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201605136

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UWHC,UWMF,

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

CSC Hem Inpt Modified Magrath Low Risk With Rituximab (A-A-A) Ver 3-4-16 (HL 3038)

CSC Hem Inpt Modified Magrath Low Risk With Rituximab (A-A-A) Ver 3-4-16 (HL 3038) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Lymphoma


CSC HEM INPT MODIFIED MAGRATH LOW RISK WITH RITUXIMAB (A-A-A) VER: 3-4-16 – Properties
Cycle 1 – 3/3/2016 through 3/23/2016 (21 days), Planned
Days 1 through 3 (Regimen A) (Inpatient), Cycle 1 – Planned for 3/3/2016
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: LOW RISK (A-A-
A). REGIMEN A: rituximab 375mg/m2 IV Day 1, doxorubicin 50mg/m2 IV Day 1, vinCRIStine 1.4 mg/m2 IV Days 1 and
10 (maximum dose = 2mg), cyclophosphamide 800mg/m2 IV Days 1 and 2, methotrexate 3gm/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; CYCLE LENGTH: 21 days COURSE: 3 cycles (A-A-A)
INTRATHECAL MEDICATIONS FOR REGIMEN A:
(Schedule at MD discretion). Hydrocortisone 30mg IT to be given with each intrathecal treatment. Cytarabine 50mg IT
and Methotrexate 12mg IT on Day 1, Cytarabine 50mg IT on Day 3.
IF CENTRAL NERVOUS SYSTEM INVOLVEMENT AT DIAGNOSIS - cycle 1 only add Cytarabine 50mg IT on Day
5, and Methotrexate 12mg IT on Day 10.
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.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
HEPATITIS B CORE AB, TOTAL
Expected-S Approximate, Expires-S+365, Routine
HEPATITIS B SURFACE AG
Expected-S Approximate, Expires-S+365, Routine
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.
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Zztestonc,Edward E [2435061]
3/3/2016 12:52:15 PM Page 1 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2016CCKM@uwhealth.org

Monitoring Parameters (1)
Educate patients regarding the potential of occurence for severe mucocutaneous
reactions with rituximab.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Vital Signs every 15 minutes for the first 60 minutes and then every 30 minutes until rituximab infusion complete.
If patient experiences fever accompanied by chills or rigors, shortness of breath, chest pain, or hypotension, stop infusion
and contact MD. Once the patient returns to baseline, infusion may be restarted at half the rate during which the reaction
occurred.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 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
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Zztestonc,Edward E [2435061]
3/3/2016 12:52:15 PM Page 2 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
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04/2016CCKM@uwhealth.org

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
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
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
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Zztestonc,Edward E [2435061]
3/3/2016 12:52:15 PM Page 3 of 23
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2016CCKM@uwhealth.org

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.
Day 10 (Regimen A) (Inpatient) , Cycle 1 – Planned for 3/12/2016
Treatment Plan Information
Reference Information (1)
NON HODGKIN (BURKITT OR BURKITT LIKE) LYMPHOMA: Mead GM, et al. Blood 2008;15
(112):2248-60
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Zztestonc,Edward E [2435061]
3/3/2016 12:52:15 PM Page 4 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2016CCKM@uwhealth.org

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: LOW RISK (A-A-A).
REGIMEN A: rituximab 375mg/m2 IV Day 1, doxorubicin 50mg/m2 IV Day 1, vinCRIStine 1.4 mg/m2 IV Days 1 and 10
(maximum dose = 2mg), cyclophosphamide 800mg/m2 IV Days 1 and 2, methotrexate 3gm/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; CYCLE LENGTH: 21 days COURSE: 3 cycles (A-A-A)
INTRATHECAL MEDICATIONS FOR REGIMEN A:
(Schedule at MD discretion). Hydrocortisone 30mg IT to be given with each intrathecal treatment. Cytarabine 50mg IT
and Methotrexate 12mg IT on Day 1, Cytarabine 50mg IT on Day 3.
IF CENTRAL NERVOUS SYSTEM INVOLVEMENT AT DIAGNOSIS - cycle 1 only add Cytarabine 50mg IT on Day
5, and Methotrexate 12mg IT on Day 10.
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.
NOTE:
ONCE, 1 dose Starting when released
Hold TMP/SMX during infusion and until methotrexate level is undetectable.
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.
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Zztestonc,Edward E [2435061]
3/3/2016 12:52:15 PM Page 5 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2016CCKM@uwhealth.org

PH, URINE (METHOTREXATE PROTOCOL)
CONDITIONAL - RN COLLECT Starting when released until S+7 for 7 days
If Urine pH falls below 7, obtain pH, Urine (Methotrexate Protocol) every 2 hours as needed until Urine pH is greater than
or equal to 7 for two consecutive occurrences.
METHOTREXATE
ONCE Starting when released
Obtain methotrexate level 24 hours after the start of methotrexate infusion.
METHOTREXATE
NEXT AM Starting S+2 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate
levels when drug level is undetectable.
METHOTREXATE
NEXT AM Starting S+9 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate
levels when drug level is undetectable.
CREATININE
ONCE Starting when released
Obtain creatinine at 24 hours after the start of methotrexate infusion.
CREATININE
NEXT AM Starting S+2 As Scheduled for 7 days
CREATININE
NEXT AM Starting S+9 As Scheduled for 7 days
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin, AST, ALT,
Alkaline Phosphatase, pH Urine (Methotrexate Protocol).
Verify Labs (2)
Verify ongoing treatment labs: Creatinine, pH, Urine (Methotrexate Protocol) and Methotrexate
levels.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Total Bilirubin greater than ULN 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
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Zztestonc,Edward E [2435061]
3/3/2016 12:52:15 PM Page 6 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2016CCKM@uwhealth.org

sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium bicarbonate 100 mEq in dextrose 5 % 1,000 mL infusion
Intravenous, CONTINUOUS Starting when released Until Discontinued
Begin 4 hours prior to start of methotrexate. May discontinue when methotrexate level is undetectable. Sodium
Bicarbonate infusion must NOT be interrupted for any reason without an order from the attending physician or fellow.
NOTE:
EVERY 6 HOURS Starting when released
Sodium Bicarbonate infusion must NOT be interrupted for any reason without an order from the attending physician or
fellow.
Pre-Medications
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.
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
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Zztestonc,Edward E [2435061]
3/3/2016 12:52:15 PM Page 7 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
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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,
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.
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Zztestonc,Edward E [2435061]
3/3/2016 12:52:15 PM Page 8 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
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Cycle 2 – 3/24/2016 through 4/13/2016 (21 days), Planned
Days 1 through 3 (Regimen A) (Inpatient), Cycle 2 – Planned for 3/24/2016 through 3/26/2016
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: LOW RISK (A-A-A).
REGIMEN A: rituximab 375mg/m2 IV Day 1, doxorubicin 50mg/m2 IV Day 1, vinCRIStine 1.4 mg/m2 IV Days 1 and 10
(maximum dose = 2mg), cyclophosphamide 800mg/m2 IV Days 1 and 2, methotrexate 3gm/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; CYCLE LENGTH: 21 days COURSE: 3 cycles (A-A-A)
INTRATHECAL MEDICATIONS FOR REGIMEN A:
(Schedule at MD discretion). Hydrocortisone 30mg IT to be given with each intrathecal treatment. Cytarabine 50mg IT
and Methotrexate 12mg IT on Day 1, Cytarabine 50mg IT on Day 3.
IF CENTRAL NERVOUS SYSTEM INVOLVEMENT AT DIAGNOSIS - cycle 1 only add Cytarabine 50mg IT on Day
5, and Methotrexate 12mg IT on Day 10.
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.
Consent
Verify Consent
Verify informed consent has been obtained.
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.
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Zztestonc,Edward E [2435061]
3/3/2016 12:52:15 PM Page 9 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2016CCKM@uwhealth.org

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
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
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Zztestonc,Edward E [2435061]
3/3/2016 12:52:15 PM Page 10 of 23
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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) 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,
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Zztestonc,Edward E [2435061]
3/3/2016 12:52:15 PM Page 11 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2016CCKM@uwhealth.org

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
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 (Regimen A) (Inpatient) , Cycle 2 – Planned for 4/2/2016
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: LOW RISK (A-A-A).
REGIMEN A: rituximab 375mg/m2 IV Day 1, doxorubicin 50mg/m2 IV Day 1, vinCRIStine 1.4 mg/m2 IV Days 1 and 10
(maximum dose = 2mg), cyclophosphamide 800mg/m2 IV Days 1 and 2, methotrexate 3gm/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; CYCLE LENGTH: 21 days COURSE: 3 cycles (A-A-A)
INTRATHECAL MEDICATIONS FOR REGIMEN A:
(Schedule at MD discretion). Hydrocortisone 30mg IT to be given with each intrathecal treatment. Cytarabine 50mg IT
and Methotrexate 12mg IT on Day 1, Cytarabine 50mg IT on Day 3.
IF CENTRAL NERVOUS SYSTEM INVOLVEMENT AT DIAGNOSIS - cycle 1 only add Cytarabine 50mg IT on Day
5, and Methotrexate 12mg IT on Day 10.
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.
NOTE:
ONCE, 1 dose Starting when released
Hold TMP/SMX during infusion and until methotrexate level is undetectable.
Pre-Labs
CBC WITH DIFFERENTIAL
ONCE Starting when released, Routine
CREATININE
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Zztestonc,Edward E [2435061]
3/3/2016 12:52:15 PM Page 12 of 23
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ONCE Starting when released, Routine
BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALT/SGPT
ONCE Starting when released
ALKALINE PHOSPHATASE
ONCE Starting when released, Routine
Additional Labs
PH, URINE (METHOTREXATE PROTOCOL)
ONCE Starting when released
Obtain pH, Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 2 HOURS Starting when released for 2 occurrences
Obtain pH, Urine (Methotrexate Protocol) at 2 hours and 4 hours after start of Methotrexate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting when released for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is
undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting S+8 at 0000 for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is
undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
CONDITIONAL - RN COLLECT Starting when released until S+7 for 7 days
If Urine pH falls below 7, obtain pH, Urine (Methotrexate Protocol) every 2 hours as needed until Urine pH is greater than
or equal to 7 for two consecutive occurrences.
METHOTREXATE
ONCE Starting when released
Obtain methotrexate level 24 hours after the start of methotrexate infusion.
METHOTREXATE
NEXT AM Starting S+2 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate
levels when drug level is undetectable.
METHOTREXATE
NEXT AM Starting S+9 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate
levels when drug level is undetectable.
CREATININE
ONCE Starting when released
Obtain creatinine at 24 hours after the start of methotrexate infusion.
CREATININE
NEXT AM Starting S+2 As Scheduled for 7 days
CREATININE
NEXT AM Starting S+9 As Scheduled for 7 days
Treatment Conditions
Verify Labs
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Zztestonc,Edward E [2435061]
3/3/2016 12:52:15 PM Page 13 of 23
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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
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.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
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Zztestonc,Edward E [2435061]
3/3/2016 12:52:15 PM Page 14 of 23
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04/2016CCKM@uwhealth.org

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,
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
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Zztestonc,Edward E [2435061]
3/3/2016 12:52:15 PM Page 15 of 23
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2016CCKM@uwhealth.org

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 3 – 4/14/2016 through 5/4/2016 (21 days), Planned
Days 1 through 3 (Regimen A) (Inpatient), Cycle 3 – Planned for 4/14/2016 through 4/16/2016
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: LOW RISK (A-A-A).
REGIMEN A: rituximab 375mg/m2 IV Day 1, doxorubicin 50mg/m2 IV Day 1, vinCRIStine 1.4 mg/m2 IV Days 1 and 10
(maximum dose = 2mg), cyclophosphamide 800mg/m2 IV Days 1 and 2, methotrexate 3gm/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; CYCLE LENGTH: 21 days COURSE: 3 cycles (A-A-A)
INTRATHECAL MEDICATIONS FOR REGIMEN A:
(Schedule at MD discretion). Hydrocortisone 30mg IT to be given with each intrathecal treatment. Cytarabine 50mg IT
and Methotrexate 12mg IT on Day 1, Cytarabine 50mg IT on Day 3.
IF CENTRAL NERVOUS SYSTEM INVOLVEMENT AT DIAGNOSIS - cycle 1 only add Cytarabine 50mg IT on Day
5, and Methotrexate 12mg IT on Day 10.
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.
Consent
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Verify Consent
Verify informed consent has been obtained.
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.
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Zztestonc,Edward E [2435061]
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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
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
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.
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3/3/2016 12:52:15 PM Page 18 of 23
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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
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 (Regimen A) (Inpatient) , Cycle 3 – Planned for 4/23/2016
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
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Zztestonc,Edward E [2435061]
3/3/2016 12:52:15 PM Page 19 of 23
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2012;156(2):234-44
Treatment Plan Summary
DISEASE: Non-Hodgkin (Burkitt or Burkitt like) Lymphoma; THERAPY: LOW RISK (A-A-A).
REGIMEN A: rituximab 375mg/m2 IV Day 1, doxorubicin 50mg/m2 IV Day 1, vinCRIStine 1.4 mg/m2 IV Days 1 and 10
(maximum dose = 2mg), cyclophosphamide 800mg/m2 IV Days 1 and 2, methotrexate 3gm/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; CYCLE LENGTH: 21 days COURSE: 3 cycles (A-A-A)
INTRATHECAL MEDICATIONS FOR REGIMEN A:
(Schedule at MD discretion). Hydrocortisone 30mg IT to be given with each intrathecal treatment. Cytarabine 50mg IT
and Methotrexate 12mg IT on Day 1, Cytarabine 50mg IT on Day 3.
IF CENTRAL NERVOUS SYSTEM INVOLVEMENT AT DIAGNOSIS - cycle 1 only add Cytarabine 50mg IT on Day
5, and Methotrexate 12mg IT on Day 10.
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.
NOTE:
ONCE, 1 dose Starting when released
Hold TMP/SMX during infusion and until methotrexate level is undetectable.
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)
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CONDITIONAL - RN COLLECT Starting when released until S+7 for 7 days
If Urine pH falls below 7, obtain pH, Urine (Methotrexate Protocol) every 2 hours as needed until Urine pH is greater than
or equal to 7 for two consecutive occurrences.
METHOTREXATE
ONCE Starting when released
Obtain methotrexate level 24 hours after the start of methotrexate infusion.
METHOTREXATE
NEXT AM Starting S+2 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate
levels when drug level is undetectable.
METHOTREXATE
NEXT AM Starting S+9 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate
levels when drug level is undetectable.
CREATININE
ONCE Starting when released
Obtain creatinine at 24 hours after the start of methotrexate infusion.
CREATININE
NEXT AM Starting S+2 As Scheduled for 7 days
CREATININE
NEXT AM Starting S+9 As Scheduled for 7 days
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin, AST, ALT,
Alkaline Phosphatase, pH Urine (Methotrexate Protocol).
Verify Labs (2)
Verify ongoing treatment labs: Creatinine, pH, Urine (Methotrexate Protocol) and Methotrexate
levels.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Total Bilirubin greater than ULN 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
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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.
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
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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,
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.
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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