/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/beacon-protocols/,/clinical/cckm-tools/content/beacon-protocols/hem---lymphoma/,

/clinical/cckm-tools/content/beacon-protocols/hem---lymphoma/name-96867-en.cckm

201605136

page

100

UWHC,UWMF,

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

CSC Hem Inpt Rituximab With ESHAP For Lymphoma Ver 2-2-16 (HL 2008)

CSC Hem Inpt Rituximab With ESHAP For Lymphoma Ver 2-2-16 (HL 2008) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Lymphoma


CSC HEM-INPT RITUXIMAB WITH ESHAP FOR LYMPHOMA VER: 2-2-16 – Properties
Cycle 1 – 2/4/2016 through 2/24/2016 (21 days), Planned
Day 1, Cycle 1 – Planned for 2/4/2016
Treatment Plan Information
Reference Information (1)
NON-HODGKIN LYMPHOMA: Velasquez WS, et al. J Clinic Oncol 1994;12(6):1169-76.
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, methylprednisolone
250 mg (for patients less than or equal to 70kg) or 500 mg (for patients greater than 70kg) IV Day 1 through 5, etoposide
40 mg/m2/day IV Day 1 through 4, CISplatin 25 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4,
cytarabine 2 g/m2 IV Day 5 after completion of CISplatin; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 to 28
days; COURSE: 4 to 6 cycles
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.
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
POTASSIUM
ONCE Starting when released, Routine
LD, TOTAL
ONCE Starting when released
URIC ACID
ONCE Starting when released
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
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Zztestonc,PedsBeiber [2668824]
2/4/2016 9:58:27 AM Page 1 of 17
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 (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, AST, ALT, Alkaline
Phosphatase, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less
than or equal to 50K/µL or Creatinine Clearance less than 60 mL/min or Total Bilirubin greater than 2 mg/dL or AST
greater than ULN or ALT greater than ULN or Alkaline Phosphatase greater than 3 X ULN.
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.
Monitoring Parameters (2)
Monitor for cerebellar toxicity (incoordination, slurred speech) with neurology checks prior to each dose of
cytarabine and as needed. For any symptoms or concerns of toxicity, hold cytarabine and contact Hematology Fellow or
Staff on call.
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 150 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Day 1 through 5: Administer beginning 6 hours before start of CISplatin and continue throughout CISplatin infusion and
until chemotherapy in complete on Day 5.
Pre-Medications
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Zztestonc,PedsBeiber [2668824]
2/4/2016 9:58:27 AM Page 2 of 17
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

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.
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, EVERY 12 HOURS, 10 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
Days 1 through 5: Administer first dose prior to start of chemotherapy if unable to tolerate PO.
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
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
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. 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.
methylprednisolone sod. succ. in sodium chloride 0.9% (SOLU-MEDROL) bag
Intravenous, 1 X DAILY, 5 doses Starting S As Scheduled
Days 1 through 5: Administer first dose prior to IV chemotherapy 250 mg (for patients less than or equal to 70kg) or
500mg (for patients greater than 70kg) IV Day 1 through 5. Administer over 15 minutes.
etoposide (VEPESID) 84 mg in sodium chloride 0.9 % 500 mL NSS bag
84 mg (rounded from 83.6 mg = 40 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous
Administer over 60 minutes. Administer with non-PVC tubing.
CISplatin (PLATINOL) 52 mg in sodium chloride 0.9 % 1,000 mL bag
52 mg (rounded from 52.25 mg = 25 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous
Days 1, 2, 3, and 4: Administer as a continuous infusion over 24 hours on Days 1 through 4 for a total of 96 hours (Total
dose = 100 mg/m2).
cytarabine PF (CYTOSAR) 4,180 mg in sodium chloride 0.9 % 250 mL bag
4,180 mg (2,000 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous
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Zztestonc,PedsBeiber [2668824]
2/4/2016 9:58:27 AM Page 3 of 17
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

Day 5: Administer after completion of CISplatin on Day 5.
prednisolone (PRED FORTE) 1 % ophthalmic susp 1 drop
1 drop, Eyes (Each), 4 X DAILY, 8 doses Starting S+5 As Scheduled
Day 5 and 6: Administer 1 drop in each eye 4 times daily.
Supportive Care Medications (delete all that do not apply)
acyclovir (ZOVIRAX) tab 400 mg
400 mg, Oral, 2 X DAILY Starting S As Scheduled
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 Starting when released
fluconazole (DIFLUCAN) tab 400 mg
400 mg, Oral, 1 X DAILY Starting when released
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, 1 X DAILY, 3 doses Starting S+5 As Scheduled
Day 6 and 7 and 8 - for delayed nausea.
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
IV push slowly, max rate 5 mg/minute.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
Do not exceed total of 24 mg ondansetron per 24 hours (scheduled and PRN)
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting,
If unable to tolerate PO., for 3 Minutes
Do not exceed total of 24 mg of ondansetron per 24 hours (scheduled and PRN). Administer over 3 to 5 minutes
Take Home Medications
ondansetron (ZOFRAN) 8 MG tab
Take 1 tablet by mouth twice daily for 2 days on Day 6 and 7., Disp-4 tab, R-0, starting S, Local Printer
dexamethasone (DECADRON) 4 MG tab
Take 2 tabs by mouth one time daily. Take on Day 6, 7 and 8., 8 mg, Disp-24 tab, R-1, 1 X DAILY
starting S, Local Printer
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.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 9:58:27 AM Page 4 of 17
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

Follow-Up
MULTIPLE DAY FOLLOW-UP (1)
INTERIM LAB APPOINTMENTS: CBC with DIFF every Monday and Thursday starting *** and
Creatinine, Potassium, Uric Acid, and LDH twice weekly for one week starting ***
DAY 22 FOLLOW-UP
(Day 1 of next Cycle) Admit to B6/6 per MD orders.
Cycle 2 – 2/25/2016 through 3/16/2016 (21 days), Planned
Day 1, Cycle 2 – Planned for 2/25/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, methylprednisolone 250
mg (for patients less than or equal to 70kg) or 500 mg (for patients greater than 70kg) IV Day 1 through 5, etoposide 40
mg/m2/day IV Day 1 through 4, CISplatin 25 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4,
cytarabine 2 g/m2 IV Day 5 after completion of CISplatin; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 to 28
days; COURSE: 4 to 6 cycles
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.
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
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
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Zztestonc,PedsBeiber [2668824]
2/4/2016 9:58:27 AM Page 5 of 17
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 (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, AST, ALT, Alkaline
Phosphatase, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less
than or equal to 50K/µL or Creatinine Clearance less than 60 mL/min or Total Bilirubin greater than 2 mg/dL or AST
greater than ULN or ALT greater than ULN or Alkaline Phosphatase greater than 3 X ULN.
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.
Monitoring Parameters (2)
Monitor for cerebellar toxicity (incoordination, slurred speech) with neurology checks prior to each dose of
cytarabine and as needed. For any symptoms or concerns of toxicity, hold cytarabine and contact Hematology Fellow or
Staff on call.
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 150 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Day 1 through 5: Administer beginning 6 hours before start of CISplatin and continue throughout CISplatin infusion and
until chemotherapy in complete on Day 5.
Pre-Medications
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Zztestonc,PedsBeiber [2668824]
2/4/2016 9:58:27 AM Page 6 of 17
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

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.
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, EVERY 12 HOURS, 10 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
Days 1 through 5: Administer first dose prior to start of chemotherapy if unable to tolerate PO.
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
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
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. 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.
methylprednisolone sod. succ. in sodium chloride 0.9% (SOLU-MEDROL) bag
Intravenous, 1 X DAILY, 5 doses Starting S As Scheduled
Days 1 through 5: Administer first dose prior to IV chemotherapy 250 mg (for patients less than or equal to 70kg) or
500mg (for patients greater than 70kg) IV Day 1 through 5. Administer over 15 minutes.
etoposide (VEPESID) 84 mg in sodium chloride 0.9 % 500 mL NSS bag
84 mg (rounded from 83.6 mg = 40 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous
Administer over 60 minutes. Administer with non-PVC tubing.
CISplatin (PLATINOL) 52 mg in sodium chloride 0.9 % 1,000 mL bag
52 mg (rounded from 52.25 mg = 25 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous
Days 1, 2, 3, and 4: Administer as a continuous infusion over 24 hours on Days 1 through 4 for a total of 96 hours (Total
dose = 100 mg/m2).
cytarabine PF (CYTOSAR) 4,180 mg in sodium chloride 0.9 % 250 mL bag
4,180 mg (2,000 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous
Day 5: Administer after completion of CISplatin on Day 5.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 9:58:27 AM Page 7 of 17
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

prednisolone (PRED FORTE) 1 % ophthalmic susp 1 drop
1 drop, Eyes (Each), 4 X DAILY, 8 doses Starting S+5 As Scheduled
Day 5 and 6: Administer 1 drop in each eye 4 times daily.
Supportive Care Medications (delete all that do not apply)
acyclovir (ZOVIRAX) tab 400 mg
400 mg, Oral, 2 X DAILY Starting S As Scheduled
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 Starting when released
fluconazole (DIFLUCAN) tab 400 mg
400 mg, Oral, 1 X DAILY Starting when released
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, 1 X DAILY, 3 doses Starting S+5 As Scheduled
Day 6 and 7 and 8 - for delayed nausea.
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
IV push slowly, max rate 5 mg/minute.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
Do not exceed total of 24 mg ondansetron per 24 hours (scheduled and PRN)
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting,
If unable to tolerate PO., for 3 Minutes
Do not exceed total of 24 mg of ondansetron per 24 hours (scheduled and PRN). Administer over 3 to 5 minutes
Take Home Medications
ondansetron (ZOFRAN) 8 MG tab
Take 1 tablet by mouth twice daily for 2 days on Day 6 and 7., Disp-4 tab, R-0, starting S, Local Printer
dexamethasone (DECADRON) 4 MG tab
Take 2 tabs by mouth one time daily. Take on Day 6, 7 and 8., 8 mg, Disp-24 tab, R-1, 1 X DAILY
starting S, Local Printer
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 9:58:27 AM Page 8 of 17
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 *** and
Creatinine, Potassium, Uric Acid, and LDH twice weekly for one week starting ***
DAY 22 FOLLOW-UP
(Day 1 of next Cycle) Admit to B6/6 per MD orders.
Cycle 3 – 3/17/2016 through 4/6/2016 (21 days), Planned
Day 1, Cycle 3 – Planned for 3/17/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, methylprednisolone 250
mg (for patients less than or equal to 70kg) or 500 mg (for patients greater than 70kg) IV Day 1 through 5, etoposide 40
mg/m2/day IV Day 1 through 4, CISplatin 25 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4,
cytarabine 2 g/m2 IV Day 5 after completion of CISplatin; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 to 28
days; COURSE: 4 to 6 cycles
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.
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
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)
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Zztestonc,PedsBeiber [2668824]
2/4/2016 9:58:27 AM Page 9 of 17
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

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, AST, ALT, Alkaline
Phosphatase, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less
than or equal to 50K/µL or Creatinine Clearance less than 60 mL/min or Total Bilirubin greater than 2 mg/dL or AST
greater than ULN or ALT greater than ULN or Alkaline Phosphatase greater than 3 X ULN.
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.
Monitoring Parameters (2)
Monitor for cerebellar toxicity (incoordination, slurred speech) with neurology checks prior to each dose of
cytarabine and as needed. For any symptoms or concerns of toxicity, hold cytarabine and contact Hematology Fellow or
Staff on call.
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 150 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Day 1 through 5: Administer beginning 6 hours before start of CISplatin and continue throughout CISplatin infusion and
until chemotherapy in complete on Day 5.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
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Zztestonc,PedsBeiber [2668824]
2/4/2016 9:58:27 AM Page 10 of 17
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

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.
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, EVERY 12 HOURS, 10 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
Days 1 through 5: Administer first dose prior to start of chemotherapy if unable to tolerate PO.
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
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
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. 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.
methylprednisolone sod. succ. in sodium chloride 0.9% (SOLU-MEDROL) bag
Intravenous, 1 X DAILY, 5 doses Starting S As Scheduled
Days 1 through 5: Administer first dose prior to IV chemotherapy 250 mg (for patients less than or equal to 70kg) or
500mg (for patients greater than 70kg) IV Day 1 through 5. Administer over 15 minutes.
etoposide (VEPESID) 84 mg in sodium chloride 0.9 % 500 mL NSS bag
84 mg (rounded from 83.6 mg = 40 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous
Administer over 60 minutes. Administer with non-PVC tubing.
CISplatin (PLATINOL) 52 mg in sodium chloride 0.9 % 1,000 mL bag
52 mg (rounded from 52.25 mg = 25 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous
Days 1, 2, 3, and 4: Administer as a continuous infusion over 24 hours on Days 1 through 4 for a total of 96 hours (Total
dose = 100 mg/m2).
cytarabine PF (CYTOSAR) 4,180 mg in sodium chloride 0.9 % 250 mL bag
4,180 mg (2,000 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous
Day 5: Administer after completion of CISplatin on Day 5.
prednisolone (PRED FORTE) 1 % ophthalmic susp 1 drop
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Zztestonc,PedsBeiber [2668824]
2/4/2016 9:58:27 AM Page 11 of 17
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 drop, Eyes (Each), 4 X DAILY, 8 doses Starting S+5 As Scheduled
Day 5 and 6: Administer 1 drop in each eye 4 times daily.
Supportive Care Medications (delete all that do not apply)
acyclovir (ZOVIRAX) tab 400 mg
400 mg, Oral, 2 X DAILY Starting S As Scheduled
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 Starting when released
fluconazole (DIFLUCAN) tab 400 mg
400 mg, Oral, 1 X DAILY Starting when released
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, 1 X DAILY, 3 doses Starting S+5 As Scheduled
Day 6 and 7 and 8 - for delayed nausea.
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
IV push slowly, max rate 5 mg/minute.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
Do not exceed total of 24 mg ondansetron per 24 hours (scheduled and PRN)
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting,
If unable to tolerate PO., for 3 Minutes
Do not exceed total of 24 mg of ondansetron per 24 hours (scheduled and PRN). Administer over 3 to 5 minutes
Take Home Medications
ondansetron (ZOFRAN) 8 MG tab
Take 1 tablet by mouth twice daily for 2 days on Day 6 and 7., Disp-4 tab, R-0, starting S, Local Printer
dexamethasone (DECADRON) 4 MG tab
Take 2 tabs by mouth one time daily. Take on Day 6, 7 and 8., 8 mg, Disp-24 tab, R-1, 1 X DAILY
starting S, Local Printer
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)
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Zztestonc,PedsBeiber [2668824]
2/4/2016 9:58:27 AM Page 12 of 17
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

INTERIM LAB APPOINTMENTS: CBC with DIFF every Monday and Thursday starting *** and Creatinine, Potassium,
Uric Acid, and LDH twice weekly for one week starting ***
DAY 22 FOLLOW-UP
(Day 1 of next Cycle) Admit to B6/6 per MD orders.
Cycle 4 – 4/7/2016 through 4/27/2016 (21 days), Planned
Day 1, Cycle 4 – Planned for 4/7/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, methylprednisolone 250
mg (for patients less than or equal to 70kg) or 500 mg (for patients greater than 70kg) IV Day 1 through 5, etoposide 40
mg/m2/day IV Day 1 through 4, CISplatin 25 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4,
cytarabine 2 g/m2 IV Day 5 after completion of CISplatin; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 to 28
days; COURSE: 4 to 6 cycles
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.
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
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)
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Zztestonc,PedsBeiber [2668824]
2/4/2016 9:58:27 AM Page 13 of 17
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

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, AST, ALT, Alkaline
Phosphatase, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less
than or equal to 50K/µL or Creatinine Clearance less than 60 mL/min or Total Bilirubin greater than 2 mg/dL or AST
greater than ULN or ALT greater than ULN or Alkaline Phosphatase greater than 3 X ULN.
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.
Monitoring Parameters (2)
Monitor for cerebellar toxicity (incoordination, slurred speech) with neurology checks prior to each dose of
cytarabine and as needed. For any symptoms or concerns of toxicity, hold cytarabine and contact Hematology Fellow or
Staff on call.
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 150 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Day 1 through 5: Administer beginning 6 hours before start of CISplatin and continue throughout CISplatin infusion and
until chemotherapy in complete on Day 5.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 9:58:27 AM Page 14 of 17
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

diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, EVERY 12 HOURS, 10 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
Days 1 through 5: Administer first dose prior to start of chemotherapy if unable to tolerate PO.
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
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
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. 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.
methylprednisolone sod. succ. in sodium chloride 0.9% (SOLU-MEDROL) bag
Intravenous, 1 X DAILY, 5 doses Starting S As Scheduled
Days 1 through 5: Administer first dose prior to IV chemotherapy 250 mg (for patients less than or equal to 70kg) or
500mg (for patients greater than 70kg) IV Day 1 through 5. Administer over 15 minutes.
etoposide (VEPESID) 84 mg in sodium chloride 0.9 % 500 mL NSS bag
84 mg (rounded from 83.6 mg = 40 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous
Administer over 60 minutes. Administer with non-PVC tubing.
CISplatin (PLATINOL) 52 mg in sodium chloride 0.9 % 1,000 mL bag
52 mg (rounded from 52.25 mg = 25 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous
Days 1, 2, 3, and 4: Administer as a continuous infusion over 24 hours on Days 1 through 4 for a total of 96 hours (Total
dose = 100 mg/m2).
cytarabine PF (CYTOSAR) 4,180 mg in sodium chloride 0.9 % 250 mL bag
4,180 mg (2,000 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous
Day 5: Administer after completion of CISplatin on Day 5.
prednisolone (PRED FORTE) 1 % ophthalmic susp 1 drop
1 drop, Eyes (Each), 4 X DAILY, 8 doses Starting S+5 As Scheduled
Day 5 and 6: Administer 1 drop in each eye 4 times daily.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 9:58:27 AM Page 15 of 17
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
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 Starting when released
fluconazole (DIFLUCAN) tab 400 mg
400 mg, Oral, 1 X DAILY Starting when released
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, 1 X DAILY, 3 doses Starting S+5 As Scheduled
Day 6 and 7 and 8 - for delayed nausea.
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
IV push slowly, max rate 5 mg/minute.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
Do not exceed total of 24 mg ondansetron per 24 hours (scheduled and PRN)
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting,
If unable to tolerate PO., for 3 Minutes
Do not exceed total of 24 mg of ondansetron per 24 hours (scheduled and PRN). Administer over 3 to 5 minutes
Take Home Medications
ondansetron (ZOFRAN) 8 MG tab
Take 1 tablet by mouth twice daily for 2 days on Day 6 and 7., Disp-4 tab, R-0, starting S, Local Printer
dexamethasone (DECADRON) 4 MG tab
Take 2 tabs by mouth one time daily. Take on Day 6, 7 and 8., 8 mg, Disp-24 tab, R-1, 1 X DAILY
starting S, Local Printer
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 *** and
Creatinine, Potassium, Uric Acid, and LDH twice weekly for one week starting ***
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Zztestonc,PedsBeiber [2668824]
2/4/2016 9:58:27 AM Page 16 of 17
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

DAY 22 FOLLOW-UP
(Day 1 of next Cycle) Admit to B6/6 per MD orders.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 9:58:27 AM Page 17 of 17
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