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

CSC Hem Inpt-Op CHOEP With High Dose Methotrexate (Day 10) Ver 3-4-16 (HL 4400)

CSC Hem Inpt-Op CHOEP With High Dose Methotrexate (Day 10) Ver 3-4-16 (HL 4400) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Lymphoma


CSC HEM INPT/OP CHOEP WITH HIGH DOSE METHOTREXATE (DAY 10) VER: 3-4-16 – Properties
Cycle 1 – 3/3/2016 through 3/23/2016 (21 days), Planned
Day 1 (Outpatient), Cycle 1 – Planned for 3/3/2016
Treatment Plan Information
Reference Information (1)
LYMPHOMA: Schmitz N, et al. Blood 2010;116:3418-25.
Reference Information (2)
LYMPHOMA: Abramson JS, et al. Cancer 2010;116:4283-90.
Reference Information (3)
LYMPHOMA: Bernstein SH, et al. J Clin Oncol 2009;27:114-9.
Reference Information (4)
LYMPHOMA: Ellin F, et al. Blood 2014;124(10):1570-77.
Reference Information (5)
LYMPHOMA: Boehme V, et al. Ann Oncol 2007;18:149-57.
Treatment Plan Summary
DISEASE: Lymphoma: THERAPY: prednisone 100 mg by mouth Day 1, 2, 3, 4, 5 (All
cycles), doxorubicin 50 mg/m2 IV Day 1 (All cycles), vinCRIStine 2 mg IV Day 1 (All cycles), cyclophosphamide 750
mg/m2 IV Day 1 (All cycles), etoposide 100mg/m2 IV Day 1 and etoposide 100 mg/m2 by mouth twice daily on Day 2
and 3, methotrexate 3500 mg/m2 IV Day 10 (Cycles 2, 4, 6, 8), 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 (Cycles 2, 4, 6, 8); CYCLE LENGTH: 21 days ; COURSE: 6 to 8 cycles
Note to All Staff (1)
This regimen is not preferred for T-cell and NK-cell lymphoma patients greater than 60
years of age.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
URIC ACID
Expected-S Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S Approximate, Expires-S+365, Routine
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3/3/2016 1:03:25 PM Page 1 of 33
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2016CCKM@uwhealth.org

LD, TOTAL
Expected-S Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin,
Uric Acid, Potassium, LDH.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than
50K/µL or Total Bilirubin greater than 2 mg/dL or Creatinine greater than 1.5 mg/dL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for
two days after treatment.
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 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 0.5 mg
0.5 mg, Oral, ONCE, 1 dose Starting when released
Premedication for chemotherapy.
prednisone (DELTASONE) tab 100 mg
100 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
Treatment Medications
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 3-5 mL/minute into running IV.
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3/3/2016 1:03:25 PM Page 2 of 33
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vinCRIStine (ONCOVIN) 2 mg in sodium chloride 0.9 % 25 mL bag
2 mg, Intravenous, ONCE, 1 dose Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump).
etoposide (VEPESID) 201 mg in sodium chloride 0.9 % 500 mL NSS bag
201 mg (100 mg/m2 × 2.01 m2 Treatment plan actual BSA), Intravenous, ONCE, 1 dose
Starting when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
cyclophosphamide (CYTOXAN) 1,507.6 mg in sodium chloride 0.9 % 250 mL bag
1,507.6 mg (rounded from 1,507.5 mg = 750 mg/m2 × 2.01 m2 Treatment plan actual
BSA), Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. RN instruct patient to drink 8-10 (8 ounce) glasses of water daily throughout treatment.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s):
prednisone (dispensed Day 1 of Cycle 1) and oral etoposide (dispensed Day 1 of each cycle)
Take Home Medications
etoposide (VEPESID) 50 MG cap
Take 4 caps by mouth 2 times daily. Take only on Day 2 and 3 of each cycle., 200 mg
(rounded from 201 mg = 100 mg/m2 × 2.01 m2 Treatment plan actual BSA), R-0, 2 X DAILY starting S, Local Printer
prednisone (DELTASONE) 20 MG tab
Take 5 tabs by mouth one time daily. Take on Days 2 through 5., 100 mg, Disp-20 tab, R-
7, 1 X DAILY starting S, Local Printer
Patient received Day 1 dose as premedication in clinic
aprepitant (EMEND) 80 MG cap
Take 1 cap by mouth one time daily. Take for 2 days following chemotherapy., 80 mg,
Disp-2 cap, R-7, 1 X DAILY starting S, Local Printer
acyclovir (ZOVIRAX) 400 MG tab
Take 1 tab by mouth 2 times daily., 400 mg, Disp-60 tab, R-7, 2 X DAILY starting S, Local
Printer
fluconazole (DIFLUCAN) 200 MG tab
Take 2 tabs by mouth one time daily., 400 mg, Disp-60 tab, R-7, 1 X DAILY starting S,
Local Printer
sulfamethoxazole-trimethoprim (BACTRIM DS) 800-160 MG per tab
Take 1 tab by mouth 2 times daily Sat,Sun., 1 tab, Disp-16 tab, R-7, 2 X DAILY SAT,
SUN starting S, Local Printer
ranitidine (ZANTAC) 150 MG tab
Take 1 tab by mouth 2 times daily., 150 mg, Disp-60 tab, R-5, 2 X DAILY starting S, Local
Printer
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting., 8 mg, Disp-30 tab,
R-5, EVERY 8 HOURS PRN starting S, Local Printer
prochlorperazine (COMPAZINE) 10 MG tab
Take 1 tab by mouth every 6 hours as needed for nausea/vomiting., 10 mg, Disp-30 tab,
R-5, EVERY 6 HOURS PRN starting S, Local Printer
Take Home Medications (delete all that do not apply)
allopurinol (ZYLOPRIM) 300 MG tab
Take 1 tab by mouth one time daily. Take on Days 1 through 7., 300 mg, R-0, 1 X
DAILY starting S, Local Printer
TBO-filgrastim (GRANIX) 300 MCG/0.5ML soln prefilled syringe
Inject 300 mcg under skin one time daily in evening. Begin Day ***. Continue until
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ANC is greater than *** after nadir., 300 mcg, Disp-10 Syringe, R-5, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
TBO-filgrastim (GRANIX) 480 MCG/0.8ML soln prefilled syringe
Inject 480 mcg under skin one time daily in evening. Begin Day ***. Continue until
ANC is greater than *** after nadir., 480 mcg, Disp-10 Syringe, R-5, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC
with DIFF, Creatinine, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: cyclophosphamide, doxorubicin,
vinCRIStine and etoposide for 150 minutes.
Cycle 2 – 3/24/2016 through 4/13/2016 (21 days), Planned
Day 1 (Outpatient), Cycle 2 – Planned for 3/24/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Lymphoma: THERAPY: prednisone 100 mg by mouth Day 1, 2, 3, 4, 5 (All cycles),
doxorubicin 50 mg/m2 IV Day 1 (All cycles), vinCRIStine 2 mg IV Day 1 (All cycles), cyclophosphamide 750 mg/m2 IV
Day 1 (All cycles), etoposide 100mg/m2 IV Day 1 and etoposide 100 mg/m2 by mouth twice daily on Day 2 and 3,
methotrexate 3500 mg/m2 IV Day 10 (Cycles 2, 4, 6, 8), 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
(Cycles 2, 4, 6, 8); CYCLE LENGTH: 21 days ; COURSE: 6 to 8 cycles
Note to All Staff (1)
This regimen is not preferred for T-cell and NK-cell lymphoma patients greater than 60 years of
age.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
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3/3/2016 1:03:25 PM Page 4 of 33
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2016CCKM@uwhealth.org

Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 50K/µL or
Total Bilirubin greater than 2 mg/dL or Creatinine greater than 1.5 mg/dL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days
after treatment.
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 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 0.5 mg
0.5 mg, Oral, ONCE, 1 dose Starting when released
Premedication for chemotherapy.
prednisone (DELTASONE) tab 100 mg
100 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
Treatment Medications
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 3-5 mL/minute into running IV.
vinCRIStine (ONCOVIN) 2 mg in sodium chloride 0.9 % 25 mL bag
2 mg, Intravenous, ONCE, 1 dose Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump).
etoposide (VEPESID) 201 mg in sodium chloride 0.9 % 500 mL NSS bag
201 mg (100 mg/m2 × 2.01 m2 Treatment plan actual BSA), Intravenous, ONCE, 1 dose Starting
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when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
cyclophosphamide (CYTOXAN) 1,507.6 mg in sodium chloride 0.9 % 250 mL bag
1,507.6 mg (rounded from 1,507.5 mg = 750 mg/m2 × 2.01 m2 Treatment plan actual BSA),
Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. RN instruct patient to drink 8-10 (8 ounce) glasses of water daily throughout treatment.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone
(dispensed Day 1 of Cycle 1) and oral etoposide (dispensed Day 1 of each cycle)
Take Home Medications
etoposide (VEPESID) 50 MG cap
Take 4 caps by mouth 2 times daily. Take only on Day 2 and 3 of each cycle., 200 mg (rounded
from 201 mg = 100 mg/m2 × 2.01 m2 Treatment plan actual BSA), R-0, 2 X DAILY starting S, Local Printer
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
Follow-Up
DAY 10 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; ADMIT TO INPATIENT: High dose
methotrexate infusion.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF,
Creatinine, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT; cyclophosphamide, doxorubicin, etoposide and
vinCRIStine for 150 minutes.
Days 10 through 12 (Inpatient), Cycle 2 – Planned for 4/2/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Lymphoma: THERAPY: prednisone 100 mg by mouth Day 1, 2, 3, 4, 5 (All cycles),
doxorubicin 50 mg/m2 IV Day 1 (All cycles), vinCRIStine 2 mg IV Day 1 (All cycles), cyclophosphamide 750 mg/m2 IV
Day 1 (All cycles), etoposide 100mg/m2 IV Day 1 and etoposide 100 mg/m2 by mouth twice daily on Day 2 and 3,
methotrexate 3500 mg/m2 IV Day 10 (Cycles 2, 4, 6, 8), 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
(Cycles 2, 4, 6, 8); CYCLE LENGTH: 21 days ; COURSE: 6 to 8 cycles
Note to All Staff (1)
This regimen is not preferred for T-cell and NK-cell lymphoma patients greater than 60 years of
age.
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
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3/3/2016 1:03:25 PM Page 6 of 33
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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
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin, AST, ALT,
Alkaline Phosphatase, pH Urine (Methotrexate Protocol).
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Verify Labs (2)
Verify ongoing treatment labs: Creatinine, pH, Urine (Methotrexate Protocol) and Methotrexate
levels.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than
50K/µL or Total Bilirubin greater than ULN or AST greater than 3 X ULN or ALT greater than 3 X 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, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
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Give 30 minutes prior to chemotherapy.
Treatment Medications
methotrexate PF 7,035 mg in dextrose 5 % 1,000 mL bag
7,035 mg (3,500 mg/m2 × 2.01 m2 Treatment plan actual BSA), Intravenous, ONCE, 1 dose
Starting when released
Administer over 6 hours. Do not administer methotrexate until Urine pH is 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
Supportive Care Medications (delete all that do not apply)
acyclovir (ZOVIRAX) tab 400 mg
400 mg, Oral, 2 X DAILY Starting when released
fluconazole (DIFLUCAN) tab 400 mg
400 mg, Oral, 1 X DAILY Starting when released
ranitidine (ZANTAC) tab 150 mg
150 mg, Oral, 2 X DAILY Starting when released
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
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. Discontinue when methotrexate level is undectectable.
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
Follow-Up
Verify Appointments
Verify next day appointment(s) have been scheduled.
Cycle 3 – 4/14/2016 through 5/4/2016 (21 days), Planned
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Zztestonc,Edward E [2435061]
3/3/2016 1:03:25 PM Page 9 of 33
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Day 1 (Outpatient), Cycle 3 – Planned for 4/14/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Lymphoma: THERAPY: prednisone 100 mg by mouth Day 1, 2, 3, 4, 5 (All cycles),
doxorubicin 50 mg/m2 IV Day 1 (All cycles), vinCRIStine 2 mg IV Day 1 (All cycles), cyclophosphamide 750 mg/m2 IV
Day 1 (All cycles), etoposide 100mg/m2 IV Day 1 and etoposide 100 mg/m2 by mouth twice daily on Day 2 and 3,
methotrexate 3500 mg/m2 IV Day 10 (Cycles 2, 4, 6, 8), 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
(Cycles 2, 4, 6, 8); CYCLE LENGTH: 21 days ; COURSE: 6 to 8 cycles
Note to All Staff (1)
This regimen is not preferred for T-cell and NK-cell lymphoma patients greater than 60 years of
age.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 50K/µL or
Total Bilirubin greater than 2 mg/dL or Creatinine greater than 1.5 mg/dL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days
after treatment.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
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Zztestonc,Edward E [2435061]
3/3/2016 1:03:25 PM Page 10 of 33
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1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 0.5 mg
0.5 mg, Oral, ONCE, 1 dose Starting when released
Premedication for chemotherapy.
prednisone (DELTASONE) tab 100 mg
100 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
Treatment Medications
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 3-5 mL/minute into running IV.
vinCRIStine (ONCOVIN) 2 mg in sodium chloride 0.9 % 25 mL bag
2 mg, Intravenous, ONCE, 1 dose Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump).
etoposide (VEPESID) 201 mg in sodium chloride 0.9 % 500 mL NSS bag
201 mg (100 mg/m2 × 2.01 m2 Treatment plan actual BSA), Intravenous, ONCE, 1 dose Starting
when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
cyclophosphamide (CYTOXAN) 1,507.6 mg in sodium chloride 0.9 % 250 mL bag
1,507.6 mg (rounded from 1,507.5 mg = 750 mg/m2 × 2.01 m2 Treatment plan actual BSA),
Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. RN instruct patient to drink 8-10 (8 ounce) glasses of water daily throughout treatment.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone
(dispensed Day 1 of Cycle 1) and oral etoposide (dispensed Day 1 of each cycle)
Take Home Medications
etoposide (VEPESID) 50 MG cap
Take 4 caps by mouth 2 times daily. Take only on Day 2 and 3 of each cycle., 200 mg (rounded
from 201 mg = 100 mg/m2 × 2.01 m2 Treatment plan actual BSA), R-0, 2 X DAILY starting S, Local Printer
Follow-Up
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3/3/2016 1:03:25 PM Page 11 of 33
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DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF,
Creatinine, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: cyclophosphamide, doxorubicin, vinCRIStine and
etoposide for 150 minutes.
Cycle 4 – 5/5/2016 through 5/25/2016 (21 days), Planned
Day 1 (Outpatient), Cycle 4 – Planned for 5/5/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Lymphoma: THERAPY: prednisone 100 mg by mouth Day 1, 2, 3, 4, 5 (All cycles),
doxorubicin 50 mg/m2 IV Day 1 (All cycles), vinCRIStine 2 mg IV Day 1 (All cycles), cyclophosphamide 750 mg/m2 IV
Day 1 (All cycles), etoposide 100mg/m2 IV Day 1 and etoposide 100 mg/m2 by mouth twice daily on Day 2 and 3,
methotrexate 3500 mg/m2 IV Day 10 (Cycles 2, 4, 6, 8), 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
(Cycles 2, 4, 6, 8); CYCLE LENGTH: 21 days ; COURSE: 6 to 8 cycles
Note to All Staff (1)
This regimen is not preferred for T-cell and NK-cell lymphoma patients greater than 60 years of
age.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 50K/µL or
Total Bilirubin greater than 2 mg/dL or Creatinine greater than 1.5 mg/dL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days
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Zztestonc,Edward E [2435061]
3/3/2016 1:03:25 PM Page 12 of 33
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after treatment.
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 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 0.5 mg
0.5 mg, Oral, ONCE, 1 dose Starting when released
Premedication for chemotherapy.
prednisone (DELTASONE) tab 100 mg
100 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
Treatment Medications
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 3-5 mL/minute into running IV.
vinCRIStine (ONCOVIN) 2 mg in sodium chloride 0.9 % 25 mL bag
2 mg, Intravenous, ONCE, 1 dose Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump).
etoposide (VEPESID) 201 mg in sodium chloride 0.9 % 500 mL NSS bag
201 mg (100 mg/m2 × 2.01 m2 Treatment plan actual BSA), Intravenous, ONCE, 1 dose Starting
when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
cyclophosphamide (CYTOXAN) 1,507.6 mg in sodium chloride 0.9 % 250 mL bag
1,507.6 mg (rounded from 1,507.5 mg = 750 mg/m2 × 2.01 m2 Treatment plan actual BSA),
Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. RN instruct patient to drink 8-10 (8 ounce) glasses of water daily throughout treatment.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone
(dispensed Day 1 of Cycle 1) and oral etoposide (dispensed Day 1 of each cycle)
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Zztestonc,Edward E [2435061]
3/3/2016 1:03:25 PM Page 13 of 33
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Take Home Medications
etoposide (VEPESID) 50 MG cap
Take 4 caps by mouth 2 times daily. Take only on Day 2 and 3 of each cycle., 200 mg (rounded
from 201 mg = 100 mg/m2 × 2.01 m2 Treatment plan actual BSA), R-0, 2 X DAILY starting S, Local Printer
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
Follow-Up
DAY 10 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; ADMIT TO INPATIENT: High dose
methotrexate infusion.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF,
Creatinine, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT; cyclophosphamide, doxorubicin, etoposide and
vinCRIStine for 150 minutes.
Days 10 through 12 (Inpatient), Cycle 4 – Planned for 5/14/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Lymphoma: THERAPY: prednisone 100 mg by mouth Day 1, 2, 3, 4, 5 (All cycles),
doxorubicin 50 mg/m2 IV Day 1 (All cycles), vinCRIStine 2 mg IV Day 1 (All cycles), cyclophosphamide 750 mg/m2 IV
Day 1 (All cycles), etoposide 100mg/m2 IV Day 1 and etoposide 100 mg/m2 by mouth twice daily on Day 2 and 3,
methotrexate 3500 mg/m2 IV Day 10 (Cycles 2, 4, 6, 8), 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
(Cycles 2, 4, 6, 8); CYCLE LENGTH: 21 days ; COURSE: 6 to 8 cycles
Note to All Staff (1)
This regimen is not preferred for T-cell and NK-cell lymphoma patients greater than 60 years of
age.
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
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Zztestonc,Edward E [2435061]
3/3/2016 1:03:25 PM Page 14 of 33
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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
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 ANC less than 1000/µL or Platelets less than
50K/µL or Total Bilirubin greater than ULN or AST greater than 3 X ULN or ALT greater than 3 X ULN or Creatinine
Clearance less than 60 mL/min or Creatinine greater than 1.5 mg/dL.
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3/3/2016 1:03:25 PM Page 15 of 33
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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, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
methotrexate PF 7,035 mg in dextrose 5 % 1,000 mL bag
7,035 mg (3,500 mg/m2 × 2.01 m2 Treatment plan actual BSA), Intravenous, ONCE, 1 dose
Starting when released
Administer over 6 hours. Do not administer methotrexate until Urine pH is greater than or equal to 7.
leucovorin 20 MG/ML injection 101 mg
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3/3/2016 1:03:25 PM Page 16 of 33
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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
Supportive Care Medications (delete all that do not apply)
acyclovir (ZOVIRAX) tab 400 mg
400 mg, Oral, 2 X DAILY Starting when released
fluconazole (DIFLUCAN) tab 400 mg
400 mg, Oral, 1 X DAILY Starting when released
ranitidine (ZANTAC) tab 150 mg
150 mg, Oral, 2 X DAILY Starting when released
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
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. Discontinue when methotrexate level is undectectable.
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
Follow-Up
Verify Appointments
Verify next day appointment(s) have been scheduled.
Cycle 5 – 5/26/2016 through 6/15/2016 (21 days), Planned
Day 1 (Outpatient), Cycle 5 – Planned for 5/26/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Lymphoma: THERAPY: prednisone 100 mg by mouth Day 1, 2, 3, 4, 5 (All cycles),
doxorubicin 50 mg/m2 IV Day 1 (All cycles), vinCRIStine 2 mg IV Day 1 (All cycles), cyclophosphamide 750 mg/m2 IV
Day 1 (All cycles), etoposide 100mg/m2 IV Day 1 and etoposide 100 mg/m2 by mouth twice daily on Day 2 and 3,
methotrexate 3500 mg/m2 IV Day 10 (Cycles 2, 4, 6, 8), 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
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3/3/2016 1:03:25 PM Page 17 of 33
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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
(Cycles 2, 4, 6, 8); CYCLE LENGTH: 21 days ; COURSE: 6 to 8 cycles
Note to All Staff (1)
This regimen is not preferred for T-cell and NK-cell lymphoma patients greater than 60 years of
age.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 50K/µL or
Total Bilirubin greater than 2 mg/dL or Creatinine greater than 1.5 mg/dL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days
after treatment.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
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Zztestonc,Edward E [2435061]
3/3/2016 1:03:25 PM Page 18 of 33
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04/2016CCKM@uwhealth.org

at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 0.5 mg
0.5 mg, Oral, ONCE, 1 dose Starting when released
Premedication for chemotherapy.
prednisone (DELTASONE) tab 100 mg
100 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
Treatment Medications
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 3-5 mL/minute into running IV.
vinCRIStine (ONCOVIN) 2 mg in sodium chloride 0.9 % 25 mL bag
2 mg, Intravenous, ONCE, 1 dose Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump).
etoposide (VEPESID) 201 mg in sodium chloride 0.9 % 500 mL NSS bag
201 mg (100 mg/m2 × 2.01 m2 Treatment plan actual BSA), Intravenous, ONCE, 1 dose Starting
when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
cyclophosphamide (CYTOXAN) 1,507.6 mg in sodium chloride 0.9 % 250 mL bag
1,507.6 mg (rounded from 1,507.5 mg = 750 mg/m2 × 2.01 m2 Treatment plan actual BSA),
Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. RN instruct patient to drink 8-10 (8 ounce) glasses of water daily throughout treatment.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone
(dispensed Day 1 of Cycle 1) and oral etoposide (dispensed Day 1 of each cycle)
Take Home Medications
etoposide (VEPESID) 50 MG cap
Take 4 caps by mouth 2 times daily. Take only on Day 2 and 3 of each cycle., 200 mg (rounded
from 201 mg = 100 mg/m2 × 2.01 m2 Treatment plan actual BSA), R-0, 2 X DAILY starting S, Local Printer
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF,
Creatinine, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: cyclophosphamide, doxorubicin, vinCRIStine and
etoposide for 150 minutes.
Cycle 6 – 6/16/2016 through 7/6/2016 (21 days), Planned
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Zztestonc,Edward E [2435061]
3/3/2016 1:03:25 PM Page 19 of 33
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
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04/2016CCKM@uwhealth.org

Day 1 (Outpatient), Cycle 6 – Planned for 6/16/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Lymphoma: THERAPY: prednisone 100 mg by mouth Day 1, 2, 3, 4, 5 (All cycles),
doxorubicin 50 mg/m2 IV Day 1 (All cycles), vinCRIStine 2 mg IV Day 1 (All cycles), cyclophosphamide 750 mg/m2 IV
Day 1 (All cycles), etoposide 100mg/m2 IV Day 1 and etoposide 100 mg/m2 by mouth twice daily on Day 2 and 3,
methotrexate 3500 mg/m2 IV Day 10 (Cycles 2, 4, 6, 8), 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
(Cycles 2, 4, 6, 8); CYCLE LENGTH: 21 days ; COURSE: 6 to 8 cycles
Note to All Staff (1)
This regimen is not preferred for T-cell and NK-cell lymphoma patients greater than 60 years of
age.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 50K/µL or
Total Bilirubin greater than 2 mg/dL or Creatinine greater than 1.5 mg/dL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days
after treatment.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
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Zztestonc,Edward E [2435061]
3/3/2016 1:03:25 PM Page 20 of 33
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04/2016CCKM@uwhealth.org

1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 0.5 mg
0.5 mg, Oral, ONCE, 1 dose Starting when released
Premedication for chemotherapy.
prednisone (DELTASONE) tab 100 mg
100 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
Treatment Medications
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 3-5 mL/minute into running IV.
vinCRIStine (ONCOVIN) 2 mg in sodium chloride 0.9 % 25 mL bag
2 mg, Intravenous, ONCE, 1 dose Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump).
etoposide (VEPESID) 201 mg in sodium chloride 0.9 % 500 mL NSS bag
201 mg (100 mg/m2 × 2.01 m2 Treatment plan actual BSA), Intravenous, ONCE, 1 dose Starting
when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
cyclophosphamide (CYTOXAN) 1,507.6 mg in sodium chloride 0.9 % 250 mL bag
1,507.6 mg (rounded from 1,507.5 mg = 750 mg/m2 × 2.01 m2 Treatment plan actual BSA),
Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. RN instruct patient to drink 8-10 (8 ounce) glasses of water daily throughout treatment.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone
(dispensed Day 1 of Cycle 1) and oral etoposide (dispensed Day 1 of each cycle)
Take Home Medications
etoposide (VEPESID) 50 MG cap
Take 4 caps by mouth 2 times daily. Take only on Day 2 and 3 of each cycle., 200 mg (rounded
from 201 mg = 100 mg/m2 × 2.01 m2 Treatment plan actual BSA), R-0, 2 X DAILY starting S, Local Printer
sodium bicarbonate oral powder
Mix 1/2 teaspoon sodium bicarbonate oral powder (baking soda) in 6-8 ounces of a non-acidic fluid
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Zztestonc,Edward E [2435061]
3/3/2016 1:03:25 PM Page 21 of 33
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2016CCKM@uwhealth.org

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
Follow-Up
DAY 10 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; ADMIT TO INPATIENT: High dose
methotrexate infusion.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF,
Creatinine, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT; cyclophosphamide, doxorubicin, etoposide and
vinCRIStine for 150 minutes.
Days 10 through 12 (Inpatient), Cycle 6 – Planned for 6/25/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Lymphoma: THERAPY: prednisone 100 mg by mouth Day 1, 2, 3, 4, 5 (All cycles),
doxorubicin 50 mg/m2 IV Day 1 (All cycles), vinCRIStine 2 mg IV Day 1 (All cycles), cyclophosphamide 750 mg/m2 IV
Day 1 (All cycles), etoposide 100mg/m2 IV Day 1 and etoposide 100 mg/m2 by mouth twice daily on Day 2 and 3,
methotrexate 3500 mg/m2 IV Day 10 (Cycles 2, 4, 6, 8), 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
(Cycles 2, 4, 6, 8); CYCLE LENGTH: 21 days ; COURSE: 6 to 8 cycles
Note to All Staff (1)
This regimen is not preferred for T-cell and NK-cell lymphoma patients greater than 60 years of
age.
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
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Zztestonc,Edward E [2435061]
3/3/2016 1:03:25 PM Page 22 of 33
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2016CCKM@uwhealth.org

Obtain pH, Urine (Methotrexate Protocol) at 2 hours and 4 hours after start of Methotrexate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting when released for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is
undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting S+8 at 0000 for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is
undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
CONDITIONAL - RN COLLECT Starting when released until S+7 for 7 days
If Urine pH falls below 7, obtain pH, Urine (Methotrexate Protocol) every 2 hours as needed until Urine pH is greater than
or equal to 7 for two consecutive occurrences.
METHOTREXATE
ONCE Starting when released
Obtain methotrexate level 24 hours after the start of methotrexate infusion.
METHOTREXATE
NEXT AM Starting S+2 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate
levels when drug level is undetectable.
METHOTREXATE
NEXT AM Starting S+9 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate
levels when drug level is undetectable.
CREATININE
ONCE Starting when released
Obtain creatinine at 24 hours after the start of methotrexate infusion.
CREATININE
NEXT AM Starting S+2 As Scheduled for 7 days
CREATININE
NEXT AM Starting S+9 As Scheduled for 7 days
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin, AST, ALT,
Alkaline Phosphatase, pH Urine (Methotrexate Protocol).
Verify Labs (2)
Verify ongoing treatment labs: Creatinine, pH, Urine (Methotrexate Protocol) and Methotrexate
levels.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than
50K/µL or Total Bilirubin greater than ULN or AST greater than 3 X ULN or ALT greater than 3 X 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)
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Zztestonc,Edward E [2435061]
3/3/2016 1:03:25 PM Page 23 of 33
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2016CCKM@uwhealth.org

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, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
methotrexate PF 7,035 mg in dextrose 5 % 1,000 mL bag
7,035 mg (3,500 mg/m2 × 2.01 m2 Treatment plan actual BSA), Intravenous, ONCE, 1 dose
Starting when released
Administer over 6 hours. Do not administer methotrexate until Urine pH is 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
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Zztestonc,Edward E [2435061]
3/3/2016 1:03:25 PM Page 24 of 33
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
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04/2016CCKM@uwhealth.org

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
Supportive Care Medications (delete all that do not apply)
acyclovir (ZOVIRAX) tab 400 mg
400 mg, Oral, 2 X DAILY Starting when released
fluconazole (DIFLUCAN) tab 400 mg
400 mg, Oral, 1 X DAILY Starting when released
ranitidine (ZANTAC) tab 150 mg
150 mg, Oral, 2 X DAILY Starting when released
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
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. Discontinue when methotrexate level is undectectable.
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
Follow-Up
Verify Appointments
Verify next day appointment(s) have been scheduled.
Cycle 7 – 7/7/2016 through 7/27/2016 (21 days), Planned
Day 1 (Outpatient), Cycle 7 – Planned for 7/7/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Lymphoma: THERAPY: prednisone 100 mg by mouth Day 1, 2, 3, 4, 5 (All cycles),
doxorubicin 50 mg/m2 IV Day 1 (All cycles), vinCRIStine 2 mg IV Day 1 (All cycles), cyclophosphamide 750 mg/m2 IV
Day 1 (All cycles), etoposide 100mg/m2 IV Day 1 and etoposide 100 mg/m2 by mouth twice daily on Day 2 and 3,
methotrexate 3500 mg/m2 IV Day 10 (Cycles 2, 4, 6, 8), 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
(Cycles 2, 4, 6, 8); CYCLE LENGTH: 21 days ; COURSE: 6 to 8 cycles
Note to All Staff (1)
This regimen is not preferred for T-cell and NK-cell lymphoma patients greater than 60 years of
age.
Consent
Verify Consent
Verify informed consent has been obtained.
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Zztestonc,Edward E [2435061]
3/3/2016 1:03:25 PM Page 25 of 33
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2016CCKM@uwhealth.org

IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 50K/µL or
Total Bilirubin greater than 2 mg/dL or Creatinine greater than 1.5 mg/dL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days
after treatment.
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 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
ondansetron (ZOFRAN) tab 24 mg
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Zztestonc,Edward E [2435061]
3/3/2016 1:03:25 PM Page 26 of 33
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2016CCKM@uwhealth.org

24 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 0.5 mg
0.5 mg, Oral, ONCE, 1 dose Starting when released
Premedication for chemotherapy.
prednisone (DELTASONE) tab 100 mg
100 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
Treatment Medications
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 3-5 mL/minute into running IV.
vinCRIStine (ONCOVIN) 2 mg in sodium chloride 0.9 % 25 mL bag
2 mg, Intravenous, ONCE, 1 dose Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump).
etoposide (VEPESID) 201 mg in sodium chloride 0.9 % 500 mL NSS bag
201 mg (100 mg/m2 × 2.01 m2 Treatment plan actual BSA), Intravenous, ONCE, 1 dose Starting
when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
cyclophosphamide (CYTOXAN) 1,507.6 mg in sodium chloride 0.9 % 250 mL bag
1,507.6 mg (rounded from 1,507.5 mg = 750 mg/m2 × 2.01 m2 Treatment plan actual BSA),
Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. RN instruct patient to drink 8-10 (8 ounce) glasses of water daily throughout treatment.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone
(dispensed Day 1 of Cycle 1) and oral etoposide (dispensed Day 1 of each cycle)
Take Home Medications
etoposide (VEPESID) 50 MG cap
Take 4 caps by mouth 2 times daily. Take only on Day 2 and 3 of each cycle., 200 mg (rounded
from 201 mg = 100 mg/m2 × 2.01 m2 Treatment plan actual BSA), R-0, 2 X DAILY starting S, Local Printer
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF,
Creatinine, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: cyclophosphamide, doxorubicin, vinCRIStine and
etoposide for 150 minutes.
Cycle 8 – 7/28/2016 through 8/17/2016 (21 days), Planned
Day 1 (Outpatient), Cycle 8 – Planned for 7/28/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Lymphoma: THERAPY: prednisone 100 mg by mouth Day 1, 2, 3, 4, 5 (All cycles),
doxorubicin 50 mg/m2 IV Day 1 (All cycles), vinCRIStine 2 mg IV Day 1 (All cycles), cyclophosphamide 750 mg/m2 IV
Day 1 (All cycles), etoposide 100mg/m2 IV Day 1 and etoposide 100 mg/m2 by mouth twice daily on Day 2 and 3,
methotrexate 3500 mg/m2 IV Day 10 (Cycles 2, 4, 6, 8), 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
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Zztestonc,Edward E [2435061]
3/3/2016 1:03:25 PM Page 27 of 33
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2016CCKM@uwhealth.org

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
(Cycles 2, 4, 6, 8); CYCLE LENGTH: 21 days ; COURSE: 6 to 8 cycles
Note to All Staff (1)
This regimen is not preferred for T-cell and NK-cell lymphoma patients greater than 60 years of
age.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 50K/µL or
Total Bilirubin greater than 2 mg/dL or Creatinine greater than 1.5 mg/dL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days
after treatment.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
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Zztestonc,Edward E [2435061]
3/3/2016 1:03:25 PM Page 28 of 33
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2016CCKM@uwhealth.org

at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 0.5 mg
0.5 mg, Oral, ONCE, 1 dose Starting when released
Premedication for chemotherapy.
prednisone (DELTASONE) tab 100 mg
100 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
Treatment Medications
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 3-5 mL/minute into running IV.
vinCRIStine (ONCOVIN) 2 mg in sodium chloride 0.9 % 25 mL bag
2 mg, Intravenous, ONCE, 1 dose Starting when released
MUST be administered via gravity through a peripheral IV (not on an infusion pump).
etoposide (VEPESID) 201 mg in sodium chloride 0.9 % 500 mL NSS bag
201 mg (100 mg/m2 × 2.01 m2 Treatment plan actual BSA), Intravenous, ONCE, 1 dose Starting
when released
Administer over 30 to 60 minutes. Administer with non-PVC tubing.
cyclophosphamide (CYTOXAN) 1,507.6 mg in sodium chloride 0.9 % 250 mL bag
1,507.6 mg (rounded from 1,507.5 mg = 750 mg/m2 × 2.01 m2 Treatment plan actual BSA),
Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. RN instruct patient to drink 8-10 (8 ounce) glasses of water daily throughout treatment.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone
(dispensed Day 1 of Cycle 1) and oral etoposide (dispensed Day 1 of each cycle)
Take Home Medications
etoposide (VEPESID) 50 MG cap
Take 4 caps by mouth 2 times daily. Take only on Day 2 and 3 of each cycle., 200 mg (rounded
from 201 mg = 100 mg/m2 × 2.01 m2 Treatment plan actual BSA), R-0, 2 X DAILY starting S, Local Printer
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
Follow-Up
DAY 10 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; ADMIT TO INPATIENT: High dose
methotrexate infusion.
DAY 22 FOLLOW-UP
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Zztestonc,Edward E [2435061]
3/3/2016 1:03:25 PM Page 29 of 33
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2016CCKM@uwhealth.org

(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Creatinine, Total
Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT; cyclophosphamide, doxorubicin, etoposide and vinCRIStine for
150 minutes.
Days 10 through 12 (Inpatient), Cycle 8 – Planned for 8/6/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Lymphoma: THERAPY: prednisone 100 mg by mouth Day 1, 2, 3, 4, 5 (All cycles),
doxorubicin 50 mg/m2 IV Day 1 (All cycles), vinCRIStine 2 mg IV Day 1 (All cycles), cyclophosphamide 750 mg/m2 IV
Day 1 (All cycles), etoposide 100mg/m2 IV Day 1 and etoposide 100 mg/m2 by mouth twice daily on Day 2 and 3,
methotrexate 3500 mg/m2 IV Day 10 (Cycles 2, 4, 6, 8), 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
(Cycles 2, 4, 6, 8); CYCLE LENGTH: 21 days ; COURSE: 6 to 8 cycles
Note to All Staff (1)
This regimen is not preferred for T-cell and NK-cell lymphoma patients greater than 60 years of
age.
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
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Zztestonc,Edward E [2435061]
3/3/2016 1:03:25 PM Page 30 of 33
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2016CCKM@uwhealth.org

undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
CONDITIONAL - RN COLLECT Starting when released until S+7 for 7 days
If Urine pH falls below 7, obtain pH, Urine (Methotrexate Protocol) every 2 hours as needed until Urine pH is greater than
or equal to 7 for two consecutive occurrences.
METHOTREXATE
ONCE Starting when released
Obtain methotrexate level 24 hours after the start of methotrexate infusion.
METHOTREXATE
NEXT AM Starting S+2 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate
levels when drug level is undetectable.
METHOTREXATE
NEXT AM Starting S+9 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate
levels when drug level is undetectable.
CREATININE
ONCE Starting when released
Obtain creatinine at 24 hours after the start of methotrexate infusion.
CREATININE
NEXT AM Starting S+2 As Scheduled for 7 days
CREATININE
NEXT AM Starting S+9 As Scheduled for 7 days
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin, AST, ALT,
Alkaline Phosphatase, pH Urine (Methotrexate Protocol).
Verify Labs (2)
Verify ongoing treatment labs: Creatinine, pH, Urine (Methotrexate Protocol) and Methotrexate
levels.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than
50K/µL or Total Bilirubin greater than ULN or AST greater than 3 X ULN or ALT greater than 3 X 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.
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Zztestonc,Edward E [2435061]
3/3/2016 1:03:25 PM Page 31 of 33
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 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, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Treatment Medications
methotrexate PF 7,035 mg in dextrose 5 % 1,000 mL bag
7,035 mg (3,500 mg/m2 × 2.01 m2 Treatment plan actual BSA), Intravenous, ONCE, 1 dose
Starting when released
Administer over 6 hours. Do not administer methotrexate until Urine pH is 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
Supportive Care 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 1:03:25 PM Page 32 of 33
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 when released
ranitidine (ZANTAC) tab 150 mg
150 mg, Oral, 2 X DAILY Starting when released
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea
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. Discontinue when methotrexate level is undectectable.
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
Follow-Up
Verify Appointments
Verify next day appointment(s) have been scheduled.
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Zztestonc,Edward E [2435061]
3/3/2016 1:03:25 PM Page 33 of 33
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2016CCKM@uwhealth.org