LYMPHOMA: Purroy N, et al. Br J Haematol 2015;169(2):188-98.
Reference Information (2)
NON-HODGKIN LYMPHOMA: Petrich AM, et al. Blood 2014;124(15):2354-61.
Reference Information (3)
NON-HODGKIN LYMPHOMA: Howlett C, et al. Br J Haematol;170(4):504-14.
Reference Information (4)
BURKITTS LYMPHOMA: Dunleavy K, et al. N Eng J Med 2013;369(20):1915-20.
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma/ Burkitts Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1,
prednisone 60 mg/m2 by mouth twice daily Day 1 through 5, etoposide 50 mg/m2/day IV continuous infusion over 24
hours Day 1 through 4 (infuse over 96 hours: Total dose = 200 mg/m2), vinCRIStine 0.4 mg/m2/day IV continous infusion
over 24 hours Day 1 through 4 (infuse over 96 hours: Total dose = 1.6 mg/m2), doxorubicin 10 mg/m2/day IV continuous
infusion over 24 hours Day 1 through 4 (infuse over 96 hours: Total dose = 40 mg/m2), cyclophosphamide 750 mg/m2 IV
Day 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 4 to 8 cycles. Note: CSF negative
patients receive methotrexate 12 mg IT Days 1 and 5 of Cycles 3, 4, 5 and 6.
NOTE : Doses listed above are for cycle 1. For subsequent cycles of doxorubicin, etoposide, and cyclophosphamide see
dose calculation instructions below. Doses are not adjusted per protocol for prednisone, rituximab and vinCRIStine.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:17:04 PM Page 8 of 30
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Note to All Staff (1)
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.
Dose Calculation Instructions
All patients will be started on dose level 1 for cycle 1. If ANC nadir is greater than or equal to 500/uL
increase one dose level. If ANC nadir less than 500/uL for 1 or 2 measurements maintain the same dose level. If ANC
nadir less than 500/uL on at least 3 measurements decrease one dose level. OR if the platelet count is less than 25/uL
on one measurement decrease one dose level
Dose Calculation Instructions
Doxorubicin dose adjustment: Dose Level (Dose): -3(10 mg/m2/day), -2(10 mg/m2/day), -1(10
mg/m2/day), 1(10 mg/m2/day), 2(12 mg/m2/day), 3(14.4 mg/m2/day), 4(17.3 mg/m2/day), 5(20.7 mg/m2/day), 6
(24.8 mg/m2/day), 7(29.8 mg/m2/day),
Dose Calculation Instructions
Etoposide dose adjustment: Dose Level (Dose): -3(50 mg/m2/day), -2(50 mg/m2/day), -1(50
mg/m2/day), 1(50 mg/m2/day), 2(60 mg/m2/day), 3(72 mg/m2/day), 4(86.4 mg/m2/day), 5(103.7 mg/m2/day), 6
(124.4 mg/m2/day), 7(149.3 mg/m2/day),
Dose Calculation Instructions
Cyclophosphamide dose adjustment: Dose Level (Dose): -3(384 mg/m2), -2(480 mg/m2), -1(600
mg/m2), 1(750 mg/m2), 2(900 mg/m2), 3(1080 mg/m2), 4(1296 mg/m2), 5(1555 mg/m2), 6(1866 mg/m2), 7
(2239 mg/m2),
Dose Per Protocol
Dose level for current cycle *** . Date of current cycle ***. DO NOT PROPAGATE THIS ORDER.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (2)
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.
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
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:17:04 PM Page 9 of 30
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

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
Days 1 through 6: Administer at 100 mL/hr continuously. When chemotherapy starts, keep TOTAL IV fluids at 100 mL/hr.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, EVERY 24 HOURS, 5 doses Starting when released
Days 1 through 5: Administer first dose prior to start of chemotherapy. May give IV if PO not tolerated.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, nausea/vomiting, if unable to tolerate PO
Days 1 through 5: Administer first dose prior to start of chemotherapy. May give IV if PO not tolerated.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 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 (delete all that do not apply)
LEUKEMIA/LYMPHOMA SCREEN, CSF
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:17:04 PM Page 10 of 30
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

ONCE Starting when released
methotrexate PF 12 mg in sodium chloride 0.9 % 2.4 mL intraTHECAL injection
12 mg, Intrathecal
Day 1. Indication: prophylactic CSF treatment. Dose to be given by provider.
LEUKEMIA/LYMPHOMA SCREEN, CSF
ONCE Starting S+4 at 0000
methotrexate PF 12 mg in sodium chloride 0.9 % 2.4 mL intraTHECAL injection
12 mg, Intrathecal
Day 5. Indication: prophylactic CSF treatment. Dose to be given by provider.
Treatment Medications
prednisone (DELTASONE) tab 125.5 mg
125.5 mg (rounded from 125.4 mg = 60 mg/m2 × 2.09 m2 Treatment plan actual BSA), Oral, 2 X DAILY,
For 5 days Starting when released
Days 1 through 5: Administer first dose 30 to 60 minutes prior to start of chemotherapy.
rituximab (RITUXAN) 784 mg in sodium chloride 0.9 % 500 mL bag
784 mg (rounded from 783.75 mg = 375 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous,
ONCE, 1 dose Starting when released
Day 1: 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.
etoposide (VEPESID) 105 mg, vinCRIStine (ONCOVIN) 0.8 mg, doxorubicin CONVENTIONAL (ADRIAMYCIN)
21 mg, sodium chloride 0.9 % 1,000 mL bag
Intravenous, EVERY 24 HOURS, 4 doses Starting when released
Day 1, 2, 3 and 4: Continuous infusion over 24 hours days 1 through 4 for a total of 96 hour. (etoposide Total dose =
***mg/m2/96 hours, vinCRIStine Total dose = ***mg/m2/96 hours, doxorubicin Total dose = ***mg/m2/96 hours.).
cyclophosphamide (CYTOXAN) in sodium chloride 0.9 % 250 mL bag
Intravenous
Day 5:
Cyclophosphamide dose less than 2000 mg infuse IV over 30 minutes.
Cyclophosphamide dose 2000 mg to 3999 mg infuse IV over 90 minutes.
Cyclophosphamide dose greater than 4000 mg infuse IV over 120 minutes.
Supportive Care Medications (delete all that do not apply)
acyclovir (ZOVIRAX) tab 400 mg
400 mg, Oral, 2 X DAILY Starting S As Scheduled
fluconazole (DIFLUCAN) tab 400 mg
400 mg, Oral, 1 X DAILY Starting when released
ranitidine (ZANTAC) tab 150 mg
150 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 Include Now
senna-docusate (SENOKOT S) 8.6-50 MG per tab 2 tab
2 tab, Oral, 1 X DAILY (HS) Starting S As Scheduled
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:17:04 PM Page 11 of 30
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Take Home Medications (delete all that do not apply)
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
MULTIPLE DAY FOLLOW-UP (1)
INTERIM LAB APPOINTMENTS: CBC with DIFF every Monday and Thursday starting ***
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF,
Creatinine, Total Bilirubin; NOTE: Admit to B6/6 through clinic for next Cycle
Cycle 4 – 4/7/2016 through 4/27/2016 (21 days), Planned
Days 1 through 6 (Inpatient) , Cycle 4 – Planned for 4/7/2016 through 4/12/2016
Treatment Plan Information
Reference Information (1)
NON-HODGKIN LYMPHOMA: Purroy N, et al. Br J Haematol 2015;169(2):188-98.
Reference Information (2)
NON-HODGKIN LYMPHOMA: Petrich AM, et al. Blood 2014;124(15):2354-61.
Reference Information (3)
NON-HODGKIN LYMPHOMA: Howlett C, et al. Br J Haematol;170(4):504-14.
Reference Information (4)
BURKITTS LYMPHOMA: Dunleavy K, et al. N Eng J Med 2013;369(20):1915-20.
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma/ Burkitts Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1,
prednisone 60 mg/m2 by mouth twice daily Day 1 through 5, etoposide 50 mg/m2/day IV continuous infusion over 24
hours Day 1 through 4 (infuse over 96 hours: Total dose = 200 mg/m2), vinCRIStine 0.4 mg/m2/day IV continous infusion
over 24 hours Day 1 through 4 (infuse over 96 hours: Total dose = 1.6 mg/m2), doxorubicin 10 mg/m2/day IV continuous
infusion over 24 hours Day 1 through 4 (infuse over 96 hours: Total dose = 40 mg/m2), cyclophosphamide 750 mg/m2 IV
Day 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 4 to 8 cycles. Note: CSF negative
patients receive methotrexate 12 mg IT Days 1 and 5 of Cycles 3, 4, 5 and 6.
NOTE : Doses listed above are for cycle 1. For subsequent cycles of doxorubicin, etoposide, and cyclophosphamide see
dose calculation instructions below. Doses are not adjusted per protocol for prednisone, rituximab and vinCRIStine.
Note to All Staff (1)
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.
Dose Calculation Instructions
All patients will be started on dose level 1 for cycle 1. If ANC nadir is greater than or equal to 500/uL
increase one dose level. If ANC nadir less than 500/uL for 1 or 2 measurements maintain the same dose level. If ANC
nadir less than 500/uL on at least 3 measurements decrease one dose level. OR if the platelet count is less than 25/uL
on one measurement decrease one dose level
Dose Calculation Instructions
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:17:04 PM Page 12 of 30
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Doxorubicin dose adjustment: Dose Level (Dose): -3(10 mg/m2/day), -2(10 mg/m2/day), -1(10
mg/m2/day), 1(10 mg/m2/day), 2(12 mg/m2/day), 3(14.4 mg/m2/day), 4(17.3 mg/m2/day), 5(20.7
mg/m2/day), 6(24.8 mg/m2/day), 7(29.8 mg/m2/day),
Dose Calculation Instructions
Etoposide dose adjustment: Dose Level (Dose): -3(50 mg/m2/day), -2(50 mg/m2/day), -1(50
mg/m2/day), 1(50 mg/m2/day), 2(60 mg/m2/day), 3(72 mg/m2/day), 4(86.4 mg/m2/day), 5(103.7 mg/m2/day), 6
(124.4 mg/m2/day), 7(149.3 mg/m2/day),
Dose Calculation Instructions
Cyclophosphamide dose adjustment: Dose Level (Dose): -3(384 mg/m2), -2(480 mg/m2), -1(600
mg/m2), 1(750 mg/m2), 2(900 mg/m2), 3(1080 mg/m2), 4(1296 mg/m2), 5(1555 mg/m2), 6(1866 mg/m2), 7
(2239 mg/m2),
Dose Per Protocol
Dose level for current cycle *** . Date of current cycle ***. DO NOT PROPAGATE THIS ORDER.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (2)
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.
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
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:17:04 PM Page 13 of 30
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

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
Days 1 through 6: Administer at 100 mL/hr continuously. When chemotherapy starts, keep TOTAL IV fluids at 100 mL/hr.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, EVERY 24 HOURS, 5 doses Starting when released
Days 1 through 5: Administer first dose prior to start of chemotherapy. May give IV if PO not tolerated.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, nausea/vomiting, if unable to tolerate PO
Days 1 through 5: Administer first dose prior to start of chemotherapy. May give IV if PO not tolerated.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 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 (delete all that do not apply)
LEUKEMIA/LYMPHOMA SCREEN, CSF
ONCE Starting when released
methotrexate PF 12 mg in sodium chloride 0.9 % 2.4 mL intraTHECAL injection
12 mg, Intrathecal
Day 1. Indication: prophylactic CSF treatment. Dose to be given by provider.
LEUKEMIA/LYMPHOMA SCREEN, CSF
ONCE Starting S+4 at 0000
methotrexate PF 12 mg in sodium chloride 0.9 % 2.4 mL intraTHECAL injection
12 mg, Intrathecal
Day 5. Indication: prophylactic CSF treatment. Dose to be given by provider.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:17:04 PM Page 14 of 30
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Treatment Medications
prednisone (DELTASONE) tab 125.5 mg
125.5 mg (rounded from 125.4 mg = 60 mg/m2 × 2.09 m2 Treatment plan actual BSA), Oral, 2 X DAILY,
For 5 days Starting when released
Days 1 through 5: Administer first dose 30 to 60 minutes prior to start of chemotherapy.
rituximab (RITUXAN) 784 mg in sodium chloride 0.9 % 500 mL bag
784 mg (rounded from 783.75 mg = 375 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous,
ONCE, 1 dose Starting when released
Day 1: 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.
etoposide (VEPESID) 105 mg, vinCRIStine (ONCOVIN) 0.8 mg, doxorubicin CONVENTIONAL (ADRIAMYCIN)
21 mg, sodium chloride 0.9 % 1,000 mL bag
Intravenous, EVERY 24 HOURS, 4 doses Starting when released
Day 1, 2, 3 and 4: Continuous infusion over 24 hours days 1 through 4 for a total of 96 hour. (etoposide Total dose =
***mg/m2/96 hours, vinCRIStine Total dose = ***mg/m2/96 hours, doxorubicin Total dose = ***mg/m2/96 hours.).
cyclophosphamide (CYTOXAN) in sodium chloride 0.9 % 250 mL bag
Intravenous
Day 5:
Cyclophosphamide dose less than 2000 mg infuse IV over 30 minutes.
Cyclophosphamide dose 2000 mg to 3999 mg infuse IV over 90 minutes.
Cyclophosphamide dose greater than 4000 mg infuse IV over 120 minutes.
Supportive Care Medications (delete all that do not apply)
acyclovir (ZOVIRAX) tab 400 mg
400 mg, Oral, 2 X DAILY Starting S As Scheduled
fluconazole (DIFLUCAN) tab 400 mg
400 mg, Oral, 1 X DAILY Starting when released
ranitidine (ZANTAC) tab 150 mg
150 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 Include Now
senna-docusate (SENOKOT S) 8.6-50 MG per tab 2 tab
2 tab, Oral, 1 X DAILY (HS) Starting S As Scheduled
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
Take Home Medications (delete all that do not apply)
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
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:17:04 PM Page 15 of 30
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

MULTIPLE DAY FOLLOW-UP (1)
INTERIM LAB APPOINTMENTS: CBC with DIFF every Monday and Thursday starting ***
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF,
Creatinine, Total Bilirubin; NOTE: Admit to B6/6 through clinic for next Cycle
Cycle 5 – 4/28/2016 through 5/18/2016 (21 days), Planned
Days 1 through 6 (Inpatient) , Cycle 5 – Planned for 4/28/2016 through 5/3/2016
Treatment Plan Information
Reference Information (1)
NON-HODGKIN LYMPHOMA: Purroy N, et al. Br J Haematol 2015;169(2):188-98.
Reference Information (2)
NON-HODGKIN LYMPHOMA: Petrich AM, et al. Blood 2014;124(15):2354-61.
Reference Information (3)
NON-HODGKIN LYMPHOMA: Howlett C, et al. Br J Haematol;170(4):504-14.
Reference Information (4)
BURKITTS LYMPHOMA: Dunleavy K, et al. N Eng J Med 2013;369(20):1915-20.
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma/ Burkitts Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1,
prednisone 60 mg/m2 by mouth twice daily Day 1 through 5, etoposide 50 mg/m2/day IV continuous infusion over 24
hours Day 1 through 4 (infuse over 96 hours: Total dose = 200 mg/m2), vinCRIStine 0.4 mg/m2/day IV continous infusion
over 24 hours Day 1 through 4 (infuse over 96 hours: Total dose = 1.6 mg/m2), doxorubicin 10 mg/m2/day IV continuous
infusion over 24 hours Day 1 through 4 (infuse over 96 hours: Total dose = 40 mg/m2), cyclophosphamide 750 mg/m2 IV
Day 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 4 to 8 cycles. Note: CSF negative
patients receive methotrexate 12 mg IT Days 1 and 5 of Cycles 3, 4, 5 and 6.
NOTE : Doses listed above are for cycle 1. For subsequent cycles of doxorubicin, etoposide, and cyclophosphamide see
dose calculation instructions below. Doses are not adjusted per protocol for prednisone, rituximab and vinCRIStine.
Note to All Staff (1)
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.
Dose Calculation Instructions
All patients will be started on dose level 1 for cycle 1. If ANC nadir is greater than or equal to 500/uL
increase one dose level. If ANC nadir less than 500/uL for 1 or 2 measurements maintain the same dose level. If ANC
nadir less than 500/uL on at least 3 measurements decrease one dose level. OR if the platelet count is less than 25/uL
on one measurement decrease one dose level
Dose Calculation Instructions
Doxorubicin dose adjustment: Dose Level (Dose): -3(10 mg/m2/day), -2(10 mg/m2/day), -1(10
mg/m2/day), 1(10 mg/m2/day), 2(12 mg/m2/day), 3(14.4 mg/m2/day), 4(17.3 mg/m2/day), 5(20.7 mg/m2/day), 6
(24.8 mg/m2/day), 7(29.8 mg/m2/day),
Dose Calculation Instructions
Etoposide dose adjustment: Dose Level (Dose): -3(50 mg/m2/day), -2(50 mg/m2/day), -1(50
mg/m2/day), 1(50 mg/m2/day), 2(60 mg/m2/day), 3(72 mg/m2/day), 4(86.4 mg/m2/day), 5(103.7 mg/m2/day), 6
(124.4 mg/m2/day), 7(149.3 mg/m2/day),
Dose Calculation Instructions
Cyclophosphamide dose adjustment: Dose Level (Dose): -3(384 mg/m2), -2(480 mg/m2), -1(600
mg/m2), 1(750 mg/m2), 2(900 mg/m2), 3(1080 mg/m2), 4(1296 mg/m2), 5(1555 mg/m2), 6(1866 mg/m2), 7
(2239 mg/m2),
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:17:04 PM Page 16 of 30
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Dose Per Protocol
Dose level for current cycle *** . Date of current cycle ***. DO NOT PROPAGATE THIS ORDER.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (2)
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.
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
Days 1 through 6: Administer at 100 mL/hr continuously. When chemotherapy starts, keep TOTAL IV fluids at 100 mL/hr.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:17:04 PM Page 17 of 30
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, EVERY 24 HOURS, 5 doses Starting when released
Days 1 through 5: Administer first dose prior to start of chemotherapy. May give IV if PO not tolerated.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, nausea/vomiting, if unable to tolerate PO
Days 1 through 5: Administer first dose prior to start of chemotherapy. May give IV if PO not tolerated.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 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 (delete all that do not apply)
LEUKEMIA/LYMPHOMA SCREEN, CSF
ONCE Starting when released
methotrexate PF 12 mg in sodium chloride 0.9 % 2.4 mL intraTHECAL injection
12 mg, Intrathecal
Day 1. Indication: prophylactic CSF treatment. Dose to be given by provider.
LEUKEMIA/LYMPHOMA SCREEN, CSF
ONCE Starting S+4 at 0000
methotrexate PF 12 mg in sodium chloride 0.9 % 2.4 mL intraTHECAL injection
12 mg, Intrathecal
Day 5. Indication: prophylactic CSF treatment. Dose to be given by provider.
Treatment Medications
prednisone (DELTASONE) tab 125.5 mg
125.5 mg (rounded from 125.4 mg = 60 mg/m2 × 2.09 m2 Treatment plan actual BSA), Oral, 2 X DAILY,
For 5 days Starting when released
Days 1 through 5: Administer first dose 30 to 60 minutes prior to start of chemotherapy.
rituximab (RITUXAN) 784 mg in sodium chloride 0.9 % 500 mL bag
784 mg (rounded from 783.75 mg = 375 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous,
ONCE, 1 dose Starting when released
Day 1: 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
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:17:04 PM Page 18 of 30
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

reaction occurred.
etoposide (VEPESID) 105 mg, vinCRIStine (ONCOVIN) 0.8 mg, doxorubicin CONVENTIONAL (ADRIAMYCIN)
21 mg, sodium chloride 0.9 % 1,000 mL bag
Intravenous, EVERY 24 HOURS, 4 doses Starting when released
Day 1, 2, 3 and 4: Continuous infusion over 24 hours days 1 through 4 for a total of 96 hour. (etoposide Total dose =
***mg/m2/96 hours, vinCRIStine Total dose = ***mg/m2/96 hours, doxorubicin Total dose = ***mg/m2/96 hours.).
cyclophosphamide (CYTOXAN) in sodium chloride 0.9 % 250 mL bag
Intravenous
Day 5:
Cyclophosphamide dose less than 2000 mg infuse IV over 30 minutes.
Cyclophosphamide dose 2000 mg to 3999 mg infuse IV over 90 minutes.
Cyclophosphamide dose greater than 4000 mg infuse IV over 120 minutes.
Supportive Care Medications (delete all that do not apply)
acyclovir (ZOVIRAX) tab 400 mg
400 mg, Oral, 2 X DAILY Starting S As Scheduled
fluconazole (DIFLUCAN) tab 400 mg
400 mg, Oral, 1 X DAILY Starting when released
ranitidine (ZANTAC) tab 150 mg
150 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 Include Now
senna-docusate (SENOKOT S) 8.6-50 MG per tab 2 tab
2 tab, Oral, 1 X DAILY (HS) Starting S As Scheduled
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
Take Home Medications (delete all that do not apply)
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
MULTIPLE DAY FOLLOW-UP (1)
INTERIM LAB APPOINTMENTS: CBC with DIFF every Monday and Thursday starting ***
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF,
Creatinine, Total Bilirubin; NOTE: Admit to B6/6 through clinic for next Cycle
Cycle 6 – 5/19/2016 through 6/8/2016 (21 days), Planned
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:17:04 PM Page 19 of 30
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Days 1 through 6 (Inpatient) , Cycle 6 – Planned for 5/19/2016 through 5/24/2016
Treatment Plan Information
Reference Information (1)
NON-HODGKIN LYMPHOMA: Purroy N, et al. Br J Haematol 2015;169(2):188-98.
Reference Information (2)
NON-HODGKIN LYMPHOMA: Petrich AM, et al. Blood 2014;124(15):2354-61.
Reference Information (3)
NON-HODGKIN LYMPHOMA: Howlett C, et al. Br J Haematol;170(4):504-14.
Reference Information (4)
BURKITTS LYMPHOMA: Dunleavy K, et al. N Eng J Med 2013;369(20):1915-20.
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma/ Burkitts Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1,
prednisone 60 mg/m2 by mouth twice daily Day 1 through 5, etoposide 50 mg/m2/day IV continuous infusion over 24
hours Day 1 through 4 (infuse over 96 hours: Total dose = 200 mg/m2), vinCRIStine 0.4 mg/m2/day IV continous
infusion over 24 hours Day 1 through 4 (infuse over 96 hours: Total dose = 1.6 mg/m2), doxorubicin 10 mg/m2/day IV
continuous infusion over 24 hours Day 1 through 4 (infuse over 96 hours: Total dose = 40 mg/m2), cyclophosphamide
750 mg/m2 IV Day 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 4 to 8 cycles. Note: CSF
negative patients receive methotrexate 12 mg IT Days 1 and 5 of Cycles 3, 4, 5 and 6.
NOTE : Doses listed above are for cycle 1. For subsequent cycles of doxorubicin, etoposide, and cyclophosphamide see
dose calculation instructions below. Doses are not adjusted per protocol for prednisone, rituximab and vinCRIStine.
Note to All Staff (1)
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.
Dose Calculation Instructions
All patients will be started on dose level 1 for cycle 1. If ANC nadir is greater than or equal to 500/uL
increase one dose level. If ANC nadir less than 500/uL for 1 or 2 measurements maintain the same dose level. If ANC
nadir less than 500/uL on at least 3 measurements decrease one dose level. OR if the platelet count is less than 25/uL
on one measurement decrease one dose level
Dose Calculation Instructions
Doxorubicin dose adjustment: Dose Level (Dose): -3(10 mg/m2/day), -2(10 mg/m2/day), -1(10
mg/m2/day), 1(10 mg/m2/day), 2(12 mg/m2/day), 3(14.4 mg/m2/day), 4(17.3 mg/m2/day), 5(20.7 mg/m2/day), 6
(24.8 mg/m2/day), 7(29.8 mg/m2/day),
Dose Calculation Instructions
Etoposide dose adjustment: Dose Level (Dose): -3(50 mg/m2/day), -2(50 mg/m2/day), -1(50
mg/m2/day), 1(50 mg/m2/day), 2(60 mg/m2/day), 3(72 mg/m2/day), 4(86.4 mg/m2/day), 5(103.7 mg/m2/day), 6
(124.4 mg/m2/day), 7(149.3 mg/m2/day),
Dose Calculation Instructions
Cyclophosphamide dose adjustment: Dose Level (Dose): -3(384 mg/m2), -2(480 mg/m2), -1(600
mg/m2), 1(750 mg/m2), 2(900 mg/m2), 3(1080 mg/m2), 4(1296 mg/m2), 5(1555 mg/m2), 6(1866 mg/m2), 7
(2239 mg/m2),
Dose Per Protocol
Dose level for current cycle *** . Date of current cycle ***. DO NOT PROPAGATE THIS ORDER.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:17:04 PM Page 20 of 30
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (2)
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.
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
Days 1 through 6: Administer at 100 mL/hr continuously. When chemotherapy starts, keep TOTAL IV fluids at 100 mL/hr.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, EVERY 24 HOURS, 5 doses Starting when released
Days 1 through 5: Administer first dose prior to start of chemotherapy. May give IV if PO not tolerated.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:17:04 PM Page 21 of 30
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, nausea/vomiting, if unable to tolerate PO
Days 1 through 5: Administer first dose prior to start of chemotherapy. May give IV if PO not tolerated.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 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 (delete all that do not apply)
LEUKEMIA/LYMPHOMA SCREEN, CSF
ONCE Starting when released
methotrexate PF 12 mg in sodium chloride 0.9 % 2.4 mL intraTHECAL injection
12 mg, Intrathecal
Day 1. Indication: prophylactic CSF treatment. Dose to be given by provider.
LEUKEMIA/LYMPHOMA SCREEN, CSF
ONCE Starting S+4 at 0000
methotrexate PF 12 mg in sodium chloride 0.9 % 2.4 mL intraTHECAL injection
12 mg, Intrathecal
Day 5. Indication: prophylactic CSF treatment. Dose to be given by provider.
Treatment Medications
prednisone (DELTASONE) tab 125.5 mg
125.5 mg (rounded from 125.4 mg = 60 mg/m2 × 2.09 m2 Treatment plan actual BSA), Oral, 2 X DAILY,
For 5 days Starting when released
Days 1 through 5: Administer first dose 30 to 60 minutes prior to start of chemotherapy.
rituximab (RITUXAN) 784 mg in sodium chloride 0.9 % 500 mL bag
784 mg (rounded from 783.75 mg = 375 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous,
ONCE, 1 dose Starting when released
Day 1: 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.
etoposide (VEPESID) 105 mg, vinCRIStine (ONCOVIN) 0.8 mg, doxorubicin CONVENTIONAL (ADRIAMYCIN)
21 mg, sodium chloride 0.9 % 1,000 mL bag
Intravenous, EVERY 24 HOURS, 4 doses Starting when released
Day 1, 2, 3 and 4: Continuous infusion over 24 hours days 1 through 4 for a total of 96 hour. (etoposide Total dose =
***mg/m2/96 hours, vinCRIStine Total dose = ***mg/m2/96 hours, doxorubicin Total dose = ***mg/m2/96 hours.).
cyclophosphamide (CYTOXAN) in sodium chloride 0.9 % 250 mL bag
Intravenous
Day 5:
Cyclophosphamide dose less than 2000 mg infuse IV over 30 minutes.
Cyclophosphamide dose 2000 mg to 3999 mg infuse IV over 90 minutes.
Cyclophosphamide dose greater than 4000 mg infuse IV over 120 minutes.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:17:04 PM Page 22 of 30
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Supportive Care Medications (delete all that do not apply)
acyclovir (ZOVIRAX) tab 400 mg
400 mg, Oral, 2 X DAILY Starting S As Scheduled
fluconazole (DIFLUCAN) tab 400 mg
400 mg, Oral, 1 X DAILY Starting when released
ranitidine (ZANTAC) tab 150 mg
150 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 Include Now
senna-docusate (SENOKOT S) 8.6-50 MG per tab 2 tab
2 tab, Oral, 1 X DAILY (HS) Starting S As Scheduled
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
Take Home Medications (delete all that do not apply)
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
MULTIPLE DAY FOLLOW-UP (1)
INTERIM LAB APPOINTMENTS: CBC with DIFF every Monday and Thursday starting ***
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF,
Creatinine, Total Bilirubin; NOTE: Admit to B6/6 through clinic for next Cycle
Cycle 7 – 6/9/2016 through 6/29/2016 (21 days), Planned
Days 1 through 6 (Inpatient) , Cycle 7 – Planned for 6/9/2016 through 6/14/2016
Treatment Plan Information
Reference Information (1)
NON-HODGKIN LYMPHOMA: Purroy N, et al. Br J Haematol 2015;169(2):188-98.
Reference Information (2)
NON-HODGKIN LYMPHOMA: Petrich AM, et al. Blood 2014;124(15):2354-61.
Reference Information (3)
NON-HODGKIN LYMPHOMA: Howlett C, et al. Br J Haematol;170(4):504-14.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:17:04 PM Page 23 of 30
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Reference Information (4)
BURKITTS LYMPHOMA: Dunleavy K, et al. N Eng J Med 2013;369(20):1915-20.
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma/ Burkitts Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1,
prednisone 60 mg/m2 by mouth twice daily Day 1 through 5, etoposide 50 mg/m2/day IV continuous infusion over 24
hours Day 1 through 4 (infuse over 96 hours: Total dose = 200 mg/m2), vinCRIStine 0.4 mg/m2/day IV continous infusion
over 24 hours Day 1 through 4 (infuse over 96 hours: Total dose = 1.6 mg/m2), doxorubicin 10 mg/m2/day IV continuous
infusion over 24 hours Day 1 through 4 (infuse over 96 hours: Total dose = 40 mg/m2), cyclophosphamide 750 mg/m2 IV
Day 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 4 to 8 cycles. Note: CSF negative
patients receive methotrexate 12 mg IT Days 1 and 5 of Cycles 3, 4, 5 and 6.
NOTE : Doses listed above are for cycle 1. For subsequent cycles of doxorubicin, etoposide, and cyclophosphamide see
dose calculation instructions below. Doses are not adjusted per protocol for prednisone, rituximab and vinCRIStine.
Note to All Staff (1)
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.
Dose Calculation Instructions
All patients will be started on dose level 1 for cycle 1. If ANC nadir is greater than or equal to 500/uL
increase one dose level. If ANC nadir less than 500/uL for 1 or 2 measurements maintain the same dose level. If ANC
nadir less than 500/uL on at least 3 measurements decrease one dose level. OR if the platelet count is less than 25/uL
on one measurement decrease one dose level
Dose Calculation Instructions
Doxorubicin dose adjustment: Dose Level (Dose): -3(10 mg/m2/day), -2(10 mg/m2/day), -1(10
mg/m2/day), 1(10 mg/m2/day), 2(12 mg/m2/day), 3(14.4 mg/m2/day), 4(17.3 mg/m2/day), 5(20.7 mg/m2/day), 6
(24.8 mg/m2/day), 7(29.8 mg/m2/day),
Dose Calculation Instructions
Etoposide dose adjustment: Dose Level (Dose): -3(50 mg/m2/day), -2(50 mg/m2/day), -1(50
mg/m2/day), 1(50 mg/m2/day), 2(60 mg/m2/day), 3(72 mg/m2/day), 4(86.4 mg/m2/day), 5(103.7 mg/m2/day), 6
(124.4 mg/m2/day), 7(149.3 mg/m2/day),
Dose Calculation Instructions
Cyclophosphamide dose adjustment: Dose Level (Dose): -3(384 mg/m2), -2(480 mg/m2), -1(600
mg/m2), 1(750 mg/m2), 2(900 mg/m2), 3(1080 mg/m2), 4(1296 mg/m2), 5(1555 mg/m2), 6(1866 mg/m2), 7
(2239 mg/m2),
Dose Per Protocol
Dose level for current cycle *** . Date of current cycle ***. DO NOT PROPAGATE THIS ORDER.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:17:04 PM Page 24 of 30
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (2)
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.
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
Days 1 through 6: Administer at 100 mL/hr continuously. When chemotherapy starts, keep TOTAL IV fluids at 100 mL/hr.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, EVERY 24 HOURS, 5 doses Starting when released
Days 1 through 5: Administer first dose prior to start of chemotherapy. May give IV if PO not tolerated.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, nausea/vomiting, if unable to tolerate PO
Days 1 through 5: Administer first dose prior to start of chemotherapy. May give IV if PO not tolerated.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:17:04 PM Page 25 of 30
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

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
prednisone (DELTASONE) tab 125.5 mg
125.5 mg (rounded from 125.4 mg = 60 mg/m2 × 2.09 m2 Treatment plan actual BSA), Oral, 2 X DAILY,
For 5 days Starting when released
Days 1 through 5: Administer first dose 30 to 60 minutes prior to start of chemotherapy.
rituximab (RITUXAN) 784 mg in sodium chloride 0.9 % 500 mL bag
784 mg (rounded from 783.75 mg = 375 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous,
ONCE, 1 dose Starting when released
Day 1: 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.
etoposide (VEPESID) 105 mg, vinCRIStine (ONCOVIN) 0.8 mg, doxorubicin CONVENTIONAL (ADRIAMYCIN)
21 mg, sodium chloride 0.9 % 1,000 mL bag
Intravenous, EVERY 24 HOURS, 4 doses Starting when released
Day 1, 2, 3 and 4: Continuous infusion over 24 hours days 1 through 4 for a total of 96 hour. (etoposide Total dose =
***mg/m2/96 hours, vinCRIStine Total dose = ***mg/m2/96 hours, doxorubicin Total dose = ***mg/m2/96 hours.).
cyclophosphamide (CYTOXAN) in sodium chloride 0.9 % 250 mL bag
Intravenous
Day 5:
Cyclophosphamide dose less than 2000 mg infuse IV over 30 minutes.
Cyclophosphamide dose 2000 mg to 3999 mg infuse IV over 90 minutes.
Cyclophosphamide dose greater than 4000 mg infuse IV over 120 minutes.
Supportive Care Medications (delete all that do not apply)
acyclovir (ZOVIRAX) tab 400 mg
400 mg, Oral, 2 X DAILY Starting S As Scheduled
fluconazole (DIFLUCAN) tab 400 mg
400 mg, Oral, 1 X DAILY Starting when released
ranitidine (ZANTAC) tab 150 mg
150 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 Include Now
senna-docusate (SENOKOT S) 8.6-50 MG per tab 2 tab
2 tab, Oral, 1 X DAILY (HS) Starting S As Scheduled
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
Take Home Medications (delete all that do not apply)
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
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:17:04 PM Page 26 of 30
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

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
MULTIPLE DAY FOLLOW-UP (1)
INTERIM LAB APPOINTMENTS: CBC with DIFF every Monday and Thursday starting ***
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF,
Creatinine, Total Bilirubin; NOTE: Admit to B6/6 through clinic for next Cycle
Cycle 8 – 6/30/2016 through 7/20/2016 (21 days), Planned
Days 1 through 6 (Inpatient) , Cycle 8 – Planned for 6/30/2016 through 7/5/2016
Treatment Plan Information
Reference Information (1)
NON-HODGKIN LYMPHOMA: Purroy N, et al. Br J Haematol 2015;169(2):188-98.
Reference Information (2)
NON-HODGKIN LYMPHOMA: Petrich AM, et al. Blood 2014;124(15):2354-61.
Reference Information (3)
NON-HODGKIN LYMPHOMA: Howlett C, et al. Br J Haematol;170(4):504-14.
Reference Information (4)
BURKITTS LYMPHOMA: Dunleavy K, et al. N Eng J Med 2013;369(20):1915-20.
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma/ Burkitts Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1,
prednisone 60 mg/m2 by mouth twice daily Day 1 through 5, etoposide 50 mg/m2/day IV continuous infusion over 24
hours Day 1 through 4 (infuse over 96 hours: Total dose = 200 mg/m2), vinCRIStine 0.4 mg/m2/day IV continous infusion
over 24 hours Day 1 through 4 (infuse over 96 hours: Total dose = 1.6 mg/m2), doxorubicin 10 mg/m2/day IV continuous
infusion over 24 hours Day 1 through 4 (infuse over 96 hours: Total dose = 40 mg/m2), cyclophosphamide 750 mg/m2 IV
Day 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 4 to 8 cycles. Note: CSF negative
patients receive methotrexate 12 mg IT Days 1 and 5 of Cycles 3, 4, 5 and 6.
NOTE : Doses listed above are for cycle 1. For subsequent cycles of doxorubicin, etoposide, and cyclophosphamide see
dose calculation instructions below. Doses are not adjusted per protocol for prednisone, rituximab and vinCRIStine.
Note to All Staff (1)
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.
Dose Calculation Instructions
All patients will be started on dose level 1 for cycle 1. If ANC nadir is greater than or equal to 500/uL
increase one dose level. If ANC nadir less than 500/uL for 1 or 2 measurements maintain the same dose level. If ANC
nadir less than 500/uL on at least 3 measurements decrease one dose level. OR if the platelet count is less than 25/uL
on one measurement decrease one dose level
Dose Calculation Instructions
Doxorubicin dose adjustment: Dose Level (Dose): -3(10 mg/m2/day), -2(10 mg/m2/day), -1(10
mg/m2/day), 1(10 mg/m2/day), 2(12 mg/m2/day), 3(14.4 mg/m2/day), 4(17.3 mg/m2/day), 5(20.7 mg/m2/day), 6
(24.8 mg/m2/day), 7(29.8 mg/m2/day),
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:17:04 PM Page 27 of 30
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Dose Calculation Instructions
Etoposide dose adjustment: Dose Level (Dose): -3(50 mg/m2/day), -2(50 mg/m2/day), -1(50
mg/m2/day), 1(50 mg/m2/day), 2(60 mg/m2/day), 3(72 mg/m2/day), 4(86.4 mg/m2/day), 5(103.7 mg/m2/day), 6
(124.4 mg/m2/day), 7(149.3 mg/m2/day),
Dose Calculation Instructions
Cyclophosphamide dose adjustment: Dose Level (Dose): -3(384 mg/m2), -2(480 mg/m2), -1(600
mg/m2), 1(750 mg/m2), 2(900 mg/m2), 3(1080 mg/m2), 4(1296 mg/m2), 5(1555 mg/m2), 6(1866 mg/m2), 7
(2239 mg/m2),
Dose Per Protocol
Dose level for current cycle *** . Date of current cycle ***. DO NOT PROPAGATE THIS ORDER.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (2)
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.
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
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:17:04 PM Page 28 of 30
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 100 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Days 1 through 6: Administer at 100 mL/hr continuously. When chemotherapy starts, keep TOTAL IV fluids at 100 mL/hr.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, EVERY 24 HOURS, 5 doses Starting when released
Days 1 through 5: Administer first dose prior to start of chemotherapy. May give IV if PO not tolerated.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, nausea/vomiting, if unable to tolerate PO
Days 1 through 5: Administer first dose prior to start of chemotherapy. May give IV if PO not tolerated.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 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
prednisone (DELTASONE) tab 125.5 mg
125.5 mg (rounded from 125.4 mg = 60 mg/m2 × 2.09 m2 Treatment plan actual BSA), Oral, 2 X DAILY,
For 5 days Starting when released
Days 1 through 5: Administer first dose 30 to 60 minutes prior to start of chemotherapy.
rituximab (RITUXAN) 784 mg in sodium chloride 0.9 % 500 mL bag
784 mg (rounded from 783.75 mg = 375 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous,
ONCE, 1 dose Starting when released
Day 1: 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.
etoposide (VEPESID) 105 mg, vinCRIStine (ONCOVIN) 0.8 mg, doxorubicin CONVENTIONAL (ADRIAMYCIN)
21 mg, sodium chloride 0.9 % 1,000 mL bag
Intravenous, EVERY 24 HOURS, 4 doses Starting when released
Day 1, 2, 3 and 4: Continuous infusion over 24 hours days 1 through 4 for a total of 96 hour. (etoposide Total dose =
***mg/m2/96 hours, vinCRIStine Total dose = ***mg/m2/96 hours, doxorubicin Total dose = ***mg/m2/96 hours.).
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:17:04 PM Page 29 of 30
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

cyclophosphamide (CYTOXAN) in sodium chloride 0.9 % 250 mL bag
Intravenous
Day 5:
Cyclophosphamide dose less than 2000 mg infuse IV over 30 minutes.
Cyclophosphamide dose 2000 mg to 3999 mg infuse IV over 90 minutes.
Cyclophosphamide dose greater than 4000 mg infuse IV over 120 minutes.
Supportive Care Medications (delete all that do not apply)
acyclovir (ZOVIRAX) tab 400 mg
400 mg, Oral, 2 X DAILY Starting S As Scheduled
fluconazole (DIFLUCAN) tab 400 mg
400 mg, Oral, 1 X DAILY Starting when released
ranitidine (ZANTAC) tab 150 mg
150 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 Include Now
senna-docusate (SENOKOT S) 8.6-50 MG per tab 2 tab
2 tab, Oral, 1 X DAILY (HS) Starting S As Scheduled
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
Take Home Medications (delete all that do not apply)
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
MULTIPLE DAY FOLLOW-UP (1)
INTERIM LAB APPOINTMENTS: CBC with DIFF every Monday and Thursday starting ***
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF,
Creatinine, Total Bilirubin; NOTE: Admit to B6/6 through clinic for next Cycle
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:17:04 PM Page 30 of 30
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org