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/clinical/cckm-tools/content/beacon-protocols/hem---lymphoma/name-96870-en.cckm

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 Modified Magrath High Risk (A-B-A-B) With Rituximab Ver 3-4-16 (HL 3187)

CSC Hem Inpt Modified Magrath High Risk (A-B-A-B) With Rituximab Ver 3-4-16 (HL 3187) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Lymphoma


CSC HEM INPT MODIFIED MAGRATH HIGH RISK (A-B-A-B) WITH RITUXIMAB VER: 3-4-16 – Properties
Cycle 1 (Regimen A) – 3/3/2016 through 3/23/2016 (21 days), Planned
Days 1 through 3 (Inpatient), Cycle 1 (Regimen A) – Planned for 3/3/2016 through
3/5/2016
Treatment Plan Information
Reference Information (1)
NON HODGKIN (BURKITT OR BURKITT LIKE) LYMPHOMA: Mead GM, et al. Blood
2008;15(112):2248-60
Reference Information (2)
NON HODGKIN (BURKITT OR BURKITT LIKE) LYMPHOMA: Corazzelli G, et al. Br J
Haematol 2012;156(2):234-44
Treatment Plan Summary
DISEASE: Non-Hodgkin (Burkitt or Burkitt like) Lymphoma; THERAPY: HIGH RISK (A-
B-A-B). REGIMEN A: rituximab 375 mg/m2 IV Day 1, doxorubicin 50 mg/m2 IV Day 1, vinCRIStine 1.4 mg/m2 IV Days 1
and 10 (maximum dose = 2mg), cyclophosphamide 800 mg/m2 IV Days 1 and 2, methotrexate 3000 mg/m2 IV Day 10,
leucovorin 50 mg/m2 IV given 24 hours after start of methotrexate infusion followed by leucovorin 15 mg/m2 IV every 6
hours until methotrexate level is less than or equal to 0.5 uM/L followed by leucovorin 15 mg by mouth every 6 hours
until methotrexate level is less than or equal to 0.05 uM/L. REGIMEN B: rituximab 375 mg/m2 IV Day 1, ifosfamide 1500
mg/m2 IV Days 1,2,3,4, and 5, mesna 500 mg/m2 IV prior to ifosfamide and 4 and 8 hours after start of ifosfamide on
Days 1,2,3,4, and 5, etoposide 60 mg/m2 IV Days 1,2,3,4, and 5, cytarabine 2000 mg/m2 IV every 12 hours on Days 1
and 2, CYCLE LENGTH: 21 days COURSE: 4 cycles (A-B-A-B)
INTRATHECAL MEDICATIONS (Schedule at MD discretion):
INTRATHECAL MEDICATIONS FOR REGIMEN A: Cytarabine 50 mg IT and Methotrexate 12 mg IT on Day 1,
Cytarabine 50 mg IT on Day 3, Hydrocortisone 30 mg IT to be given with each IT treatment (see below for additional
medication if CNS disease at diagnosis)
INTRATHECAL MEDICATIONS FOR REGIMEN B: Methotrexate 12 mg IT on Day 5, Hydrocortisone 30 mg IT to be
given with each IT treatment (see below for additional medication if CNS disease at diagnosis)
IF CENTRAL NERVOUS SYSTEM INVOLVEMENT AT DIAGNOSIS - cycle 1 only of both REGIMEN A and B add
Cytarabine 50 mg IT on Day 5 and Methotrexate 12 mg IT on Day 10, Hydrocortisone 30 mg IT to be given with each IT
treatment
Note to All Staff (1)
Regimen A: Consider dose reduction for patients greater than 65 years old to
methotrexate 1000 mg/m2 IV on Day 10.
Note to All Staff (2)
Regimen B: Consider dose reduction for patients greater than 65 years old to ifosfamide
1000 mg/m2 IV Days 1 through 5 and cytarabine 1000 mg/m2 IV every 12 hours Days 1 and 2.
Note to all Staff (3)
Regimen B: Risk factors associated with ifosfamide neurotoxicity may include
hypoalbuminemia, renal dysfunction (Creatinine Clearance < 60 mL/min), and prior history of ifosfamide-induced
encephalopathy. Consider dose reduction or methylene blue prophylaxis if present.
Note to all Staff (4)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant
hepatitis, hepatic failure, or death. Screen patients for HBV infection prior to rituximab treatment and consider
prophylaxis against reactivation.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
HEPATITIS B CORE AB, TOTAL
Actions
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Zztestonc,Edward E [2435061]
3/3/2016 12:50:34 PM Page 1 of 29
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Expected-S Approximate, Expires-S+365, Routine
HEPATITIS B SURFACE AG
Expected-S Approximate, Expires-S+365, Routine
HEPATITIS B SURFACE AB
Expected-S Approximate, Expires-S+122, Routine
Pre-Labs (delete all that do not apply)
HEPATITIS B DNA, ULTRA QUANT, PCR
Approximate, Expires-S+122, Routine
Draw if Hepatitis B Core AB is positive.
Pre-Labs
POTASSIUM
ONCE Starting when released, Routine
URIC ACID
ONCE Starting when released
LD, TOTAL
ONCE Starting when released
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total bilirubin (Note: Labs ordered outside
of Beacon Treatment Plan)
Treatment Parameters
Hold treatment and notify authorizing prescriber for Total Bilirubin greater than upper limit
of normal.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to rituximab can occur and is most common with the first or
second dose or if greater than 6 months since last dose. For first and second dose patient should be treated in a location
to optimize emergency care. See Emergency Meds.
Monitoring Parameters (1)
Educate patients regarding the potential of occurence for severe mucocutaneous
reactions with rituximab.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Vital Signs every 15 minutes for the first 60 minutes and then every 30 minutes until rituximab infusion complete.
If patient experiences fever accompanied by chills or rigors, shortness of breath, chest pain, or hypotension, stop infusion
and contact MD. Once the patient returns to baseline, infusion may be restarted at half the rate during which the reaction
occurred.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
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Zztestonc,Edward E [2435061]
3/3/2016 12:50:34 PM Page 2 of 29
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2016CCKM@uwhealth.org

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 200 mL/hr, Intravenous, CONTINUOUS, For 48 hours Starting when released until S+1
at 2359
Start hydration 4 hours prior to chemotherapy. With start of chemotherapy, adjust maintenance IV fluids to keep total
fluids 200 mL/hour. For cycle 2 and 3, rate of IV hydration may be reduced to 100 mL/hour.
sodium chloride 0.9 % infusion
at 100 mL/hr, Intravenous, CONTINUOUS Starting S+2 at 0000 Until Discontinued
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.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, EVERY 24 HOURS, 2 doses Starting when released
Give first dose prior to rituximab. If unable to tolerate PO may give IV.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, EVERY 24 HOURS PRN, For 48 hours Starting when released,
nausea/vomiting
Administer prior to chemotherapy. If unable to tolerate PO may give IV.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, EVERY 24 HOURS, 2 doses Starting when released
Days 1 and 2: First dose prior to start of chemotherapy. May give IV if unable to tolerate oral dose.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, EVERY 24 HOURS PRN, For 72 hours Starting when released,
nausea/vomiting
If unable to tolerate the oral dose
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, EVERY 12 HOURS, 2 doses Starting S+2 at 0000
Day 3. First dose prior to chemotherapy. May give IV if unable to tolerate oral dose.
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 12 HOURS PRN, For 48 hours Starting S+2 at 0000,
nausea/vomiting, for 3 Minutes
If unable to tolerate the oral dose.
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
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Zztestonc,Edward E [2435061]
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2016CCKM@uwhealth.org

albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Intrathecal Procedure Orders
LEUKEMIA/LYMPHOMA SCREEN, CSF
ONCE Starting when released, Tube 1
cytarabine PF (CYTOSAR) 50 mg in sodium chloride 0.9 % 1 mL intraTHECAL injection
50 mg, Intrathecal, ONCE, 1 dose Starting when released
Day 1: Dose to be given by provider.
methotrexate PF 12 mg in sodium chloride 0.9 % 2.4 mL intraTHECAL injection
12 mg, Intrathecal, ONCE, 1 dose Starting when released
Day 1: Dose to be given by provider.
hydrocortisone sodium succinate PF (SOLU-CORTEF) 30 mg in sodium chloride 0.9 % 3 mL
intraTHECAL injection
30 mg, Intrathecal, ONCE, 1 dose Starting when released
Day 1: Dose to be given by provider.
LEUKEMIA/LYMPHOMA SCREEN, CSF
ONCE Starting S+2 at 0000, Tube 1
cytarabine PF (CYTOSAR) 50 mg in sodium chloride 0.9 % 1 mL intraTHECAL injection
50 mg, Intrathecal, ONCE, 1 dose Starting S+2 at 0000
Day 3: Dose to be given by provider.
hydrocortisone sodium succinate PF (SOLU-CORTEF) 30 mg in sodium chloride 0.9 % 3 mL
intraTHECAL injection
30 mg, Intrathecal, ONCE, 1 dose Starting S+2 at 0000
Day 3: Dose to be given by provider.
Treatment Medications
rituximab (RITUXAN) 754 mg in sodium chloride 0.9 % 500 mL bag
754 mg (rounded from 753.75 mg = 375 mg/m2 × 2.01 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.
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 101 mg
101 mg (rounded from 100.5 mg = 50 mg/m2 × 2.01 m2 Treatment plan actual BSA),
Intravenous, ONCE, 1 dose Starting when released
IV side arm push 10-15 mL/minute into running IV.
vinCRIStine (ONCOVIN) 2.8 mg in sodium chloride 0.9 % 25 mL bag
2.8 mg (rounded from 2.814 mg = 1.4 mg/m2 × 2.01 m2 Treatment plan actual BSA),
Intravenous, ONCE, 1 dose Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
Ordered dose of 1.4 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
cyclophosphamide (CYTOXAN) 1,608 mg in sodium chloride 0.9 % 250 mL bag
1,608 mg (800 mg/m2 × 2.01 m2 Treatment plan actual BSA), Intravenous, 1 X DAILY, 2
doses Starting when released
Treatment Medications (delete all that do not apply)
acyclovir (ZOVIRAX) tab 400 mg
400 mg, Oral, 2 X DAILY Starting when released
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Zztestonc,Edward E [2435061]
3/3/2016 12:50:34 PM Page 4 of 29
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2016CCKM@uwhealth.org

fluconazole (DIFLUCAN) tab 400 mg
400 mg, Oral, 1 X DAILY Starting S+1 As Scheduled
ranitidine (ZANTAC) tab 150 mg
150 mg, Oral, 2 X DAILY Starting S+1 As Scheduled
senna-docusate (SENOKOT S) 8.6-50 MG per tab 2 tab
2 tab, Oral, 1 X DAILY Starting S+1 As Scheduled
Hold for loose stools
TBO-filgrastim (GRANIX) 300 MCG/0.5ML soln prefilled syringe
Subcutaneous, 1 X DAILY (PM), 6 doses Starting S+2 As Scheduled
Give first dose of tbo-filgrastim a minimum of 24 hours after last dose of cyclophosphamide. Less than or equal to 80kg =
300mcg; greater than 80kg = 480mcg
Conditional Orders
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
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.
Take Home Medications
sodium bicarbonate oral powder
Mix 1/2 teaspoon sodium bicarbonate oral powder (baking soda) in 6-8 ounces of a non-
acidic fluid and drink by mouth at 8 AM, 12 PM, 4 PM, 10 PM the day before methotrexate treatment and at 8 AM the
morning of methotrexate treatment., Disp-1 Bottle, R-0, starting S, No Print
sulfamethoxazole-trimethoprim (BACTRIM DS) 800-160 MG per tab
Take 1 tab by mouth 2 times daily Sat,Sun. Begin when methotrexate level is
undetectable., 1 tab, Disp-16 tab, R-5, 2 X DAILY SAT, SUN starting S
ondansetron (ZOFRAN) 8 MG tab
Take 1 tablet by mouth twice daily on Day 4 then 1 tablet by mouth every 8 hours as
needed., Disp-30 tab, R-5, 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,Edward E [2435061]
3/3/2016 12:50:34 PM Page 5 of 29
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2016CCKM@uwhealth.org

Follow-Up
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: intrathecal chemotherapy for select patients
only.
Day 5 (Intrathecal Chemotherapy - delete if not needed), Cycle 1 (Regimen A) – Planned for
3/6/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkin (Burkitt or Burkitt like) Lymphoma; THERAPY: HIGH RISK (A-B-A-B).
REGIMEN A: rituximab 375 mg/m2 IV Day 1, doxorubicin 50 mg/m2 IV Day 1, vinCRIStine 1.4 mg/m2 IV Days 1 and 10
(maximum dose = 2mg), cyclophosphamide 800 mg/m2 IV Days 1 and 2, methotrexate 3000 mg/m2 IV Day 10,
leucovorin 50 mg/m2 IV given 24 hours after start of methotrexate infusion followed by leucovorin 15 mg/m2 IV every 6
hours until methotrexate level is less than or equal to 0.5 uM/L followed by leucovorin 15 mg by mouth every 6 hours until
methotrexate level is less than or equal to 0.05 uM/L. REGIMEN B: rituximab 375 mg/m2 IV Day 1, ifosfamide 1500
mg/m2 IV Days 1,2,3,4, and 5, mesna 500 mg/m2 IV prior to ifosfamide and 4 and 8 hours after start of ifosfamide on
Days 1,2,3,4, and 5, etoposide 60 mg/m2 IV Days 1,2,3,4, and 5, cytarabine 2000 mg/m2 IV every 12 hours on Days 1
and 2, CYCLE LENGTH: 21 days COURSE: 4 cycles (A-B-A-B)
INTRATHECAL MEDICATIONS (Schedule at MD discretion):
INTRATHECAL MEDICATIONS FOR REGIMEN A: Cytarabine 50 mg IT and Methotrexate 12 mg IT on Day 1,
Cytarabine 50 mg IT on Day 3, Hydrocortisone 30 mg IT to be given with each IT treatment (see below for additional
medication if CNS disease at diagnosis)
INTRATHECAL MEDICATIONS FOR REGIMEN B: Methotrexate 12 mg IT on Day 5, Hydrocortisone 30 mg IT to be
given with each IT treatment (see below for additional medication if CNS disease at diagnosis)
IF CENTRAL NERVOUS SYSTEM INVOLVEMENT AT DIAGNOSIS - cycle 1 only of both REGIMEN A and B add
Cytarabine 50 mg IT on Day 5 and Methotrexate 12 mg IT on Day 10, Hydrocortisone 30 mg IT to be given with each IT
treatment
Note to All Staff (1)
Regimen A: Consider dose reduction for patients greater than 65 years old to methotrexate 1000
mg/m2 IV on Day 10.
Note to All Staff (2)
Regimen B: Consider dose reduction for patients greater than 65 years old to ifosfamide 1000
mg/m2 IV Days 1 through 5 and cytarabine 1000 mg/m2 IV every 12 hours Days 1 and 2.
Note to all Staff (3)
Regimen B: Risk factors associated with ifosfamide neurotoxicity may include hypoalbuminemia,
renal dysfunction (Creatinine Clearance < 60 mL/min), and prior history of ifosfamide-induced encephalopathy. Consider
dose reduction or methylene blue prophylaxis if present.
Note to all Staff (4)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis,
hepatic failure, or death. Screen patients for HBV infection prior to rituximab treatment and consider prophylaxis against
reactivation.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Intrathecal Procedure Orders (delete all that do not apply)
LEUKEMIA/LYMPHOMA SCREEN, CSF
ONCE Starting when released, Tube 1
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Zztestonc,Edward E [2435061]
3/3/2016 12:50:34 PM Page 6 of 29
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2016CCKM@uwhealth.org

cytarabine PF (CYTOSAR) 50 mg in sodium chloride 0.9 % 1 mL intraTHECAL injection
50 mg, Intrathecal, ONCE, 1 dose Starting when released
Administer if CNS involvement at time of diagnosis. Dose to be given by provider.
hydrocortisone sodium succinate PF (SOLU-CORTEF) 30 mg in sodium chloride 0.9 % 3 mL
intraTHECAL injection
30 mg, Intrathecal, ONCE, 1 dose Starting when released
Administer if CNS involvement at time of diagnosis. Dose to be given by provider.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 10 (Inpatient), Cycle 1 (Regimen A) – Planned for 3/14/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkin (Burkitt or Burkitt like) Lymphoma; THERAPY: HIGH RISK (A-B-A-B).
REGIMEN A: rituximab 375 mg/m2 IV Day 1, doxorubicin 50 mg/m2 IV Day 1, vinCRIStine 1.4 mg/m2 IV Days 1 and 10
(maximum dose = 2mg), cyclophosphamide 800 mg/m2 IV Days 1 and 2, methotrexate 3000 mg/m2 IV Day 10,
leucovorin 50 mg/m2 IV given 24 hours after start of methotrexate infusion followed by leucovorin 15 mg/m2 IV every 6
hours until methotrexate level is less than or equal to 0.5 uM/L followed by leucovorin 15 mg by mouth every 6 hours until
methotrexate level is less than or equal to 0.05 uM/L. REGIMEN B: rituximab 375 mg/m2 IV Day 1, ifosfamide 1500
mg/m2 IV Days 1,2,3,4, and 5, mesna 500 mg/m2 IV prior to ifosfamide and 4 and 8 hours after start of ifosfamide on
Days 1,2,3,4, and 5, etoposide 60 mg/m2 IV Days 1,2,3,4, and 5, cytarabine 2000 mg/m2 IV every 12 hours on Days 1
and 2, CYCLE LENGTH: 21 days COURSE: 4 cycles (A-B-A-B)
INTRATHECAL MEDICATIONS (Schedule at MD discretion):
INTRATHECAL MEDICATIONS FOR REGIMEN A: Cytarabine 50 mg IT and Methotrexate 12 mg IT on Day 1,
Cytarabine 50 mg IT on Day 3, Hydrocortisone 30 mg IT to be given with each IT treatment (see below for additional
medication if CNS disease at diagnosis)
INTRATHECAL MEDICATIONS FOR REGIMEN B: Methotrexate 12 mg IT on Day 5, Hydrocortisone 30 mg IT to be
given with each IT treatment (see below for additional medication if CNS disease at diagnosis)
IF CENTRAL NERVOUS SYSTEM INVOLVEMENT AT DIAGNOSIS - cycle 1 only of both REGIMEN A and B add
Cytarabine 50 mg IT on Day 5 and Methotrexate 12 mg IT on Day 10, Hydrocortisone 30 mg IT to be given with each IT
treatment
Note to All Staff (1)
Regimen A: Consider dose reduction for patients greater than 65 years old to methotrexate 1000
mg/m2 IV on Day 10.
Note to All Staff (2)
Regimen B: Consider dose reduction for patients greater than 65 years old to ifosfamide 1000
mg/m2 IV Days 1 through 5 and cytarabine 1000 mg/m2 IV every 12 hours Days 1 and 2.
Note to all Staff (3)
Regimen B: Risk factors associated with ifosfamide neurotoxicity may include hypoalbuminemia,
renal dysfunction (Creatinine Clearance < 60 mL/min), and prior history of ifosfamide-induced encephalopathy. Consider
dose reduction or methylene blue prophylaxis if present.
Note to all Staff (4)
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.
NOTE:
ONCE, 1 dose Starting when released
Hold TMP/SMX during infusion and until methotrexate level is undetectable.
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Zztestonc,Edward E [2435061]
3/3/2016 12:50:34 PM Page 7 of 29
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2016CCKM@uwhealth.org

Pre-Labs
CBC WITH DIFFERENTIAL
ONCE Starting when released, Routine
CREATININE
ONCE Starting when released, Routine
BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALT/SGPT
ONCE Starting when released
ALKALINE PHOSPHATASE
ONCE Starting when released, Routine
Additional Labs
PH, URINE (METHOTREXATE PROTOCOL)
ONCE Starting when released
Obtain pH, Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 2 HOURS Starting when released for 2 occurrences
Obtain pH, Urine (Methotrexate Protocol) at 2 hours and 4 hours after start of Methotrexate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting when released for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is
undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting S+8 at 0000 for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is
undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
CONDITIONAL - RN COLLECT Starting when released until S+7 for 7 days
If Urine pH falls below 7, obtain pH, Urine (Methotrexate Protocol) every 2 hours as needed until Urine pH is greater than
or equal to 7 for two consecutive occurrences.
METHOTREXATE
ONCE Starting when released
Obtain methotrexate level 24 hours after the start of methotrexate infusion.
METHOTREXATE
NEXT AM Starting S+2 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate
levels when drug level is undetectable.
METHOTREXATE
NEXT AM Starting S+9 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate
levels when drug level is undetectable.
CREATININE
ONCE Starting when released
Obtain creatinine at 24 hours after the start of methotrexate infusion.
CREATININE
NEXT AM Starting S+2 As Scheduled for 7 days
CREATININE
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3/3/2016 12:50:34 PM Page 8 of 29
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NEXT AM Starting S+9 As Scheduled for 7 days
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin, AST, ALT,
Alkaline Phosphatase, pH Urine (Methotrexate Protocol).
Verify Labs (2)
Verify ongoing treatment labs: Creatinine, pH, Urine (Methotrexate Protocol) and Methotrexate
levels.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Total Bilirubin greater than ULN or Creatinine
Clearance less than 60 mL/min or Creatinine greater than 1.5 mg/dL.
Treatment Parameters (2)
Do not administer methotrexate until urine pH is greater than or equal to 7.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Check pH Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion. If
less than 7, give sodium bicarbonate 50 mEq IV. See Conditional Medications.
Monitoring Parameters (2)
Check pH Urine (Methotrexate Protocol) at 2 hours, 4 hours, and 8 hours after start of methotrexate
and then every 8 hours until methotrexate level is undetectable. If less than 7, give sodium bicarbonate 50 mEq IV and
check urine pH every 2 hours until urine pH is greater than or equal to 7. See Conditional Medications and Additional
Labs.
Nursing Communication
CONTINUOUS Starting when released Until Specified
If sodium bicarbonate bolus given, recheck Urine pH in 2 hours. If two boluses of sodium bicarbonate have been given in
8 hours or three boluses in 24 hours, notify pharmacy and provider to review IV fluid orders.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium bicarbonate 100 mEq in dextrose 5 % 1,000 mL infusion
Intravenous, CONTINUOUS Starting when released Until Discontinued
Begin 4 hours prior to start of methotrexate. May discontinue when methotrexate level is undetectable. Sodium
Bicarbonate infusion must NOT be interrupted for any reason without an order from the attending physician or fellow.
NOTE:
EVERY 6 HOURS Starting when released
Sodium Bicarbonate infusion must NOT be interrupted for any reason without an order from the attending physician or
fellow.
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3/3/2016 12:50:34 PM Page 9 of 29
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Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, EVERY 24 HOURS, 1 dose Starting when released
May give IV if unable to tolerate oral dose.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, EVERY 24 HOURS PRN, For 48 hours Starting when released,
nausea/vomiting
If unable to tolerate the oral dose
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Once prior to methotrexate. If unable to give PO may give IV.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, EVERY 24 HOURS PRN, For 48 hours Starting when released
Administer prior to methotrexate. If unable to give PO may give IV.
Intrathecal Procedure Orders (delete all that do not apply)
LEUKEMIA/LYMPHOMA SCREEN, CSF
ONCE Starting when released, Tube 1
methotrexate PF 12 mg in sodium chloride 0.9 % 2.4 mL intraTHECAL injection
12 mg, Intrathecal, ONCE, 1 dose Starting when released
Administer if CNS involvement at time of diagnosis. Dose to be given by provider.
hydrocortisone sodium succinate PF (SOLU-CORTEF) 30 mg in sodium chloride 0.9 % 3 mL
intraTHECAL injection
30 mg, Intrathecal, ONCE, 1 dose Starting when released
Administer if CNS involvement at time of diagnosis. Dose to be given by provider.
Treatment Medications
vinCRIStine (ONCOVIN) 2.8 mg in sodium chloride 0.9 % 25 mL bag
2.8 mg (rounded from 2.814 mg = 1.4 mg/m2 × 2.01 m2 Treatment plan actual BSA),
Intravenous, ONCE, 1 dose Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
Ordered dose of 1.4 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
methotrexate PF 6,030 mg in dextrose 5 % 1,000 mL bag
6,030 mg (3,000 mg/m2 × 2.01 m2 Treatment plan actual BSA), Intravenous, ONCE, 1 dose
Starting when released
Do not start methotrexate until urine pH greater than or equal to 7.
leucovorin 20 MG/ML injection 101 mg
101 mg (rounded from 100.5 mg = 50 mg/m2 × 2.01 m2 Treatment plan actual BSA), Intravenous,
ONCE, 1 dose Starting S+1 at 0000, for 10 Minutes
Start 24 hours after the start of methotrexate infusion.
leucovorin 20 MG/ML injection 30 mg
30 mg (rounded from 30.15 mg = 15 mg/m2 × 2.01 m2 Treatment plan actual BSA), Intravenous,
EVERY 6 HOURS Starting S+1 at 0000, for 10 Minutes
Start 6 hours after IV leucovorin loading dose. Give every 6 hours until the serum methotrexate level is less than or equal
to 0.5 µM/L, then give PO leucovorin. See PRN NOTIFY PHARMACY order.
leucovorin tab 15 mg
15 mg, Oral, PRN - NOTIFY PHARMACY WHEN NEEDED Starting S+1 at 0000 Until
Discontinued, High Dose Methotrexate
Once methotrexate level is less than or equal to 0.5 µM/L, starting 6 hours after last IV leucovorin dose give 15 mg
leucovorin PO every 6 hours until serum methotrexate level is less than or equal to 0.05 µM/L
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3/3/2016 12:50:34 PM Page 10 of 29
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Treatment Medications (delete all that do not apply)
TBO-filgrastim (GRANIX) 300 MCG/0.5ML soln prefilled syringe
Subcutaneous, 1 X DAILY (PM) Starting S+4 As Scheduled
Start if ANC less than 1000/µL and when methotrexate level is undetectable. Discontinue when ANC is greater than
2000/µL after nadir.
Conditional Orders
sodium bicarbonate 8.4 % injection 50 mEq
50 mEq, Intravenous, EVERY 2 HOURS PRN, For 7 days Starting when released until S+7, For
urine pH less than 7, for 1 Minutes
Administer over 1 to 2 minutes. Give if urine pH is less than 7. Discontinue when methotrexate level is undetectable.
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
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.
Take Home Medications
leucovorin 15 MG tab
Take 1 tab by mouth every 6 hours. Take until seen in clinic for follow up appt to confirm
methotrexate level undetectable, 15 mg, Disp-16 tab, R-0, EVERY 6 HOURS starting S
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.
Cycle 2 (Regimen B) – 3/24/2016 through 4/13/2016 (21 days), Planned
Days 1 through 7 (Inpatient), Cycle 2 (Regimen B) – Planned for 3/24/2016 through 3/30/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkin (Burkitt or Burkitt like) Lymphoma; THERAPY: HIGH RISK (A-B-A-B).
REGIMEN A: rituximab 375 mg/m2 IV Day 1, doxorubicin 50 mg/m2 IV Day 1, vinCRIStine 1.4 mg/m2 IV Days 1 and 10
(maximum dose = 2mg), cyclophosphamide 800 mg/m2 IV Days 1 and 2, methotrexate 3000 mg/m2 IV Day 10,
leucovorin 50 mg/m2 IV given 24 hours after start of methotrexate infusion followed by leucovorin 15 mg/m2 IV every 6
hours until methotrexate level is less than or equal to 0.5 uM/L followed by leucovorin 15 mg by mouth every 6 hours until
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3/3/2016 12:50:34 PM Page 11 of 29
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methotrexate level is less than or equal to 0.05 uM/L. REGIMEN B: rituximab 375 mg/m2 IV Day 1, ifosfamide 1500
mg/m2 IV Days 1,2,3,4, and 5, mesna 500 mg/m2 IV prior to ifosfamide and 4 and 8 hours after start of ifosfamide on
Days 1,2,3,4, and 5, etoposide 60 mg/m2 IV Days 1,2,3,4, and 5, cytarabine 2000 mg/m2 IV every 12 hours on Days 1
and 2, CYCLE LENGTH: 21 days COURSE: 4 cycles (A-B-A-B)
INTRATHECAL MEDICATIONS (Schedule at MD discretion):
INTRATHECAL MEDICATIONS FOR REGIMEN A: Cytarabine 50 mg IT and Methotrexate 12 mg IT on Day 1,
Cytarabine 50 mg IT on Day 3, Hydrocortisone 30 mg IT to be given with each IT treatment (see below for additional
medication if CNS disease at diagnosis)
INTRATHECAL MEDICATIONS FOR REGIMEN B: Methotrexate 12 mg IT on Day 5, Hydrocortisone 30 mg IT to be
given with each IT treatment (see below for additional medication if CNS disease at diagnosis)
IF CENTRAL NERVOUS SYSTEM INVOLVEMENT AT DIAGNOSIS - cycle 1 only of both REGIMEN A and B add
Cytarabine 50 mg IT on Day 5 and Methotrexate 12 mg IT on Day 10, Hydrocortisone 30 mg IT to be given with each IT
treatment
Note to All Staff (1)
Regimen A: Consider dose reduction for patients greater than 65 years old to methotrexate 1000
mg/m2 IV on Day 10.
Note to All Staff (2)
Regimen B: Consider dose reduction for patients greater than 65 years old to ifosfamide 1000
mg/m2 IV Days 1 through 5 and cytarabine 1000 mg/m2 IV every 12 hours Days 1 and 2.
Note to all Staff (3)
Regimen B: Risk factors associated with ifosfamide neurotoxicity may include hypoalbuminemia,
renal dysfunction (Creatinine Clearance < 60 mL/min), and prior history of ifosfamide-induced encephalopathy. Consider
dose reduction or methylene blue prophylaxis if present.
Note to all Staff (4)
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
URINALYSIS WITH MICROSCOPY
NEXT AM Starting S+1 at 0000 until S+5 for 5 occurrences
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total bilirubin (Note: Labs ordered outside of Beacon
Treatment Plan)
Treatment Parameters
Hold treatment and notify authorizing prescriber for Total Bilirubin greater than upper limit of
normal.
Treatment Parameters (2)
Hold treatment and notify authorizing prescriber for Urine Hemoglobin greater than Trace prior to
ifosfamide administration on Day 2, 3, 4 and 5.
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
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emergency care. See Emergency Meds.
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.
Monitoring Parameters (1)
Send daily UA to monitor for hematuria during ifosfamide therapy.
Monitoring Parameters (2)
Assess patient for signs of cerebellar toxicity (incoordination, slurred speech) with neurochecks
prior to each dose of cytarabine. Hold and notify MD for any concerns of toxicity.
Monitoring Parameters (3)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with
rituximab.
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 200 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Upon initiation of chemotherapy, adjust maintenance IV fluids to maintain total IV fluids at 200mL/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.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, 1 X DAILY, 5 doses Starting when released
Administer first dose before start of rituximab. May give IV if unable to tolerate oral dose.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, 1 X DAILY PRN, For 144 hours Starting when released, if unable to tolerate
the oral dose
Administer first dose before start of rituximab. If unable to tolerate oral dose.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, 2 X DAILY (AT MEALTIME), 4 doses Starting when released
Administer before start of cytarabine. May give IV if unable to tolerate oral dose.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, 1 X DAILY, 3 doses Starting S+2 As Scheduled
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Administer prior to chemotherapy. May give IV if unable to tolerate oral dose.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, EVERY 12 HOURS PRN, For 2 days Starting when released until S+2,
nausea/vomiting
Administer before start of cytarabine. If unable to tolerate the oral dose.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, EVERY 24 HOURS PRN, For 3 days Starting S+2 at 0000 until S+5,
nausea/vomiting
prednisolone (PRED FORTE) 1 % ophthalmic susp 1 drop
1 drop, Eyes (Each), 4 X DAILY, For 3 days Starting when released
Day 1-3: Instill one drop into each eye four time daily. First dose before start of chemotherapy
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
LEUKEMIA/LYMPHOMA SCREEN, CSF
ONCE Starting when released, Tube 1
methotrexate PF 12 mg in sodium chloride 0.9 % 2.4 mL intraTHECAL injection
12 mg, Intrathecal, ONCE, 1 dose Starting S+4 at 0000
Day 5: Dose to be given by provider.
hydrocortisone sodium succinate PF (SOLU-CORTEF) 30 mg in sodium chloride 0.9 % 3 mL
intraTHECAL injection
30 mg, Intrathecal, ONCE, 1 dose Starting S+4 at 0000
Day 5: Dose to be given by provider.
Intrathecal Procedure Orders (delete all that do not apply)
cytarabine PF (CYTOSAR) 50 mg in sodium chloride 0.9 % 1 mL intraTHECAL injection
50 mg, Intrathecal, ONCE, 1 dose Starting S+4 at 0000
Day 5: Administer if CNS involvement at time of diagnosis. Dose to be given by provider
Treatment Medications
rituximab (RITUXAN) 754 mg in sodium chloride 0.9 % 500 mL bag
754 mg (rounded from 753.75 mg = 375 mg/m2 × 2.01 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.
cytarabine PF (CYTOSAR) 4,020 mg in sodium chloride 0.9 % 250 mL bag
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4,020 mg (2,000 mg/m2 × 2.01 m2 Treatment plan actual BSA), Intravenous, EVERY 12 HOURS, 4 doses Starting when
released
mesna (MESNEX) 1,005 mg in sodium chloride 0.9 % 100 mL bag
1,005 mg (500 mg/m2 × 2.01 m2 Treatment plan actual BSA), Intravenous, 3 X DAILY, 15 doses
Starting when released
To be given 15 minutes before start of ifosfamide dose, then 4 hours and 8 hours after the start of each ifosfamide dose.
ifosfamide (IFEX) 3,015 mg in sodium chloride 0.9 % 250 mL bag
3,015 mg (1,500 mg/m2 × 2.01 m2 Treatment plan actual BSA), Intravenous, 1 X DAILY, 5 doses
Starting when released
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, 1 X DAILY, 5 doses Starting when released
Administer 1 hour after the start of ifosfamide. IV push rate 10 mg/minute. (May order additional doses if decreased urine
output).
etoposide (VEPESID) 121 mg in sodium chloride 0.9 % 500 mL NSS bag
121 mg (rounded from 120.6 mg = 60 mg/m2 × 2.01 m2 Treatment plan actual BSA), Intravenous,
1 X DAILY, 5 doses Starting when released
Administer with non-PVC tubing.
leucovorin tab 15 mg
15 mg, Oral, ONCE, 1 dose Starting S+5 at 0000
Give approximately 24 hours after intrathecal methotrexate.
TBO-filgrastim (GRANIX) 300 MCG/0.5ML soln prefilled syringe
Subcutaneous, 1 X DAILY (PM) Starting S+6 As Scheduled
Discontinue when neutrophil count is greater than 2000/µL after nadir.
Less than or equal to 80kg = 300mcg; greater than 80kg = 480mcg
Conditional Orders
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
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.
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
DAY 10 FOLLOW-UP
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CHEMOTHERAPY ROOM APPOINTMENT: intrathecal chemotherapy for select patients only.
Day 10 (Intrathecal Chemotherapy - delete if not needed), Cycle 2 (Regimen B) – Planned for
4/2/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkin (Burkitt or Burkitt like) Lymphoma; THERAPY: HIGH RISK (A-B-A-B).
REGIMEN A: rituximab 375 mg/m2 IV Day 1, doxorubicin 50 mg/m2 IV Day 1, vinCRIStine 1.4 mg/m2 IV Days 1 and 10
(maximum dose = 2mg), cyclophosphamide 800 mg/m2 IV Days 1 and 2, methotrexate 3000 mg/m2 IV Day 10,
leucovorin 50 mg/m2 IV given 24 hours after start of methotrexate infusion followed by leucovorin 15 mg/m2 IV every 6
hours until methotrexate level is less than or equal to 0.5 uM/L followed by leucovorin 15 mg by mouth every 6 hours until
methotrexate level is less than or equal to 0.05 uM/L. REGIMEN B: rituximab 375 mg/m2 IV Day 1, ifosfamide 1500
mg/m2 IV Days 1,2,3,4, and 5, mesna 500 mg/m2 IV prior to ifosfamide and 4 and 8 hours after start of ifosfamide on
Days 1,2,3,4, and 5, etoposide 60 mg/m2 IV Days 1,2,3,4, and 5, cytarabine 2000 mg/m2 IV every 12 hours on Days 1
and 2, CYCLE LENGTH: 21 days COURSE: 4 cycles (A-B-A-B)
INTRATHECAL MEDICATIONS (Schedule at MD discretion):
INTRATHECAL MEDICATIONS FOR REGIMEN A: Cytarabine 50 mg IT and Methotrexate 12 mg IT on Day 1,
Cytarabine 50 mg IT on Day 3, Hydrocortisone 30 mg IT to be given with each IT treatment (see below for additional
medication if CNS disease at diagnosis)
INTRATHECAL MEDICATIONS FOR REGIMEN B: Methotrexate 12 mg IT on Day 5, Hydrocortisone 30 mg IT to be
given with each IT treatment (see below for additional medication if CNS disease at diagnosis)
IF CENTRAL NERVOUS SYSTEM INVOLVEMENT AT DIAGNOSIS - cycle 1 only of both REGIMEN A and B add
Cytarabine 50 mg IT on Day 5 and Methotrexate 12 mg IT on Day 10, Hydrocortisone 30 mg IT to be given with each IT
treatment
Note to All Staff (1)
Regimen A: Consider dose reduction for patients greater than 65 years old to methotrexate 1000
mg/m2 IV on Day 10.
Note to All Staff (2)
Regimen B: Consider dose reduction for patients greater than 65 years old to ifosfamide 1000
mg/m2 IV Days 1 through 5 and cytarabine 1000 mg/m2 IV every 12 hours Days 1 and 2.
Note to all Staff (3)
Regimen B: Risk factors associated with ifosfamide neurotoxicity may include hypoalbuminemia,
renal dysfunction (Creatinine Clearance < 60 mL/min), and prior history of ifosfamide-induced encephalopathy. Consider
dose reduction or methylene blue prophylaxis if present.
Note to all Staff (4)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis,
hepatic failure, or death. Screen patients for HBV infection prior to rituximab treatment and consider prophylaxis against
reactivation.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Intrathecal Procedure Orders (delete all that do not apply)
LEUKEMIA/LYMPHOMA SCREEN, CSF
ONCE Starting when released, Tube 1
methotrexate PF 12 mg in sodium chloride 0.9 % 2.4 mL intraTHECAL injection
12 mg, Intrathecal, ONCE, 1 dose Starting when released
Administer if CNS involvement at time of diagnosis. Dose to be given by provider.
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hydrocortisone sodium succinate PF (SOLU-CORTEF) 30 mg in sodium chloride 0.9 % 3 mL
intraTHECAL injection
30 mg, Intrathecal, ONCE, 1 dose Starting when released
Administer if CNS involvement at time of diagnosis. Dose to be given by provider.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 (Regimen A) – 4/14/2016 through 5/4/2016 (21 days), Planned
Days 1 through 3 (Inpatient), Cycle 3 (Regimen A) – Planned for 4/14/2016 through 4/16/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkin (Burkitt or Burkitt like) Lymphoma; THERAPY: HIGH RISK (A-B-A-B).
REGIMEN A: rituximab 375 mg/m2 IV Day 1, doxorubicin 50 mg/m2 IV Day 1, vinCRIStine 1.4 mg/m2 IV Days 1 and 10
(maximum dose = 2mg), cyclophosphamide 800 mg/m2 IV Days 1 and 2, methotrexate 3000 mg/m2 IV Day 10,
leucovorin 50 mg/m2 IV given 24 hours after start of methotrexate infusion followed by leucovorin 15 mg/m2 IV every 6
hours until methotrexate level is less than or equal to 0.5 uM/L followed by leucovorin 15 mg by mouth every 6 hours until
methotrexate level is less than or equal to 0.05 uM/L. REGIMEN B: rituximab 375 mg/m2 IV Day 1, ifosfamide 1500
mg/m2 IV Days 1,2,3,4, and 5, mesna 500 mg/m2 IV prior to ifosfamide and 4 and 8 hours after start of ifosfamide on
Days 1,2,3,4, and 5, etoposide 60 mg/m2 IV Days 1,2,3,4, and 5, cytarabine 2000 mg/m2 IV every 12 hours on Days 1
and 2, CYCLE LENGTH: 21 days COURSE: 4 cycles (A-B-A-B)
INTRATHECAL MEDICATIONS (Schedule at MD discretion):
INTRATHECAL MEDICATIONS FOR REGIMEN A: Cytarabine 50 mg IT and Methotrexate 12 mg IT on Day 1,
Cytarabine 50 mg IT on Day 3, Hydrocortisone 30 mg IT to be given with each IT treatment (see below for additional
medication if CNS disease at diagnosis)
INTRATHECAL MEDICATIONS FOR REGIMEN B: Methotrexate 12 mg IT on Day 5, Hydrocortisone 30 mg IT to be
given with each IT treatment (see below for additional medication if CNS disease at diagnosis)
IF CENTRAL NERVOUS SYSTEM INVOLVEMENT AT DIAGNOSIS - cycle 1 only of both REGIMEN A and B add
Cytarabine 50 mg IT on Day 5 and Methotrexate 12 mg IT on Day 10, Hydrocortisone 30 mg IT to be given with each IT
treatment
Note to All Staff (1)
Regimen A: Consider dose reduction for patients greater than 65 years old to methotrexate 1000
mg/m2 IV on Day 10.
Note to All Staff (2)
Regimen B: Consider dose reduction for patients greater than 65 years old to ifosfamide 1000
mg/m2 IV Days 1 through 5 and cytarabine 1000 mg/m2 IV every 12 hours Days 1 and 2.
Note to all Staff (3)
Regimen B: Risk factors associated with ifosfamide neurotoxicity may include hypoalbuminemia,
renal dysfunction (Creatinine Clearance < 60 mL/min), and prior history of ifosfamide-induced encephalopathy. Consider
dose reduction or methylene blue prophylaxis if present.
Note to all Staff (4)
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.
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Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total bilirubin (Note: Labs ordered outside of Beacon
Treatment Plan)
Treatment Parameters
Hold treatment and notify authorizing prescriber for Total Bilirubin greater than upper limit of
normal.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose
or if greater than 6 months since last dose. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Meds.
Monitoring Parameters (1)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with
rituximab.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Vital Signs every 15 minutes for the first 60 minutes and then every 30 minutes until rituximab infusion complete.
If patient experiences fever accompanied by chills or rigors, shortness of breath, chest pain, or hypotension, stop infusion
and contact MD. Once the patient returns to baseline, infusion may be restarted at half the rate during which the reaction
occurred.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 200 mL/hr, Intravenous, CONTINUOUS, For 48 hours Starting when released until S+1 at 2359
Start hydration 4 hours prior to chemotherapy. With start of chemotherapy, adjust maintenance IV fluids to keep total
fluids 200 mL/hour. For cycle 2 and 3, rate of IV hydration may be reduced to 100 mL/hour.
sodium chloride 0.9 % infusion
at 100 mL/hr, Intravenous, CONTINUOUS Starting S+2 at 0000 Until Discontinued
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.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, EVERY 24 HOURS, 2 doses Starting when released
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Give first dose prior to rituximab. If unable to tolerate PO may give IV.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, EVERY 24 HOURS PRN, For 48 hours Starting when released,
nausea/vomiting
Administer prior to chemotherapy. If unable to tolerate PO may give IV.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, EVERY 24 HOURS, 2 doses Starting when released
Days 1 and 2: First dose prior to start of chemotherapy. May give IV if unable to tolerate oral dose.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, EVERY 24 HOURS PRN, For 72 hours Starting when released,
nausea/vomiting
If unable to tolerate the oral dose
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, EVERY 12 HOURS, 2 doses Starting S+2 at 0000
Day 3. First dose prior to chemotherapy. May give IV if unable to tolerate oral dose.
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 12 HOURS PRN, For 48 hours Starting S+2 at 0000, nausea/vomiting,
for 3 Minutes
If unable to tolerate the oral dose.
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
LEUKEMIA/LYMPHOMA SCREEN, CSF
ONCE Starting when released, Tube 1
cytarabine PF (CYTOSAR) 50 mg in sodium chloride 0.9 % 1 mL intraTHECAL injection
50 mg, Intrathecal, ONCE, 1 dose Starting when released
Day 1: Dose to be given by provider.
methotrexate PF 12 mg in sodium chloride 0.9 % 2.4 mL intraTHECAL injection
12 mg, Intrathecal, ONCE, 1 dose Starting when released
Day 1: Dose to be given by provider.
hydrocortisone sodium succinate PF (SOLU-CORTEF) 30 mg in sodium chloride 0.9 % 3 mL
intraTHECAL injection
30 mg, Intrathecal, ONCE, 1 dose Starting when released
Day 1: Dose to be given by provider.
LEUKEMIA/LYMPHOMA SCREEN, CSF
ONCE Starting S+2 at 0000, Tube 1
cytarabine PF (CYTOSAR) 50 mg in sodium chloride 0.9 % 1 mL intraTHECAL injection
50 mg, Intrathecal, ONCE, 1 dose Starting S+2 at 0000
Day 3: Dose to be given by provider.
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3/3/2016 12:50:34 PM Page 19 of 29
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hydrocortisone sodium succinate PF (SOLU-CORTEF) 30 mg in sodium chloride 0.9 % 3 mL
intraTHECAL injection
30 mg, Intrathecal, ONCE, 1 dose Starting S+2 at 0000
Day 3: Dose to be given by provider.
Treatment Medications
rituximab (RITUXAN) 754 mg in sodium chloride 0.9 % 500 mL bag
754 mg (rounded from 753.75 mg = 375 mg/m2 × 2.01 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.
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 101 mg
101 mg (rounded from 100.5 mg = 50 mg/m2 × 2.01 m2 Treatment plan actual BSA), Intravenous,
ONCE, 1 dose Starting when released
IV side arm push 10-15 mL/minute into running IV.
vinCRIStine (ONCOVIN) 2.8 mg in sodium chloride 0.9 % 25 mL bag
2.8 mg (rounded from 2.814 mg = 1.4 mg/m2 × 2.01 m2 Treatment plan actual BSA),
Intravenous, ONCE, 1 dose Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
Ordered dose of 1.4 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
cyclophosphamide (CYTOXAN) 1,608 mg in sodium chloride 0.9 % 250 mL bag
1,608 mg (800 mg/m2 × 2.01 m2 Treatment plan actual BSA), Intravenous, 1 X DAILY, 2 doses
Starting when released
Treatment Medications (delete all that do not apply)
TBO-filgrastim (GRANIX) 300 MCG/0.5ML soln prefilled syringe
Subcutaneous, 1 X DAILY (PM), 6 doses Starting S+2 As Scheduled
Give first dose of tbo-filgrastim a minimum of 24 hours after last dose of cyclophosphamide. Less than or equal to 80kg =
300mcg; greater than 80kg = 480mcg
Conditional Orders
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
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.
Take Home Medications
sodium bicarbonate oral powder
Mix 1/2 teaspoon sodium bicarbonate oral powder (baking soda) in 6-8 ounces of a non-acidic fluid
and drink by mouth at 8 AM, 12 PM, 4 PM, 10 PM the day before methotrexate treatment and at 8 AM the morning of
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methotrexate treatment., Disp-1 Bottle, R-0, starting S, No Print
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.
Day 10 (Inpatient), Cycle 3 (Regimen A) – Planned for 4/23/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkin (Burkitt or Burkitt like) Lymphoma; THERAPY: HIGH RISK (A-B-A-B).
REGIMEN A: rituximab 375 mg/m2 IV Day 1, doxorubicin 50 mg/m2 IV Day 1, vinCRIStine 1.4 mg/m2 IV Days 1 and 10
(maximum dose = 2mg), cyclophosphamide 800 mg/m2 IV Days 1 and 2, methotrexate 3000 mg/m2 IV Day 10,
leucovorin 50 mg/m2 IV given 24 hours after start of methotrexate infusion followed by leucovorin 15 mg/m2 IV every 6
hours until methotrexate level is less than or equal to 0.5 uM/L followed by leucovorin 15 mg by mouth every 6 hours until
methotrexate level is less than or equal to 0.05 uM/L. REGIMEN B: rituximab 375 mg/m2 IV Day 1, ifosfamide 1500
mg/m2 IV Days 1,2,3,4, and 5, mesna 500 mg/m2 IV prior to ifosfamide and 4 and 8 hours after start of ifosfamide on
Days 1,2,3,4, and 5, etoposide 60 mg/m2 IV Days 1,2,3,4, and 5, cytarabine 2000 mg/m2 IV every 12 hours on Days 1
and 2, CYCLE LENGTH: 21 days COURSE: 4 cycles (A-B-A-B)
INTRATHECAL MEDICATIONS (Schedule at MD discretion):
INTRATHECAL MEDICATIONS FOR REGIMEN A: Cytarabine 50 mg IT and Methotrexate 12 mg IT on Day 1,
Cytarabine 50 mg IT on Day 3, Hydrocortisone 30 mg IT to be given with each IT treatment (see below for additional
medication if CNS disease at diagnosis)
INTRATHECAL MEDICATIONS FOR REGIMEN B: Methotrexate 12 mg IT on Day 5, Hydrocortisone 30 mg IT to be
given with each IT treatment (see below for additional medication if CNS disease at diagnosis)
IF CENTRAL NERVOUS SYSTEM INVOLVEMENT AT DIAGNOSIS - cycle 1 only of both REGIMEN A and B add
Cytarabine 50 mg IT on Day 5 and Methotrexate 12 mg IT on Day 10, Hydrocortisone 30 mg IT to be given with each IT
treatment
Note to All Staff (1)
Regimen A: Consider dose reduction for patients greater than 65 years old to methotrexate 1000
mg/m2 IV on Day 10.
Note to All Staff (2)
Regimen B: Consider dose reduction for patients greater than 65 years old to ifosfamide 1000
mg/m2 IV Days 1 through 5 and cytarabine 1000 mg/m2 IV every 12 hours Days 1 and 2.
Note to all Staff (3)
Regimen B: Risk factors associated with ifosfamide neurotoxicity may include hypoalbuminemia,
renal dysfunction (Creatinine Clearance < 60 mL/min), and prior history of ifosfamide-induced encephalopathy. Consider
dose reduction or methylene blue prophylaxis if present.
Note to all Staff (4)
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.
NOTE:
ONCE, 1 dose Starting when released
Hold TMP/SMX during infusion and until methotrexate level is undetectable.
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Pre-Labs
CBC WITH DIFFERENTIAL
ONCE Starting when released, Routine
CREATININE
ONCE Starting when released, Routine
AST/SGOT
ONCE Starting when released
ALT/SGPT
ONCE Starting when released
ALKALINE PHOSPHATASE
ONCE Starting when released, Routine
Additional Labs
PH, URINE (METHOTREXATE PROTOCOL)
ONCE Starting when released
Obtain pH, Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 2 HOURS Starting when released for 2 occurrences
Obtain pH, Urine (Methotrexate Protocol) at 2 hours and 4 hours after start of Methotrexate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting when released for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is
undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting S+8 at 0000 for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is
undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
CONDITIONAL - RN COLLECT Starting when released until S+7 for 7 days
If Urine pH falls below 7, obtain pH, Urine (Methotrexate Protocol) every 2 hours as needed until Urine pH is greater than
or equal to 7 for two consecutive occurrences.
METHOTREXATE
ONCE Starting when released
Obtain methotrexate level 24 hours after the start of methotrexate infusion.
METHOTREXATE
NEXT AM Starting S+2 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate
levels when drug level is undetectable.
METHOTREXATE
NEXT AM Starting S+9 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate
levels when drug level is undetectable.
CREATININE
ONCE Starting when released
Obtain creatinine at 24 hours after the start of methotrexate infusion.
CREATININE
NEXT AM Starting S+2 As Scheduled for 7 days
CREATININE
NEXT AM Starting S+9 As Scheduled for 7 days
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Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin, AST, ALT,
Alkaline Phosphatase, pH Urine (Methotrexate Protocol).
Verify Labs (2)
Verify ongoing treatment labs: Creatinine, pH, Urine (Methotrexate Protocol) and Methotrexate
levels.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Total Bilirubin greater than ULN or Creatinine
Clearance less than 60 mL/min or Creatinine greater than 1.5 mg/dL.
Treatment Parameters (2)
Do not administer methotrexate until urine pH is greater than or equal to 7.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Check pH Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion. If less
than 7, give sodium bicarbonate 50 mEq IV. See Conditional Medications.
Monitoring Parameters (2)
Check pH Urine (Methotrexate Protocol) at 2 hours, 4 hours, and 8 hours after start of methotrexate
and then every 8 hours until methotrexate level is undetectable. If less than 7, give sodium bicarbonate 50 mEq IV and
check urine pH every 2 hours until urine pH is greater than or equal to 7. See Conditional Medications and Additional
Labs.
Nursing Communication
CONTINUOUS Starting when released Until Specified
If sodium bicarbonate bolus given, recheck Urine pH in 2 hours. If two boluses of sodium bicarbonate have been given in
8 hours or three boluses in 24 hours, notify pharmacy and provider to review IV fluid orders.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium bicarbonate 100 mEq in dextrose 5 % 1,000 mL infusion
Intravenous, CONTINUOUS Starting when released Until Discontinued
Begin 4 hours prior to start of methotrexate. May discontinue when methotrexate level is undetectable. Sodium
Bicarbonate infusion must NOT be interrupted for any reason without an order from the attending physician or fellow.
NOTE:
EVERY 6 HOURS Starting when released
Sodium Bicarbonate infusion must NOT be interrupted for any reason without an order from the attending physician or
fellow.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, EVERY 24 HOURS, 1 dose Starting when released
May give IV if unable to tolerate oral dose.
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ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, EVERY 24 HOURS PRN, For 48 hours Starting when released,
nausea/vomiting
If unable to tolerate the oral dose
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Once prior to methotrexate. If unable to give PO may give IV.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, EVERY 24 HOURS PRN, For 48 hours Starting when released
Administer prior to methotrexate. If unable to give PO may give IV.
Treatment Medications
vinCRIStine (ONCOVIN) 2.8 mg in sodium chloride 0.9 % 25 mL bag
2.8 mg (rounded from 2.814 mg = 1.4 mg/m2 × 2.01 m2 Treatment plan actual BSA),
Intravenous, ONCE, 1 dose Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump). Maximum dose is 2 mg.
Ordered dose of 1.4 mg/m2 ONCE exceeds the recommended single dose limit of 2 mg.
methotrexate PF 6,030 mg in dextrose 5 % 1,000 mL bag
6,030 mg (3,000 mg/m2 × 2.01 m2 Treatment plan actual BSA), Intravenous, ONCE, 1 dose
Starting when released
Do not start methotrexate until urine pH greater than or equal to 7.
leucovorin 20 MG/ML injection 101 mg
101 mg (rounded from 100.5 mg = 50 mg/m2 × 2.01 m2 Treatment plan actual BSA), Intravenous,
ONCE, 1 dose Starting S+1 at 0000, for 10 Minutes
Start 24 hours after the start of methotrexate infusion.
leucovorin 20 MG/ML injection 30 mg
30 mg (rounded from 30.15 mg = 15 mg/m2 × 2.01 m2 Treatment plan actual BSA), Intravenous,
EVERY 6 HOURS Starting S+1 at 0000, for 10 Minutes
Start 6 hours after IV leucovorin loading dose. Give every 6 hours until the serum methotrexate level is less than or equal
to 0.5 µM/L, then give PO leucovorin. See PRN NOTIFY PHARMACY order.
leucovorin tab 15 mg
15 mg, Oral, PRN - NOTIFY PHARMACY WHEN NEEDED Starting S+1 at 0000 Until
Discontinued, High Dose Methotrexate
Once methotrexate level is less than or equal to 0.5 µM/L, starting 6 hours after last IV leucovorin dose give 15 mg
leucovorin PO every 6 hours until serum methotrexate level is less than or equal to 0.05 µM/L
Treatment Medications (delete all that do not apply)
TBO-filgrastim (GRANIX) 300 MCG/0.5ML soln prefilled syringe
Subcutaneous, 1 X DAILY (PM) Starting S+4 As Scheduled
Start if ANC less than 1000/µL and when methotrexate level is undetectable. Discontinue when ANC is greater than
2000/µL after nadir.
Conditional Orders
sodium bicarbonate 8.4 % injection 50 mEq
50 mEq, Intravenous, EVERY 2 HOURS PRN, For 7 days Starting when released until S+7, For
urine pH less than 7, for 1 Minutes
Administer over 1 to 2 minutes. Give if urine pH is less than 7. Discontinue when methotrexate level is undetectable.
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,
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Zztestonc,Edward E [2435061]
3/3/2016 12:50:34 PM Page 24 of 29
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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
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.
Take Home Medications
leucovorin 15 MG tab
Take 1 tab by mouth every 6 hours. Take until seen in clinic for follow up appt to confirm
methotrexate level undetectable, 15 mg, Disp-16 tab, R-0, EVERY 6 HOURS starting S
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.
Cycle 4 (Regimen B) – 5/5/2016 through 5/25/2016 (21 days), Planned
Days 1 through 7 (Inpatient), Cycle 4 (Regimen B) – Planned for 5/5/2016 through 5/11/2016
Treatment Plan Information
Reference Information (1)
NON HODGKIN (BURKITT OR BURKITT LIKE) LYMPHOMA: Mead GM, et al. Blood 2008;15
(112):2248-60
Reference Information (2)
NON HODGKIN (BURKITT OR BURKITT LIKE) LYMPHOMA: Corazzelli G, et al. Br J Haematol
2012;156(2):234-44
Treatment Plan Summary
DISEASE: Non-Hodgkin (Burkitt or Burkitt like) Lymphoma; THERAPY: HIGH RISK (A-B-A-B).
REGIMEN A: rituximab 375 mg/m2 IV Day 1, doxorubicin 50 mg/m2 IV Day 1, vinCRIStine 1.4 mg/m2 IV Days 1 and 10
(maximum dose = 2mg), cyclophosphamide 800 mg/m2 IV Days 1 and 2, methotrexate 3000 mg/m2 IV Day 10,
leucovorin 50 mg/m2 IV given 24 hours after start of methotrexate infusion followed by leucovorin 15 mg/m2 IV every 6
hours until methotrexate level is less than or equal to 0.5 uM/L followed by leucovorin 15 mg by mouth every 6 hours until
methotrexate level is less than or equal to 0.05 uM/L. REGIMEN B: rituximab 375 mg/m2 IV Day 1, ifosfamide 1500
mg/m2 IV Days 1,2,3,4, and 5, mesna 500 mg/m2 IV prior to ifosfamide and 4 and 8 hours after start of ifosfamide on
Days 1,2,3,4, and 5, etoposide 60 mg/m2 IV Days 1,2,3,4, and 5, cytarabine 2000 mg/m2 IV every 12 hours on Days 1
and 2, CYCLE LENGTH: 21 days COURSE: 4 cycles (A-B-A-B)
INTRATHECAL MEDICATIONS (Schedule at MD discretion):
INTRATHECAL MEDICATIONS FOR REGIMEN A: Cytarabine 50 mg IT and Methotrexate 12 mg IT on Day 1,
Cytarabine 50 mg IT on Day 3, Hydrocortisone 30 mg IT to be given with each IT treatment (see below for additional
medication if CNS disease at diagnosis)
INTRATHECAL MEDICATIONS FOR REGIMEN B: Methotrexate 12 mg IT on Day 5, Hydrocortisone 30 mg IT to be
given with each IT treatment (see below for additional medication if CNS disease at diagnosis)
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3/3/2016 12:50:34 PM Page 25 of 29
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IF CENTRAL NERVOUS SYSTEM INVOLVEMENT AT DIAGNOSIS - cycle 1 only of both REGIMEN A and B add
Cytarabine 50 mg IT on Day 5 and Methotrexate 12 mg IT on Day 10, Hydrocortisone 30 mg IT to be given with each IT
treatment
Note to All Staff (1)
Regimen A: Consider dose reduction for patients greater than 65 years old to methotrexate 1000
mg/m2 IV on Day 10.
Note to All Staff (2)
Regimen B: Consider dose reduction for patients greater than 65 years old to ifosfamide 1000
mg/m2 IV Days 1 through 5 and cytarabine 1000 mg/m2 IV every 12 hours Days 1 and 2.
Note to all Staff (3)
Regimen B: Risk factors associated with ifosfamide neurotoxicity may include hypoalbuminemia,
renal dysfunction (Creatinine Clearance < 60 mL/min), and prior history of ifosfamide-induced encephalopathy. Consider
dose reduction or methylene blue prophylaxis if present.
Note to all Staff (4)
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
URINALYSIS WITH MICROSCOPY
NEXT AM Starting S+1 at 0000 until S+5 for 5 occurrences
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total bilirubin (Note: Labs ordered outside of Beacon
Treatment Plan)
Treatment Parameters
Hold treatment and notify authorizing prescriber for Total Bilirubin greater than upper limit of
normal.
Treatment Parameters (2)
Hold treatment and notify authorizing prescriber for Urine Hemoglobin greater than Trace prior to
ifosfamide administration on Day 2, 3, 4 and 5.
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.
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.
Monitoring Parameters (1)
Send daily UA to monitor for hematuria during ifosfamide therapy.
Monitoring Parameters (2)
Assess patient for signs of cerebellar toxicity (incoordination, slurred speech) with neurochecks
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prior to each dose of cytarabine. Hold and notify MD for any concerns of toxicity.
Monitoring Parameters (3)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with
rituximab.
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 200 mL/hr, Intravenous, CONTINUOUS Starting when released Until Discontinued
Upon initiation of chemotherapy, adjust maintenance IV fluids to maintain total IV fluids at 200mL/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.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, 1 X DAILY, 5 doses Starting when released
Administer first dose before start of rituximab. May give IV if unable to tolerate oral dose.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, 1 X DAILY PRN, For 144 hours Starting when released, if unable to tolerate
the oral dose
Administer first dose before start of rituximab. If unable to tolerate oral dose.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, 2 X DAILY (AT MEALTIME), 4 doses Starting when released
Administer before start of cytarabine. May give IV if unable to tolerate oral dose.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, 1 X DAILY, 3 doses Starting S+2 As Scheduled
Administer prior to chemotherapy. May give IV if unable to tolerate oral dose.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, EVERY 12 HOURS PRN, For 2 days Starting when released until S+2,
nausea/vomiting
Administer before start of cytarabine. If unable to tolerate the oral dose.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, EVERY 24 HOURS PRN, For 3 days Starting S+2 at 0000 until S+5,
nausea/vomiting
prednisolone (PRED FORTE) 1 % ophthalmic susp 1 drop
1 drop, Eyes (Each), 4 X DAILY, For 3 days Starting when released
Day 1-3: Instill one drop into each eye four time daily. First dose before start of chemotherapy
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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
LEUKEMIA/LYMPHOMA SCREEN, CSF
ONCE Starting when released, Tube 1
methotrexate PF 12 mg in sodium chloride 0.9 % 2.4 mL intraTHECAL injection
12 mg, Intrathecal, ONCE, 1 dose Starting S+4 at 0000
Day 5: Dose to be given by provider.
hydrocortisone sodium succinate PF (SOLU-CORTEF) 30 mg in sodium chloride 0.9 % 3 mL
intraTHECAL injection
30 mg, Intrathecal, ONCE, 1 dose Starting S+4 at 0000
Day 5: Dose to be given by provider.
Treatment Medications
rituximab (RITUXAN) 754 mg in sodium chloride 0.9 % 500 mL bag
754 mg (rounded from 753.75 mg = 375 mg/m2 × 2.01 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.
cytarabine PF (CYTOSAR) 4,020 mg in sodium chloride 0.9 % 250 mL bag
4,020 mg (2,000 mg/m2 × 2.01 m2 Treatment plan actual BSA), Intravenous, EVERY 12 HOURS,
4 doses Starting when released
mesna (MESNEX) 1,005 mg in sodium chloride 0.9 % 100 mL bag
1,005 mg (500 mg/m2 × 2.01 m2 Treatment plan actual BSA), Intravenous, 3 X DAILY, 15 doses
Starting when released
To be given 15 minutes before start of ifosfamide dose, then 4 hours and 8 hours after the start of each ifosfamide dose.
ifosfamide (IFEX) 3,015 mg in sodium chloride 0.9 % 250 mL bag
3,015 mg (1,500 mg/m2 × 2.01 m2 Treatment plan actual BSA), Intravenous, 1 X DAILY, 5 doses
Starting when released
furosemide (LASIX) 10 MG/ML injection 20 mg
20 mg, Intravenous, 1 X DAILY, 5 doses Starting when released
Administer 1 hour after the start of ifosfamide. IV push rate 10 mg/minute. (May order additional doses if decreased urine
output).
etoposide (VEPESID) 121 mg in sodium chloride 0.9 % 500 mL NSS bag
121 mg (rounded from 120.6 mg = 60 mg/m2 × 2.01 m2 Treatment plan actual BSA), Intravenous,
1 X DAILY, 5 doses Starting when released
Administer with non-PVC tubing.
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3/3/2016 12:50:34 PM Page 28 of 29
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04/2016CCKM@uwhealth.org

leucovorin tab 15 mg
15 mg, Oral, ONCE, 1 dose Starting S+5 at 0000
Give approximately 24 hours after intrathecal methotrexate.
TBO-filgrastim (GRANIX) 300 MCG/0.5ML soln prefilled syringe
Subcutaneous, 1 X DAILY (PM) Starting S+6 As Scheduled
Discontinue when neutrophil count is greater than 2000/µL after nadir.
Less than or equal to 80kg = 300mcg; greater than 80kg = 480mcg
Conditional Orders
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
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.
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,Edward E [2435061]
3/3/2016 12:50:34 PM Page 29 of 29
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2016CCKM@uwhealth.org