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201611327

page

100

UWHC,UWMF,

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

CSC HEM OP Dose Adjusted EPOCH Plus Rituximab VER 10-3-16 (HL 4790)

CSC HEM OP Dose Adjusted EPOCH Plus Rituximab VER 10-3-16 (HL 4790) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Lymphoma


CSC HEM OUTPT DOSE ADJUSTED EPOCH PLUS RITUXIMAB VER: 10-3-16 – Properties
Pre-Cycle – 11/15/2016 through 11/21/2016 (7 days), Planned
Day 1, Pre-Cycle – Planned for 11/15/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma/ Burkitts Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, prednisone 60 mg/m2 by
mouth twice daily Day 1 through 5, etoposide 50 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 200 mg/m2), vinCRIStine 0.4 mg/m2/day IV continous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 1.6 mg/m2), doxorubicin 10 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 40 mg/m2), cyclophosphamide 750 mg/m2 IV Day 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21
days; COURSE: 4 to 8 cycles. Note: CSF negative patients receive methotrexate 12 mg IT Days 1 and 5 of Cycles 3, 4, 5 and 6.
NOTE : Doses listed above are for cycle 1. For subsequent cycles of doxorubicin, etoposide, and cyclophosphamide see dose
calculation instructions below. Doses are not adjusted per protocol for prednisone, rituximab and vinCRIStine.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
Consent
Verify Consent
Verify informed consent has been obtained.
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
POTASSIUM
Expected-S Approximate, Expires-S+365, Routine
URIC ACID
Expected-S Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S Approximate, Expires-S+365, Routine
HEPATITIS B CORE AB, TOTAL
Expected-S Approximate, Expires-S+365, Routine
HEPATITIS B SURFACE AG
Expected-S Approximate, Expires-S+365, Routine
HEPATITIS B SURFACE AB
Expected-S Approximate, Expires-S+122, Routine
Pre-Labs (delete all that do not apply)
HEPATITIS B DNA, ULTRA QUANT, PCR
Expected-S Approximate, Expires-S+122, Routine
Draw if Hepatitis B Core AB is positive.
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
Take Home Medications
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab orally 2x daily for Day 1 thru 7 then 1 tab every 8h as needed for nausea, Disp-30 tab, R-11, starting S
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ZZtestonc,Andrew [2428787]
11/22/2016 12:28:19 PM Page 1 of 43
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

allopurinol (ZYLOPRIM) 300 MG tab
Take 1 tab by mouth one time daily. Take during Cycle 1 only., 300 mg, Disp-10 tab, R-0, 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-11, 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-11, 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-11, 2 X DAILY SAT, SUN starting S, Local Printer
omeprazole (PRILOSEC OTC) 20 MG EC tab
Take 1 tab by mouth one time daily., 20 mg, Disp-30 tab, R-11, 1 X DAILY starting S, Local Printer
senna-docusate (SENOKOT S) 8.6-50 MG per tab
Take 2 tabs by mouth 2 times daily. To prevent constipation., 2 tab, Disp-60 tab, R-5, 2 X DAILY starting S, Local Printer
Counsel patient to purchase over the counter and provide instructions for use.
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 1 – 11/22/2016 through 12/12/2016 (21 days), Planned
Day 1, Cycle 1 – Planned for 11/22/2016
Treatment Plan Information
Reference Information (1)
NON-HODGKIN LYMPHOMA: Purroy N, et al. Br J Haematol 2015;169(2):188-98.
Reference Information (2)
NON-HODGKIN LYMPHOMA: Petrich AM, et al. Blood 2014;124(15):2354-61.
Reference Information (3)
NON-HODGKIN LYMPHOMA: Howlett C, et al. Br J Haematol;170(4):504-14.
Reference Information (4)
BURKITTS LYMPHOMA: Dunleavy K, et al. N Eng J Med 2013;369(20):1915-20.
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma/ Burkitts Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, prednisone 60 mg/m2 by
mouth twice daily Day 1 through 5, etoposide 50 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 200 mg/m2), vinCRIStine 0.4 mg/m2/day IV continous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 1.6 mg/m2), doxorubicin 10 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 40 mg/m2), cyclophosphamide 750 mg/m2 IV Day 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21
days; COURSE: 4 to 8 cycles. Note: CSF negative patients receive methotrexate 12 mg IT Days 1 and 5 of Cycles 3, 4, 5 and 6.
NOTE : Doses listed above are for cycle 1. For subsequent cycles of doxorubicin, etoposide, and cyclophosphamide see dose
calculation instructions below. Doses are not adjusted per protocol for prednisone, rituximab and vinCRIStine.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
Dose Calculation Instructions
All patients will be started on dose level 1 for cycle 1. If ANC nadir is greater than or equal to 500/uL increase one dose level. If ANC
nadir less than 500/uL for 1 or 2 measurements maintain the same dose level. If ANC nadir less than 500/uL on at least 3
measurements decrease one dose level. OR if the platelet count is less than 25/uL on one measurement decrease one dose level
Dose Calculation Instructions (2)
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ZZtestonc,Andrew [2428787]
11/22/2016 12:28:19 PM Page 2 of 43
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DOXOrubicin dose adjustment: Dose Level (Dose): -3(10 mg/m2/day), -2(10 mg/m2/day), -1(10 mg/m2/day), 1
(10 mg/m2/day), 2(12 mg/m2/day), 3(14.4 mg/m2/day), 4(17.3 mg/m2/day), 5(20.7 mg/m2/day), 6(24.8
mg/m2/day), 7(29.8 mg/m2/day)
Dose Calculation Instructions (3)
Etoposide dose adjustment: Dose Level (Dose): -3(50 mg/m2/day), -2(50 mg/m2/day), -1(50 mg/m2/day), 1(50 mg/m2/day), 2
(60 mg/m2/day), 3(72 mg/m2/day), 4(86.4 mg/m2/day), 5(103.7 mg/m2/day), 6(124.4 mg/m2/day), 7(149.3 mg/m2/day),
Dose Calculation Instructions (4)
Cyclophosphamide dose adjustment: Dose Level (Dose): -3(384 mg/m2), -2(480 mg/m2), -1(600 mg/m2), 1(750 mg/m2), 2
(900 mg/m2), 3(1080 mg/m2), 4(1296 mg/m2), 5(1555 mg/m2), 6(1866 mg/m2), 7(2239 mg/m2)
Dose Per Protocol
Dose level per protocol for current cycle: DOXOrubicin {Hit F2 to choose- DOXOrubicin Dose Level:22169}, Etoposide {Hit F2 to
choose- Etoposide Dose Level:22173}, Cyclophosphamide {Hit F2 to choose- Cyclophosphamide Dose Level:7700138}. Date of
Current Cycle *** . DO NOT PROPAGATE THIS ORDER BEYOND THE CURRENT CYCLE.
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.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin, Uric Acid, Potassium, LDH.
Treatment Parameters
Hold treatment and notify authorizing prescriber for: ANC less than 1000/µL or Platelets less than 75K/µL or Total Bilirubin greater
than 1.8 mg/dL
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
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.
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 lock flush 10 UNIT/ML 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.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:28:19 PM Page 3 of 43
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
prednisone (DELTASONE) tab 107.5 mg
107.5 mg (rounded from 107.4 mg = 60 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 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) 671 mg in sodium chloride 0.9 % 500 mL bag
671 mg (rounded from 671.25 mg = 375 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Day 1: Hypersensitivity Risk. See Emergency Medications. Administer rituximab prior to any chemotherapy. See Note on MAR for
infusion rates. If patient experiences fever accompanied by chills or rigors, shortness of breath, chest pain or hypotension, contact
MD. Once the patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
etoposide (VEPESID) 179 mg, vinCRIStine (ONCOVIN) 1.4 mg, doxorubicin CONVENTIONAL (ADRIAMYCIN) 36
mg home infusion bag
Intravenous, EVERY 48 HOURS, 1 dose Starting when released
Home infusion company to supply for continuous infusion over 48 hours (Bag 1 of 2).
Take Home Medications
prednisone (DELTASONE) 20 MG tab
Take 5.5 tabs by mouth 2 times daily at mealtime. Take on Days 1 through 5., 110 mg (rounded from 107.4 mg = 60 mg/m2 ×
1.79 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY (AT MEALTIME) starting S, Local Printer
Follow-Up
MULTIPLE DAY FOLLOW-UP (1)
INTERIM LAB APPOINTMENTS: CBC with DIFF every Monday and Thursday starting ***
DAY 3 FOLLOW-UP
LABS: Creatinine, Potassium, Uric Acid, LDH; CHEMOTHERAPY ROOM APPOINTMENT: Home infusion bag change for 60
minutes
DAY 5 FOLLOW-UP
LABS: Creatinine, Potassium, Uric Acid, LDH; CHEMOTHERAPY ROOM APPOINTMENT: Discontinue home infusion and
cyclophosphamide for 150 minutes
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ZZtestonc,Andrew [2428787]
11/22/2016 12:28:19 PM Page 4 of 43
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, DIFF, Hemoglobin, Creatinine Total Bilirubin;
CHEMOTHERAPY ROOM APPOINTMENT: riTUXimab and home infusion set up for 180 minutes
Day 3 (Home Infusion Bag Change), Cycle 1 – Planned for 11/24/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma/ Burkitts Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, prednisone 60 mg/m2 by
mouth twice daily Day 1 through 5, etoposide 50 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 200 mg/m2), vinCRIStine 0.4 mg/m2/day IV continous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 1.6 mg/m2), doxorubicin 10 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 40 mg/m2), cyclophosphamide 750 mg/m2 IV Day 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21
days; COURSE: 4 to 8 cycles. Note: CSF negative patients receive methotrexate 12 mg IT Days 1 and 5 of Cycles 3, 4, 5 and 6.
NOTE : Doses listed above are for cycle 1. For subsequent cycles of doxorubicin, etoposide, and cyclophosphamide see dose
calculation instructions below. Doses are not adjusted per protocol for prednisone, rituximab and vinCRIStine.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
Dose Calculation Instructions
All patients will be started on dose level 1 for cycle 1. If ANC nadir is greater than or equal to 500/uL increase one dose level. If ANC
nadir less than 500/uL for 1 or 2 measurements maintain the same dose level. If ANC nadir less than 500/uL on at least 3
measurements decrease one dose level. OR if the platelet count is less than 25/uL on one measurement decrease one dose level
Dose Calculation Instructions (2)
DOXOrubicin dose adjustment: Dose Level (Dose): -3(10 mg/m2/day), -2(10 mg/m2/day), -1(10 mg/m2/day), 1(10
mg/m2/day), 2(12 mg/m2/day), 3(14.4 mg/m2/day), 4(17.3 mg/m2/day), 5(20.7 mg/m2/day), 6(24.8 mg/m2/day), 7(29.8
mg/m2/day)
Dose Calculation Instructions (3)
Etoposide dose adjustment: Dose Level (Dose): -3(50 mg/m2/day), -2(50 mg/m2/day), -1(50 mg/m2/day), 1(50 mg/m2/day), 2
(60 mg/m2/day), 3(72 mg/m2/day), 4(86.4 mg/m2/day), 5(103.7 mg/m2/day), 6(124.4 mg/m2/day), 7(149.3 mg/m2/day),
Dose Calculation Instructions (4)
Cyclophosphamide dose adjustment: Dose Level (Dose): -3(384 mg/m2), -2(480 mg/m2), -1(600 mg/m2), 1(750 mg/m2), 2
(900 mg/m2), 3(1080 mg/m2), 4(1296 mg/m2), 5(1555 mg/m2), 6(1866 mg/m2), 7(2239 mg/m2)
Dose Per Protocol
Dose level per protocol for current cycle: DOXOrubicin {Hit F2 to choose- DOXOrubicin Dose Level:22169}, Etoposide {Hit F2 to
choose- Etoposide Dose Level:22173}, Cyclophosphamide {Hit F2 to choose- Cyclophosphamide Dose Level:7700138}. Date of
Current Cycle *** . DO NOT PROPAGATE THIS ORDER BEYOND THE CURRENT CYCLE.
Pre-Labs
CREATININE
Expected-S+2 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+2 Approximate, Expires-S+365, Routine
URIC ACID
Expected-S+2 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+2 Approximate, Expires-S+365, Routine
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.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:28:19 PM Page 5 of 43
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

heparin lock flush 10 UNIT/ML 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.
Treatment Medications
etoposide (VEPESID) 179 mg, vinCRIStine (ONCOVIN) 1.4 mg, doxorubicin CONVENTIONAL (ADRIAMYCIN) 36
mg home infusion bag
Intravenous, EVERY 48 HOURS, 1 dose Starting when released
Home infusion company to supply for continuous infusion over 48 hours (Bag 2 of 2).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 1 – Planned for 11/26/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma/ Burkitts Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, prednisone 60 mg/m2 by
mouth twice daily Day 1 through 5, etoposide 50 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 200 mg/m2), vinCRIStine 0.4 mg/m2/day IV continous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 1.6 mg/m2), doxorubicin 10 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 40 mg/m2), cyclophosphamide 750 mg/m2 IV Day 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21
days; COURSE: 4 to 8 cycles. Note: CSF negative patients receive methotrexate 12 mg IT Days 1 and 5 of Cycles 3, 4, 5 and 6.
NOTE : Doses listed above are for cycle 1. For subsequent cycles of doxorubicin, etoposide, and cyclophosphamide see dose
calculation instructions below. Doses are not adjusted per protocol for prednisone, rituximab and vinCRIStine.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
Dose Calculation Instructions
All patients will be started on dose level 1 for cycle 1. If ANC nadir is greater than or equal to 500/uL increase one dose level. If ANC
nadir less than 500/uL for 1 or 2 measurements maintain the same dose level. If ANC nadir less than 500/uL on at least 3
measurements decrease one dose level. OR if the platelet count is less than 25/uL on one measurement decrease one dose level
Dose Calculation Instructions (2)
DOXOrubicin dose adjustment: Dose Level (Dose): -3(10 mg/m2/day), -2(10 mg/m2/day), -1(10 mg/m2/day), 1(10
mg/m2/day), 2(12 mg/m2/day), 3(14.4 mg/m2/day), 4(17.3 mg/m2/day), 5(20.7 mg/m2/day), 6(24.8 mg/m2/day), 7(29.8
mg/m2/day)
Dose Calculation Instructions (3)
Etoposide dose adjustment: Dose Level (Dose): -3(50 mg/m2/day), -2(50 mg/m2/day), -1(50 mg/m2/day), 1(50 mg/m2/day), 2
(60 mg/m2/day), 3(72 mg/m2/day), 4(86.4 mg/m2/day), 5(103.7 mg/m2/day), 6(124.4 mg/m2/day), 7(149.3 mg/m2/day),
Dose Calculation Instructions (4)
Cyclophosphamide dose adjustment: Dose Level (Dose): -3(384 mg/m2), -2(480 mg/m2), -1(600 mg/m2), 1(750 mg/m2), 2
(900 mg/m2), 3(1080 mg/m2), 4(1296 mg/m2), 5(1555 mg/m2), 6(1866 mg/m2), 7(2239 mg/m2)
Dose Per Protocol
Dose level per protocol for current cycle: DOXOrubicin {Hit F2 to choose- DOXOrubicin Dose Level:22169}, Etoposide {Hit F2 to
choose- Etoposide Dose Level:22173}, Cyclophosphamide {Hit F2 to choose- Cyclophosphamide Dose Level:7700138}. Date of
Current Cycle *** . DO NOT PROPAGATE THIS ORDER BEYOND THE CURRENT CYCLE.
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
CREATININE
Expected-S+2 Approximate, Expires-S+365, Routine
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ZZtestonc,Andrew [2428787]
11/22/2016 12:28:19 PM Page 6 of 43
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

POTASSIUM
Expected-S+2 Approximate, Expires-S+365, Routine
URIC ACID
Expected-S+2 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+2 Approximate, Expires-S+365, Routine
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 lock flush 10 UNIT/ML 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
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
Pump Disconnection Procedures
Disconnect pump upon completion of 96-hour home infusion.
cyclophosphamide (CYTOXAN) 1,342.6 mg in sodium chloride 0.9 % 250 mL bag
1,342.6 mg (rounded from 1,342.5 mg = 750 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1
dose Starting when released
Administer on Day 5.
Cyclophosphamide dose less than 2000 mg infuse IV over 30 minutes.
Cyclophosphamide dose 2000 mg to 3999 mg infuse IV over 90 minutes.
Cyclophosphamide dose greater than 4000 mg infuse IV over 120 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 12/13/2016 through 1/2/2017 (21 days), Planned
Day 1, Cycle 2 – Planned for 12/13/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma/ Burkitts Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, prednisone 60 mg/m2 by
mouth twice daily Day 1 through 5, etoposide 50 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 200 mg/m2), vinCRIStine 0.4 mg/m2/day IV continous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 1.6 mg/m2), doxorubicin 10 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 40 mg/m2), cyclophosphamide 750 mg/m2 IV Day 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21
days; COURSE: 4 to 8 cycles. Note: CSF negative patients receive methotrexate 12 mg IT Days 1 and 5 of Cycles 3, 4, 5 and 6.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:28:19 PM Page 7 of 43
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

NOTE : Doses listed above are for cycle 1. For subsequent cycles of doxorubicin, etoposide, and cyclophosphamide see dose
calculation instructions below. Doses are not adjusted per protocol for prednisone, rituximab and vinCRIStine.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
Dose Calculation Instructions
All patients will be started on dose level 1 for cycle 1. If ANC nadir is greater than or equal to 500/uL increase one dose level. If ANC
nadir less than 500/uL for 1 or 2 measurements maintain the same dose level. If ANC nadir less than 500/uL on at least 3
measurements decrease one dose level. OR if the platelet count is less than 25/uL on one measurement decrease one dose level
Dose Calculation Instructions (2)
DOXOrubicin dose adjustment: Dose Level (Dose): -3(10 mg/m2/day), -2(10 mg/m2/day), -1(10 mg/m2/day), 1(10
mg/m2/day), 2(12 mg/m2/day), 3(14.4 mg/m2/day), 4(17.3 mg/m2/day), 5(20.7 mg/m2/day), 6(24.8 mg/m2/day), 7(29.8
mg/m2/day)
Dose Calculation Instructions (3)
Etoposide dose adjustment: Dose Level (Dose): -3(50 mg/m2/day), -2(50 mg/m2/day), -1(50 mg/m2/day), 1(50 mg/m2/day), 2
(60 mg/m2/day), 3(72 mg/m2/day), 4(86.4 mg/m2/day), 5(103.7 mg/m2/day), 6(124.4 mg/m2/day), 7(149.3 mg/m2/day),
Dose Calculation Instructions (4)
Cyclophosphamide dose adjustment: Dose Level (Dose): -3(384 mg/m2), -2(480 mg/m2), -1(600 mg/m2), 1(750 mg/m2), 2
(900 mg/m2), 3(1080 mg/m2), 4(1296 mg/m2), 5(1555 mg/m2), 6(1866 mg/m2), 7(2239 mg/m2)
Dose Per Protocol
Dose level per protocol for current cycle: DOXOrubicin {Hit F2 to choose- DOXOrubicin Dose Level:22169}, Etoposide {Hit F2 to
choose- Etoposide Dose Level:22173}, Cyclophosphamide {Hit F2 to choose- Cyclophosphamide Dose Level:7700138}. Date of
Current Cycle *** . DO NOT PROPAGATE THIS ORDER BEYOND THE CURRENT CYCLE.
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+17 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+17 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+17 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin
Treatment Parameters
Hold treatment and notify authorizing prescriber for: ANC less than 1000/µL or Platelets less than 75K/µL or Total Bilirubin greater
than 1.8 mg/dL
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
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)
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ZZtestonc,Andrew [2428787]
11/22/2016 12:28:19 PM Page 8 of 43
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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.
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 lock flush 10 UNIT/ML 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 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
prednisone (DELTASONE) tab 107.5 mg
107.5 mg (rounded from 107.4 mg = 60 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 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) 671 mg in sodium chloride 0.9 % 500 mL bag
671 mg (rounded from 671.25 mg = 375 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Day 1: Hypersensitivity Risk. See Emergency Medications. Administer rituximab prior to any chemotherapy. See Note on MAR for
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ZZtestonc,Andrew [2428787]
11/22/2016 12:28:19 PM Page 9 of 43
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

infusion rates. If patient experiences fever accompanied by chills or rigors, shortness of breath, chest pain or hypotension, contact
MD. Once the patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
etoposide (VEPESID) 179 mg, vinCRIStine (ONCOVIN) 1.4 mg, doxorubicin CONVENTIONAL (ADRIAMYCIN) 36
mg home infusion bag
Intravenous, EVERY 48 HOURS, 1 dose Starting when released
Home infusion company to supply for continuous infusion over 48 hours (Bag 1 of 2).
Take Home Medications
prednisone (DELTASONE) 20 MG tab
Take 5.5 tabs by mouth 2 times daily at mealtime. Take on Days 1 through 5., 110 mg (rounded from 107.4 mg = 60 mg/m2 ×
1.79 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY (AT MEALTIME) starting S, Local Printer
Follow-Up
MULTIPLE DAY FOLLOW-UP (1)
INTERIM LAB APPOINTMENTS: CBC with DIFF every Monday and Thursday starting ***
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: Home infusion bag change for 60 minutes
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: Discontinue home infusion and cyclophosphamide for 150 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, DIFF, Hemoglobin, Creatinine Total Bilirubin;
CHEMOTHERAPY ROOM APPOINTMENT: riTUXimab and home infusion set up for 180 minutes and intrathecal methotrexate (if
applicable) for an additional 60 minutes.
Day 3 (Home Infusion Bag Change), Cycle 2 – Planned for 12/15/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma/ Burkitts Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, prednisone 60 mg/m2 by
mouth twice daily Day 1 through 5, etoposide 50 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 200 mg/m2), vinCRIStine 0.4 mg/m2/day IV continous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 1.6 mg/m2), doxorubicin 10 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 40 mg/m2), cyclophosphamide 750 mg/m2 IV Day 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21
days; COURSE: 4 to 8 cycles. Note: CSF negative patients receive methotrexate 12 mg IT Days 1 and 5 of Cycles 3, 4, 5 and 6.
NOTE : Doses listed above are for cycle 1. For subsequent cycles of doxorubicin, etoposide, and cyclophosphamide see dose
calculation instructions below. Doses are not adjusted per protocol for prednisone, rituximab and vinCRIStine.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
Dose Calculation Instructions
All patients will be started on dose level 1 for cycle 1. If ANC nadir is greater than or equal to 500/uL increase one dose level. If ANC
nadir less than 500/uL for 1 or 2 measurements maintain the same dose level. If ANC nadir less than 500/uL on at least 3
measurements decrease one dose level. OR if the platelet count is less than 25/uL on one measurement decrease one dose level
Dose Calculation Instructions (2)
DOXOrubicin dose adjustment: Dose Level (Dose): -3(10 mg/m2/day), -2(10 mg/m2/day), -1(10 mg/m2/day), 1(10
mg/m2/day), 2(12 mg/m2/day), 3(14.4 mg/m2/day), 4(17.3 mg/m2/day), 5(20.7 mg/m2/day), 6(24.8 mg/m2/day), 7(29.8
mg/m2/day)
Dose Calculation Instructions (3)
Etoposide dose adjustment: Dose Level (Dose): -3(50 mg/m2/day), -2(50 mg/m2/day), -1(50 mg/m2/day), 1(50 mg/m2/day), 2
(60 mg/m2/day), 3(72 mg/m2/day), 4(86.4 mg/m2/day), 5(103.7 mg/m2/day), 6(124.4 mg/m2/day), 7(149.3 mg/m2/day),
Dose Calculation Instructions (4)
Cyclophosphamide dose adjustment: Dose Level (Dose): -3(384 mg/m2), -2(480 mg/m2), -1(600 mg/m2), 1(750 mg/m2), 2
(900 mg/m2), 3(1080 mg/m2), 4(1296 mg/m2), 5(1555 mg/m2), 6(1866 mg/m2), 7(2239 mg/m2)
Dose Per Protocol
Dose level per protocol for current cycle: DOXOrubicin {Hit F2 to choose- DOXOrubicin Dose Level:22169}, Etoposide {Hit F2 to
choose- Etoposide Dose Level:22173}, Cyclophosphamide {Hit F2 to choose- Cyclophosphamide Dose Level:7700138}. Date of
Current Cycle *** . DO NOT PROPAGATE THIS ORDER BEYOND THE CURRENT CYCLE.
Nursing Procedure, Assessment and Monitoring
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ZZtestonc,Andrew [2428787]
11/22/2016 12:28:19 PM Page 10 of 43
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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 lock flush 10 UNIT/ML 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.
Treatment Medications
etoposide (VEPESID) 179 mg, vinCRIStine (ONCOVIN) 1.4 mg, doxorubicin CONVENTIONAL (ADRIAMYCIN) 36
mg home infusion bag
Intravenous, EVERY 48 HOURS, 1 dose Starting when released
Home infusion company to supply for continuous infusion over 48 hours (Bag 2 of 2).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 2 – Planned for 12/17/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma/ Burkitts Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, prednisone 60 mg/m2 by
mouth twice daily Day 1 through 5, etoposide 50 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 200 mg/m2), vinCRIStine 0.4 mg/m2/day IV continous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 1.6 mg/m2), doxorubicin 10 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 40 mg/m2), cyclophosphamide 750 mg/m2 IV Day 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21
days; COURSE: 4 to 8 cycles. Note: CSF negative patients receive methotrexate 12 mg IT Days 1 and 5 of Cycles 3, 4, 5 and 6.
NOTE : Doses listed above are for cycle 1. For subsequent cycles of doxorubicin, etoposide, and cyclophosphamide see dose
calculation instructions below. Doses are not adjusted per protocol for prednisone, rituximab and vinCRIStine.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
Dose Calculation Instructions
All patients will be started on dose level 1 for cycle 1. If ANC nadir is greater than or equal to 500/uL increase one dose level. If ANC
nadir less than 500/uL for 1 or 2 measurements maintain the same dose level. If ANC nadir less than 500/uL on at least 3
measurements decrease one dose level. OR if the platelet count is less than 25/uL on one measurement decrease one dose level
Dose Calculation Instructions (2)
DOXOrubicin dose adjustment: Dose Level (Dose): -3(10 mg/m2/day), -2(10 mg/m2/day), -1(10 mg/m2/day), 1(10
mg/m2/day), 2(12 mg/m2/day), 3(14.4 mg/m2/day), 4(17.3 mg/m2/day), 5(20.7 mg/m2/day), 6(24.8 mg/m2/day), 7(29.8
mg/m2/day)
Dose Calculation Instructions (3)
Etoposide dose adjustment: Dose Level (Dose): -3(50 mg/m2/day), -2(50 mg/m2/day), -1(50 mg/m2/day), 1(50 mg/m2/day), 2
(60 mg/m2/day), 3(72 mg/m2/day), 4(86.4 mg/m2/day), 5(103.7 mg/m2/day), 6(124.4 mg/m2/day), 7(149.3 mg/m2/day),
Dose Calculation Instructions (4)
Cyclophosphamide dose adjustment: Dose Level (Dose): -3(384 mg/m2), -2(480 mg/m2), -1(600 mg/m2), 1(750 mg/m2), 2
(900 mg/m2), 3(1080 mg/m2), 4(1296 mg/m2), 5(1555 mg/m2), 6(1866 mg/m2), 7(2239 mg/m2)
Dose Per Protocol
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ZZtestonc,Andrew [2428787]
11/22/2016 12:28:19 PM Page 11 of 43
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Dose level per protocol for current cycle: DOXOrubicin {Hit F2 to choose- DOXOrubicin Dose Level:22169}, Etoposide {Hit F2 to
choose- Etoposide Dose Level:22173}, Cyclophosphamide {Hit F2 to choose- Cyclophosphamide Dose Level:7700138}. Date of
Current Cycle *** . DO NOT PROPAGATE THIS ORDER BEYOND THE CURRENT CYCLE.
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.
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 lock flush 10 UNIT/ML 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
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
Pump Disconnection Procedures
Disconnect pump upon completion of 96-hour home infusion.
cyclophosphamide (CYTOXAN) in sodium chloride 0.9 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer on Day 5.
Cyclophosphamide dose less than 2000 mg infuse IV over 30 minutes.
Cyclophosphamide dose 2000 mg to 3999 mg infuse IV over 90 minutes.
Cyclophosphamide dose greater than 4000 mg infuse IV over 120 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 1/3/2017 through 1/23/2017 (21 days), Planned
Day 1, Cycle 3 – Planned for 1/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma/ Burkitts Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, prednisone 60 mg/m2 by
mouth twice daily Day 1 through 5, etoposide 50 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 200 mg/m2), vinCRIStine 0.4 mg/m2/day IV continous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 1.6 mg/m2), doxorubicin 10 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 40 mg/m2), cyclophosphamide 750 mg/m2 IV Day 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21
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ZZtestonc,Andrew [2428787]
11/22/2016 12:28:19 PM Page 12 of 43
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

days; COURSE: 4 to 8 cycles. Note: CSF negative patients receive methotrexate 12 mg IT Days 1 and 5 of Cycles 3, 4, 5 and 6.
NOTE : Doses listed above are for cycle 1. For subsequent cycles of doxorubicin, etoposide, and cyclophosphamide see dose
calculation instructions below. Doses are not adjusted per protocol for prednisone, rituximab and vinCRIStine.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
Dose Calculation Instructions
All patients will be started on dose level 1 for cycle 1. If ANC nadir is greater than or equal to 500/uL increase one dose level. If ANC
nadir less than 500/uL for 1 or 2 measurements maintain the same dose level. If ANC nadir less than 500/uL on at least 3
measurements decrease one dose level. OR if the platelet count is less than 25/uL on one measurement decrease one dose level
Dose Calculation Instructions (2)
DOXOrubicin dose adjustment: Dose Level (Dose): -3(10 mg/m2/day), -2(10 mg/m2/day), -1(10 mg/m2/day), 1(10
mg/m2/day), 2(12 mg/m2/day), 3(14.4 mg/m2/day), 4(17.3 mg/m2/day), 5(20.7 mg/m2/day), 6(24.8 mg/m2/day), 7(29.8
mg/m2/day)
Dose Calculation Instructions (3)
Etoposide dose adjustment: Dose Level (Dose): -3(50 mg/m2/day), -2(50 mg/m2/day), -1(50 mg/m2/day), 1(50 mg/m2/day), 2
(60 mg/m2/day), 3(72 mg/m2/day), 4(86.4 mg/m2/day), 5(103.7 mg/m2/day), 6(124.4 mg/m2/day), 7(149.3 mg/m2/day),
Dose Calculation Instructions (4)
Cyclophosphamide dose adjustment: Dose Level (Dose): -3(384 mg/m2), -2(480 mg/m2), -1(600 mg/m2), 1(750 mg/m2), 2
(900 mg/m2), 3(1080 mg/m2), 4(1296 mg/m2), 5(1555 mg/m2), 6(1866 mg/m2), 7(2239 mg/m2)
Dose Per Protocol
Dose level per protocol for current cycle: DOXOrubicin {Hit F2 to choose- DOXOrubicin Dose Level:22169}, Etoposide {Hit F2 to
choose- Etoposide Dose Level:22173}, Cyclophosphamide {Hit F2 to choose- Cyclophosphamide Dose Level:7700138}. Date of
Current Cycle *** . DO NOT PROPAGATE THIS ORDER BEYOND THE CURRENT CYCLE.
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+17 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+17 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+17 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin
Treatment Parameters
Hold treatment and notify authorizing prescriber for: ANC less than 1000/µL or Platelets less than 75K/µL or Total Bilirubin greater
than 1.8 mg/dL
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
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)
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ZZtestonc,Andrew [2428787]
11/22/2016 12:28:19 PM Page 13 of 43
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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.
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 lock flush 10 UNIT/ML 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 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
prednisone (DELTASONE) tab 107.5 mg
107.5 mg (rounded from 107.4 mg = 60 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Intrathecal Procedure Orders (delete all that do not apply)
LEUKEMIA/LYMPHOMA SCREEN, CSF
ONCE Starting when released
methotrexate PF 12 mg in sodium chloride 0.9 % 2.4 mL intraTHECAL injection
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ZZtestonc,Andrew [2428787]
11/22/2016 12:28:19 PM Page 14 of 43
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

12 mg, Intrathecal, ONCE, 1 dose Starting when released
Indication: prophylactic CSF treatment. Dose to be given by provider.
Treatment Medications
rituximab (RITUXAN) 671 mg in sodium chloride 0.9 % 500 mL bag
671 mg (rounded from 671.25 mg = 375 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Day 1: Hypersensitivity Risk. See Emergency Medications. Administer rituximab prior to any chemotherapy. See Note on MAR for
infusion rates. If patient experiences fever accompanied by chills or rigors, shortness of breath, chest pain or hypotension, contact
MD. Once the patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
etoposide (VEPESID) 179 mg, vinCRIStine (ONCOVIN) 1.4 mg, doxorubicin CONVENTIONAL (ADRIAMYCIN) 36
mg home infusion bag
Intravenous, EVERY 48 HOURS, 1 dose Starting when released
Home infusion company to supply for continuous infusion over 48 hours (Bag 1 of 2).
Take Home Medications
prednisone (DELTASONE) 20 MG tab
Take 5.5 tabs by mouth 2 times daily at mealtime. Take on Days 1 through 5., 110 mg (rounded from 107.4 mg = 60 mg/m2 ×
1.79 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY (AT MEALTIME) starting S, Local Printer
Follow-Up
MULTIPLE DAY FOLLOW-UP (1)
INTERIM LAB APPOINTMENTS: CBC with DIFF every Monday and Thursday starting ***
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: Home infusion bag change for 60 minutes
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: Discontinue home infusion and cyclophosphamide for 150 minutes and intrathecal
methotrexate (if applicable) for an additional 60 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, DIFF, Hemoglobin, Creatinine Total Bilirubin;
CHEMOTHERAPY ROOM APPOINTMENT: riTUXimab and home infusion set up for 180 minutes and intrathecal methotrexate (if
applicable) for an additional 60 minutes.
Day 3 (Home Infusion Bag Change), Cycle 3 – Planned for 1/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma/ Burkitts Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, prednisone 60 mg/m2 by
mouth twice daily Day 1 through 5, etoposide 50 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 200 mg/m2), vinCRIStine 0.4 mg/m2/day IV continous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 1.6 mg/m2), doxorubicin 10 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 40 mg/m2), cyclophosphamide 750 mg/m2 IV Day 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21
days; COURSE: 4 to 8 cycles. Note: CSF negative patients receive methotrexate 12 mg IT Days 1 and 5 of Cycles 3, 4, 5 and 6.
NOTE : Doses listed above are for cycle 1. For subsequent cycles of doxorubicin, etoposide, and cyclophosphamide see dose
calculation instructions below. Doses are not adjusted per protocol for prednisone, rituximab and vinCRIStine.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
Dose Calculation Instructions
All patients will be started on dose level 1 for cycle 1. If ANC nadir is greater than or equal to 500/uL increase one dose level. If ANC
nadir less than 500/uL for 1 or 2 measurements maintain the same dose level. If ANC nadir less than 500/uL on at least 3
measurements decrease one dose level. OR if the platelet count is less than 25/uL on one measurement decrease one dose level
Dose Calculation Instructions (2)
DOXOrubicin dose adjustment: Dose Level (Dose): -3(10 mg/m2/day), -2(10 mg/m2/day), -1(10 mg/m2/day), 1(10
mg/m2/day), 2(12 mg/m2/day), 3(14.4 mg/m2/day), 4(17.3 mg/m2/day), 5(20.7 mg/m2/day), 6(24.8 mg/m2/day), 7(29.8
mg/m2/day)
Dose Calculation Instructions (3)
Etoposide dose adjustment: Dose Level (Dose): -3(50 mg/m2/day), -2(50 mg/m2/day), -1(50 mg/m2/day), 1(50 mg/m2/day), 2
(60 mg/m2/day), 3(72 mg/m2/day), 4(86.4 mg/m2/day), 5(103.7 mg/m2/day), 6(124.4 mg/m2/day), 7(149.3 mg/m2/day),
Dose Calculation Instructions (4)
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ZZtestonc,Andrew [2428787]
11/22/2016 12:28:19 PM Page 15 of 43
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Cyclophosphamide dose adjustment: Dose Level (Dose): -3(384 mg/m2), -2(480 mg/m2), -1(600 mg/m2), 1(750 mg/m2), 2
(900 mg/m2), 3(1080 mg/m2), 4(1296 mg/m2), 5(1555 mg/m2), 6(1866 mg/m2), 7(2239 mg/m2)
Dose Per Protocol
Dose level per protocol for current cycle: DOXOrubicin {Hit F2 to choose- DOXOrubicin Dose Level:22169}, Etoposide {Hit F2 to
choose- Etoposide Dose Level:22173}, Cyclophosphamide {Hit F2 to choose- Cyclophosphamide Dose Level:7700138}. Date of
Current Cycle *** . DO NOT PROPAGATE THIS ORDER BEYOND THE CURRENT CYCLE.
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 lock flush 10 UNIT/ML 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.
Treatment Medications
etoposide (VEPESID) 179 mg, vinCRIStine (ONCOVIN) 1.4 mg, doxorubicin CONVENTIONAL (ADRIAMYCIN) 36
mg home infusion bag
Intravenous, EVERY 48 HOURS, 1 dose Starting when released
Home infusion company to supply for continuous infusion over 48 hours (Bag 2 of 2).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 3 – Planned for 1/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma/ Burkitts Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, prednisone 60 mg/m2 by
mouth twice daily Day 1 through 5, etoposide 50 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 200 mg/m2), vinCRIStine 0.4 mg/m2/day IV continous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 1.6 mg/m2), doxorubicin 10 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 40 mg/m2), cyclophosphamide 750 mg/m2 IV Day 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21
days; COURSE: 4 to 8 cycles. Note: CSF negative patients receive methotrexate 12 mg IT Days 1 and 5 of Cycles 3, 4, 5 and 6.
NOTE : Doses listed above are for cycle 1. For subsequent cycles of doxorubicin, etoposide, and cyclophosphamide see dose
calculation instructions below. Doses are not adjusted per protocol for prednisone, rituximab and vinCRIStine.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
Dose Calculation Instructions
All patients will be started on dose level 1 for cycle 1. If ANC nadir is greater than or equal to 500/uL increase one dose level. If ANC
nadir less than 500/uL for 1 or 2 measurements maintain the same dose level. If ANC nadir less than 500/uL on at least 3
measurements decrease one dose level. OR if the platelet count is less than 25/uL on one measurement decrease one dose level
Dose Calculation Instructions (2)
DOXOrubicin dose adjustment: Dose Level (Dose): -3(10 mg/m2/day), -2(10 mg/m2/day), -1(10 mg/m2/day), 1(10
mg/m2/day), 2(12 mg/m2/day), 3(14.4 mg/m2/day), 4(17.3 mg/m2/day), 5(20.7 mg/m2/day), 6(24.8 mg/m2/day), 7(29.8
mg/m2/day)
Dose Calculation Instructions (3)
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ZZtestonc,Andrew [2428787]
11/22/2016 12:28:19 PM Page 16 of 43
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Etoposide dose adjustment: Dose Level (Dose): -3(50 mg/m2/day), -2(50 mg/m2/day), -1(50 mg/m2/day), 1(50
mg/m2/day), 2(60 mg/m2/day), 3(72 mg/m2/day), 4(86.4 mg/m2/day), 5(103.7 mg/m2/day), 6(124.4
mg/m2/day), 7(149.3 mg/m2/day),
Dose Calculation Instructions (4)
Cyclophosphamide dose adjustment: Dose Level (Dose): -3(384 mg/m2), -2(480 mg/m2), -1(600 mg/m2), 1(750 mg/m2), 2
(900 mg/m2), 3(1080 mg/m2), 4(1296 mg/m2), 5(1555 mg/m2), 6(1866 mg/m2), 7(2239 mg/m2)
Dose Per Protocol
Dose level per protocol for current cycle: DOXOrubicin {Hit F2 to choose- DOXOrubicin Dose Level:22169}, Etoposide {Hit F2 to
choose- Etoposide Dose Level:22173}, Cyclophosphamide {Hit F2 to choose- Cyclophosphamide Dose Level:7700138}. Date of
Current Cycle *** . DO NOT PROPAGATE THIS ORDER BEYOND THE CURRENT CYCLE.
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.
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 lock flush 10 UNIT/ML 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
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Intrathecal Procedure Orders (delete all that do not apply)
LEUKEMIA/LYMPHOMA SCREEN, CSF
ONCE Starting when released
methotrexate PF 12 mg in sodium chloride 0.9 % 2.4 mL intraTHECAL injection
12 mg, Intrathecal, ONCE, 1 dose Starting when released
Indication: prophylactic CSF treatment. Dose to be given by provider.
Treatment Medications
Pump Disconnection Procedures
Disconnect pump upon completion of 96-hour home infusion.
cyclophosphamide (CYTOXAN) in sodium chloride 0.9 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer on Day 5.
Cyclophosphamide dose less than 2000 mg infuse IV over 30 minutes.
Cyclophosphamide dose 2000 mg to 3999 mg infuse IV over 90 minutes.
Cyclophosphamide dose greater than 4000 mg infuse IV over 120 minutes.
Follow-Up
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ZZtestonc,Andrew [2428787]
11/22/2016 12:28:19 PM Page 17 of 43
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 – 1/24/2017 through 2/13/2017 (21 days), Planned
Day 1, Cycle 4 – Planned for 1/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma/ Burkitts Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, prednisone 60 mg/m2 by
mouth twice daily Day 1 through 5, etoposide 50 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 200 mg/m2), vinCRIStine 0.4 mg/m2/day IV continous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 1.6 mg/m2), doxorubicin 10 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 40 mg/m2), cyclophosphamide 750 mg/m2 IV Day 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21
days; COURSE: 4 to 8 cycles. Note: CSF negative patients receive methotrexate 12 mg IT Days 1 and 5 of Cycles 3, 4, 5 and 6.
NOTE : Doses listed above are for cycle 1. For subsequent cycles of doxorubicin, etoposide, and cyclophosphamide see dose
calculation instructions below. Doses are not adjusted per protocol for prednisone, rituximab and vinCRIStine.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
Dose Calculation Instructions
All patients will be started on dose level 1 for cycle 1. If ANC nadir is greater than or equal to 500/uL increase one dose level. If ANC
nadir less than 500/uL for 1 or 2 measurements maintain the same dose level. If ANC nadir less than 500/uL on at least 3
measurements decrease one dose level. OR if the platelet count is less than 25/uL on one measurement decrease one dose level
Dose Calculation Instructions (2)
DOXOrubicin dose adjustment: Dose Level (Dose): -3(10 mg/m2/day), -2(10 mg/m2/day), -1(10 mg/m2/day), 1(10
mg/m2/day), 2(12 mg/m2/day), 3(14.4 mg/m2/day), 4(17.3 mg/m2/day), 5(20.7 mg/m2/day), 6(24.8 mg/m2/day), 7(29.8
mg/m2/day)
Dose Calculation Instructions (3)
Etoposide dose adjustment: Dose Level (Dose): -3(50 mg/m2/day), -2(50 mg/m2/day), -1(50 mg/m2/day), 1(50 mg/m2/day), 2
(60 mg/m2/day), 3(72 mg/m2/day), 4(86.4 mg/m2/day), 5(103.7 mg/m2/day), 6(124.4 mg/m2/day), 7(149.3 mg/m2/day),
Dose Calculation Instructions (4)
Cyclophosphamide dose adjustment: Dose Level (Dose): -3(384 mg/m2), -2(480 mg/m2), -1(600 mg/m2), 1(750 mg/m2), 2
(900 mg/m2), 3(1080 mg/m2), 4(1296 mg/m2), 5(1555 mg/m2), 6(1866 mg/m2), 7(2239 mg/m2)
Dose Per Protocol
Dose level per protocol for current cycle: DOXOrubicin {Hit F2 to choose- DOXOrubicin Dose Level:22169}, Etoposide {Hit F2 to
choose- Etoposide Dose Level:22173}, Cyclophosphamide {Hit F2 to choose- Cyclophosphamide Dose Level:7700138}. Date of
Current Cycle *** . DO NOT PROPAGATE THIS ORDER BEYOND THE CURRENT CYCLE.
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+17 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+17 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+17 Approximate, Expires-S+365, Routine
Treatment Conditions
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ZZtestonc,Andrew [2428787]
11/22/2016 12:28:19 PM Page 18 of 43
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin
Treatment Parameters
Hold treatment and notify authorizing prescriber for: ANC less than 1000/µL or Platelets less than 75K/µL or Total Bilirubin greater
than 1.8 mg/dL
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
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.
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 lock flush 10 UNIT/ML 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 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
prednisone (DELTASONE) tab 107.5 mg
107.5 mg (rounded from 107.4 mg = 60 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
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ZZtestonc,Andrew [2428787]
11/22/2016 12:28:19 PM Page 19 of 43
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Intrathecal Procedure Orders (delete all that do not apply)
LEUKEMIA/LYMPHOMA SCREEN, CSF
ONCE Starting when released
methotrexate PF 12 mg in sodium chloride 0.9 % 2.4 mL intraTHECAL injection
12 mg, Intrathecal, ONCE, 1 dose Starting when released
Indication: prophylactic CSF treatment. Dose to be given by provider.
Treatment Medications
rituximab (RITUXAN) 671 mg in sodium chloride 0.9 % 500 mL bag
671 mg (rounded from 671.25 mg = 375 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Day 1: Hypersensitivity Risk. See Emergency Medications. Administer rituximab prior to any chemotherapy. See Note on MAR for
infusion rates. If patient experiences fever accompanied by chills or rigors, shortness of breath, chest pain or hypotension, contact
MD. Once the patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
etoposide (VEPESID) 179 mg, vinCRIStine (ONCOVIN) 1.4 mg, doxorubicin CONVENTIONAL (ADRIAMYCIN) 36
mg home infusion bag
Intravenous, EVERY 48 HOURS, 1 dose Starting when released
Home infusion company to supply for continuous infusion over 48 hours (Bag 1 of 2).
Take Home Medications
prednisone (DELTASONE) 20 MG tab
Take 5.5 tabs by mouth 2 times daily at mealtime. Take on Days 1 through 5., 110 mg (rounded from 107.4 mg = 60 mg/m2 ×
1.79 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY (AT MEALTIME) starting S, Local Printer
Follow-Up
MULTIPLE DAY FOLLOW-UP (1)
INTERIM LAB APPOINTMENTS: CBC with DIFF every Monday and Thursday starting ***
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: Home infusion bag change for 60 minutes
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: Discontinue home infusion and cyclophosphamide for 150 minutes and intrathecal
methotrexate (if applicable) for an additional 60 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, DIFF, Hemoglobin, Creatinine Total Bilirubin;
CHEMOTHERAPY ROOM APPOINTMENT: riTUXimab and home infusion set up for 180 minutes and intrathecal methotrexate (if
applicable) for an additional 60 minutes.
Day 3 (Home Infusion Bag Change), Cycle 4 – Planned for 1/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma/ Burkitts Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, prednisone 60 mg/m2 by
mouth twice daily Day 1 through 5, etoposide 50 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 200 mg/m2), vinCRIStine 0.4 mg/m2/day IV continous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 1.6 mg/m2), doxorubicin 10 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 40 mg/m2), cyclophosphamide 750 mg/m2 IV Day 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21
days; COURSE: 4 to 8 cycles. Note: CSF negative patients receive methotrexate 12 mg IT Days 1 and 5 of Cycles 3, 4, 5 and 6.
NOTE : Doses listed above are for cycle 1. For subsequent cycles of doxorubicin, etoposide, and cyclophosphamide see dose
calculation instructions below. Doses are not adjusted per protocol for prednisone, rituximab and vinCRIStine.
Note to All Staff (1)
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ZZtestonc,Andrew [2428787]
11/22/2016 12:28:19 PM Page 20 of 43
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
Dose Calculation Instructions
All patients will be started on dose level 1 for cycle 1. If ANC nadir is greater than or equal to 500/uL increase one dose level. If ANC
nadir less than 500/uL for 1 or 2 measurements maintain the same dose level. If ANC nadir less than 500/uL on at least 3
measurements decrease one dose level. OR if the platelet count is less than 25/uL on one measurement decrease one dose level
Dose Calculation Instructions (2)
DOXOrubicin dose adjustment: Dose Level (Dose): -3(10 mg/m2/day), -2(10 mg/m2/day), -1(10 mg/m2/day), 1(10
mg/m2/day), 2(12 mg/m2/day), 3(14.4 mg/m2/day), 4(17.3 mg/m2/day), 5(20.7 mg/m2/day), 6(24.8 mg/m2/day), 7(29.8
mg/m2/day)
Dose Calculation Instructions (3)
Etoposide dose adjustment: Dose Level (Dose): -3(50 mg/m2/day), -2(50 mg/m2/day), -1(50 mg/m2/day), 1(50 mg/m2/day), 2
(60 mg/m2/day), 3(72 mg/m2/day), 4(86.4 mg/m2/day), 5(103.7 mg/m2/day), 6(124.4 mg/m2/day), 7(149.3 mg/m2/day),
Dose Calculation Instructions (4)
Cyclophosphamide dose adjustment: Dose Level (Dose): -3(384 mg/m2), -2(480 mg/m2), -1(600 mg/m2), 1(750 mg/m2), 2
(900 mg/m2), 3(1080 mg/m2), 4(1296 mg/m2), 5(1555 mg/m2), 6(1866 mg/m2), 7(2239 mg/m2)
Dose Per Protocol
Dose level per protocol for current cycle: DOXOrubicin {Hit F2 to choose- DOXOrubicin Dose Level:22169}, Etoposide {Hit F2 to
choose- Etoposide Dose Level:22173}, Cyclophosphamide {Hit F2 to choose- Cyclophosphamide Dose Level:7700138}. Date of
Current Cycle *** . DO NOT PROPAGATE THIS ORDER BEYOND THE CURRENT CYCLE.
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 lock flush 10 UNIT/ML 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.
Treatment Medications
etoposide (VEPESID) 179 mg, vinCRIStine (ONCOVIN) 1.4 mg, doxorubicin CONVENTIONAL (ADRIAMYCIN) 36
mg home infusion bag
Intravenous, EVERY 48 HOURS, 1 dose Starting when released
Home infusion company to supply for continuous infusion over 48 hours (Bag 2 of 2).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 4 – Planned for 1/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma/ Burkitts Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, prednisone 60 mg/m2 by
mouth twice daily Day 1 through 5, etoposide 50 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 200 mg/m2), vinCRIStine 0.4 mg/m2/day IV continous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 1.6 mg/m2), doxorubicin 10 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 40 mg/m2), cyclophosphamide 750 mg/m2 IV Day 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21
days; COURSE: 4 to 8 cycles. Note: CSF negative patients receive methotrexate 12 mg IT Days 1 and 5 of Cycles 3, 4, 5 and 6.
NOTE : Doses listed above are for cycle 1. For subsequent cycles of doxorubicin, etoposide, and cyclophosphamide see dose
calculation instructions below. Doses are not adjusted per protocol for prednisone, rituximab and vinCRIStine.
Note to All Staff (1)
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ZZtestonc,Andrew [2428787]
11/22/2016 12:28:19 PM Page 21 of 43
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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 to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
Dose Calculation Instructions
All patients will be started on dose level 1 for cycle 1. If ANC nadir is greater than or equal to 500/uL increase one dose level. If ANC
nadir less than 500/uL for 1 or 2 measurements maintain the same dose level. If ANC nadir less than 500/uL on at least 3
measurements decrease one dose level. OR if the platelet count is less than 25/uL on one measurement decrease one dose level
Dose Calculation Instructions (2)
DOXOrubicin dose adjustment: Dose Level (Dose): -3(10 mg/m2/day), -2(10 mg/m2/day), -1(10 mg/m2/day), 1(10
mg/m2/day), 2(12 mg/m2/day), 3(14.4 mg/m2/day), 4(17.3 mg/m2/day), 5(20.7 mg/m2/day), 6(24.8 mg/m2/day), 7(29.8
mg/m2/day)
Dose Calculation Instructions (3)
Etoposide dose adjustment: Dose Level (Dose): -3(50 mg/m2/day), -2(50 mg/m2/day), -1(50 mg/m2/day), 1(50 mg/m2/day), 2
(60 mg/m2/day), 3(72 mg/m2/day), 4(86.4 mg/m2/day), 5(103.7 mg/m2/day), 6(124.4 mg/m2/day), 7(149.3 mg/m2/day),
Dose Calculation Instructions (4)
Cyclophosphamide dose adjustment: Dose Level (Dose): -3(384 mg/m2), -2(480 mg/m2), -1(600 mg/m2), 1(750 mg/m2), 2
(900 mg/m2), 3(1080 mg/m2), 4(1296 mg/m2), 5(1555 mg/m2), 6(1866 mg/m2), 7(2239 mg/m2)
Dose Per Protocol
Dose level per protocol for current cycle: DOXOrubicin {Hit F2 to choose- DOXOrubicin Dose Level:22169}, Etoposide {Hit F2 to
choose- Etoposide Dose Level:22173}, Cyclophosphamide {Hit F2 to choose- Cyclophosphamide Dose Level:7700138}. Date of
Current Cycle *** . DO NOT PROPAGATE THIS ORDER BEYOND THE CURRENT CYCLE.
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.
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 lock flush 10 UNIT/ML 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
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Intrathecal Procedure Orders (delete all that do not apply)
LEUKEMIA/LYMPHOMA SCREEN, CSF
ONCE Starting when released
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ZZtestonc,Andrew [2428787]
11/22/2016 12:28:19 PM Page 22 of 43
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

methotrexate PF 12 mg in sodium chloride 0.9 % 2.4 mL intraTHECAL injection
12 mg, Intrathecal, ONCE, 1 dose Starting when released
Indication: prophylactic CSF treatment. Dose to be given by provider.
Treatment Medications
Pump Disconnection Procedures
Disconnect pump upon completion of 96-hour home infusion.
cyclophosphamide (CYTOXAN) in sodium chloride 0.9 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer on Day 5.
Cyclophosphamide dose less than 2000 mg infuse IV over 30 minutes.
Cyclophosphamide dose 2000 mg to 3999 mg infuse IV over 90 minutes.
Cyclophosphamide dose greater than 4000 mg infuse IV over 120 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 – 2/14/2017 through 3/6/2017 (21 days), Planned
Day 1, Cycle 5 – Planned for 2/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma/ Burkitts Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, prednisone 60 mg/m2 by
mouth twice daily Day 1 through 5, etoposide 50 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 200 mg/m2), vinCRIStine 0.4 mg/m2/day IV continous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 1.6 mg/m2), doxorubicin 10 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 40 mg/m2), cyclophosphamide 750 mg/m2 IV Day 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21
days; COURSE: 4 to 8 cycles. Note: CSF negative patients receive methotrexate 12 mg IT Days 1 and 5 of Cycles 3, 4, 5 and 6.
NOTE : Doses listed above are for cycle 1. For subsequent cycles of doxorubicin, etoposide, and cyclophosphamide see dose
calculation instructions below. Doses are not adjusted per protocol for prednisone, rituximab and vinCRIStine.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
Dose Calculation Instructions
All patients will be started on dose level 1 for cycle 1. If ANC nadir is greater than or equal to 500/uL increase one dose level. If ANC
nadir less than 500/uL for 1 or 2 measurements maintain the same dose level. If ANC nadir less than 500/uL on at least 3
measurements decrease one dose level. OR if the platelet count is less than 25/uL on one measurement decrease one dose level
Dose Calculation Instructions (2)
DOXOrubicin dose adjustment: Dose Level (Dose): -3(10 mg/m2/day), -2(10 mg/m2/day), -1(10 mg/m2/day), 1(10
mg/m2/day), 2(12 mg/m2/day), 3(14.4 mg/m2/day), 4(17.3 mg/m2/day), 5(20.7 mg/m2/day), 6(24.8 mg/m2/day), 7(29.8
mg/m2/day)
Dose Calculation Instructions (3)
Etoposide dose adjustment: Dose Level (Dose): -3(50 mg/m2/day), -2(50 mg/m2/day), -1(50 mg/m2/day), 1(50 mg/m2/day), 2
(60 mg/m2/day), 3(72 mg/m2/day), 4(86.4 mg/m2/day), 5(103.7 mg/m2/day), 6(124.4 mg/m2/day), 7(149.3 mg/m2/day),
Dose Calculation Instructions (4)
Cyclophosphamide dose adjustment: Dose Level (Dose): -3(384 mg/m2), -2(480 mg/m2), -1(600 mg/m2), 1(750 mg/m2), 2
(900 mg/m2), 3(1080 mg/m2), 4(1296 mg/m2), 5(1555 mg/m2), 6(1866 mg/m2), 7(2239 mg/m2)
Dose Per Protocol
Dose level per protocol for current cycle: DOXOrubicin {Hit F2 to choose- DOXOrubicin Dose Level:22169}, Etoposide {Hit F2 to
choose- Etoposide Dose Level:22173}, Cyclophosphamide {Hit F2 to choose- Cyclophosphamide Dose Level:7700138}. Date of
Current Cycle *** . DO NOT PROPAGATE THIS ORDER BEYOND THE CURRENT CYCLE.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/22/2016 12:28:19 PM Page 23 of 43
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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+17 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+17 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+17 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin
Treatment Parameters
Hold treatment and notify authorizing prescriber for: ANC less than 1000/µL or Platelets less than 75K/µL or Total Bilirubin greater
than 1.8 mg/dL
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
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.
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 lock flush 10 UNIT/ML 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 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
diphenhydramine (BENADRYL) cap 50 mg
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ZZtestonc,Andrew [2428787]
11/22/2016 12:28:19 PM Page 24 of 43
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

50 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
prednisone (DELTASONE) tab 107.5 mg
107.5 mg (rounded from 107.4 mg = 60 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Intrathecal Procedure Orders (delete all that do not apply)
LEUKEMIA/LYMPHOMA SCREEN, CSF
ONCE Starting when released
methotrexate PF 12 mg in sodium chloride 0.9 % 2.4 mL intraTHECAL injection
12 mg, Intrathecal, ONCE, 1 dose Starting when released
Indication: prophylactic CSF treatment. Dose to be given by provider.
Treatment Medications
rituximab (RITUXAN) 671 mg in sodium chloride 0.9 % 500 mL bag
671 mg (rounded from 671.25 mg = 375 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Day 1: Hypersensitivity Risk. See Emergency Medications. Administer rituximab prior to any chemotherapy. See Note on MAR for
infusion rates. If patient experiences fever accompanied by chills or rigors, shortness of breath, chest pain or hypotension, contact
MD. Once the patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
etoposide (VEPESID) 179 mg, vinCRIStine (ONCOVIN) 1.4 mg, doxorubicin CONVENTIONAL (ADRIAMYCIN) 36
mg home infusion bag
Intravenous, EVERY 48 HOURS, 1 dose Starting when released
Home infusion company to supply for continuous infusion over 48 hours (Bag 1 of 2).
Take Home Medications
prednisone (DELTASONE) 20 MG tab
Take 5.5 tabs by mouth 2 times daily at mealtime. Take on Days 1 through 5., 110 mg (rounded from 107.4 mg = 60 mg/m2 ×
1.79 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY (AT MEALTIME) starting S, Local Printer
Follow-Up
MULTIPLE DAY FOLLOW-UP (1)
INTERIM LAB APPOINTMENTS: CBC with DIFF every Monday and Thursday starting ***
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: Home infusion bag change for 60 minutes
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: Discontinue home infusion and cyclophosphamide for 150 minutes and intrathecal
methotrexate (if applicable) for an additional 60 minutes.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, DIFF, Hemoglobin, Creatinine Total Bilirubin;
CHEMOTHERAPY ROOM APPOINTMENT: riTUXimab and home infusion set up for 180 minutes and intrathecal methotrexate (if
applicable) for an additional 60 minutes.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:28:19 PM Page 25 of 43
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Day 3 (Home Infusion Bag Change), Cycle 5 – Planned for 2/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma/ Burkitts Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, prednisone 60 mg/m2 by
mouth twice daily Day 1 through 5, etoposide 50 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 200 mg/m2), vinCRIStine 0.4 mg/m2/day IV continous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 1.6 mg/m2), doxorubicin 10 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 40 mg/m2), cyclophosphamide 750 mg/m2 IV Day 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21
days; COURSE: 4 to 8 cycles. Note: CSF negative patients receive methotrexate 12 mg IT Days 1 and 5 of Cycles 3, 4, 5 and 6.
NOTE : Doses listed above are for cycle 1. For subsequent cycles of doxorubicin, etoposide, and cyclophosphamide see dose
calculation instructions below. Doses are not adjusted per protocol for prednisone, rituximab and vinCRIStine.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
Dose Calculation Instructions
All patients will be started on dose level 1 for cycle 1. If ANC nadir is greater than or equal to 500/uL increase one dose level. If ANC
nadir less than 500/uL for 1 or 2 measurements maintain the same dose level. If ANC nadir less than 500/uL on at least 3
measurements decrease one dose level. OR if the platelet count is less than 25/uL on one measurement decrease one dose level
Dose Calculation Instructions (2)
DOXOrubicin dose adjustment: Dose Level (Dose): -3(10 mg/m2/day), -2(10 mg/m2/day), -1(10 mg/m2/day), 1(10
mg/m2/day), 2(12 mg/m2/day), 3(14.4 mg/m2/day), 4(17.3 mg/m2/day), 5(20.7 mg/m2/day), 6(24.8 mg/m2/day), 7(29.8
mg/m2/day)
Dose Calculation Instructions (3)
Etoposide dose adjustment: Dose Level (Dose): -3(50 mg/m2/day), -2(50 mg/m2/day), -1(50 mg/m2/day), 1(50 mg/m2/day), 2
(60 mg/m2/day), 3(72 mg/m2/day), 4(86.4 mg/m2/day), 5(103.7 mg/m2/day), 6(124.4 mg/m2/day), 7(149.3 mg/m2/day),
Dose Calculation Instructions (4)
Cyclophosphamide dose adjustment: Dose Level (Dose): -3(384 mg/m2), -2(480 mg/m2), -1(600 mg/m2), 1(750 mg/m2), 2
(900 mg/m2), 3(1080 mg/m2), 4(1296 mg/m2), 5(1555 mg/m2), 6(1866 mg/m2), 7(2239 mg/m2)
Dose Per Protocol
Dose level per protocol for current cycle: DOXOrubicin {Hit F2 to choose- DOXOrubicin Dose Level:22169}, Etoposide {Hit F2 to
choose- Etoposide Dose Level:22173}, Cyclophosphamide {Hit F2 to choose- Cyclophosphamide Dose Level:7700138}. Date of
Current Cycle *** . DO NOT PROPAGATE THIS ORDER BEYOND THE CURRENT CYCLE.
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 lock flush 10 UNIT/ML 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.
Treatment Medications
etoposide (VEPESID) 179 mg, vinCRIStine (ONCOVIN) 1.4 mg, doxorubicin CONVENTIONAL (ADRIAMYCIN) 36
mg home infusion bag
Intravenous, EVERY 48 HOURS, 1 dose Starting when released
Home infusion company to supply for continuous infusion over 48 hours (Bag 2 of 2).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:28:19 PM Page 26 of 43
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Day 5, Cycle 5 – Planned for 2/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma/ Burkitts Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, prednisone 60 mg/m2 by
mouth twice daily Day 1 through 5, etoposide 50 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 200 mg/m2), vinCRIStine 0.4 mg/m2/day IV continous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 1.6 mg/m2), doxorubicin 10 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 40 mg/m2), cyclophosphamide 750 mg/m2 IV Day 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21
days; COURSE: 4 to 8 cycles. Note: CSF negative patients receive methotrexate 12 mg IT Days 1 and 5 of Cycles 3, 4, 5 and 6.
NOTE : Doses listed above are for cycle 1. For subsequent cycles of doxorubicin, etoposide, and cyclophosphamide see dose
calculation instructions below. Doses are not adjusted per protocol for prednisone, rituximab and vinCRIStine.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
Dose Calculation Instructions
All patients will be started on dose level 1 for cycle 1. If ANC nadir is greater than or equal to 500/uL increase one dose level. If ANC
nadir less than 500/uL for 1 or 2 measurements maintain the same dose level. If ANC nadir less than 500/uL on at least 3
measurements decrease one dose level. OR if the platelet count is less than 25/uL on one measurement decrease one dose level
Dose Calculation Instructions (2)
DOXOrubicin dose adjustment: Dose Level (Dose): -3(10 mg/m2/day), -2(10 mg/m2/day), -1(10 mg/m2/day), 1(10
mg/m2/day), 2(12 mg/m2/day), 3(14.4 mg/m2/day), 4(17.3 mg/m2/day), 5(20.7 mg/m2/day), 6(24.8 mg/m2/day), 7(29.8
mg/m2/day)
Dose Calculation Instructions (3)
Etoposide dose adjustment: Dose Level (Dose): -3(50 mg/m2/day), -2(50 mg/m2/day), -1(50 mg/m2/day), 1(50 mg/m2/day), 2
(60 mg/m2/day), 3(72 mg/m2/day), 4(86.4 mg/m2/day), 5(103.7 mg/m2/day), 6(124.4 mg/m2/day), 7(149.3 mg/m2/day),
Dose Calculation Instructions (4)
Cyclophosphamide dose adjustment: Dose Level (Dose): -3(384 mg/m2), -2(480 mg/m2), -1(600 mg/m2), 1(750 mg/m2), 2
(900 mg/m2), 3(1080 mg/m2), 4(1296 mg/m2), 5(1555 mg/m2), 6(1866 mg/m2), 7(2239 mg/m2)
Dose Per Protocol
Dose level per protocol for current cycle: DOXOrubicin {Hit F2 to choose- DOXOrubicin Dose Level:22169}, Etoposide {Hit F2 to
choose- Etoposide Dose Level:22173}, Cyclophosphamide {Hit F2 to choose- Cyclophosphamide Dose Level:7700138}. Date of
Current Cycle *** . DO NOT PROPAGATE THIS ORDER BEYOND THE CURRENT CYCLE.
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.
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 lock flush 10 UNIT/ML 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.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:28:19 PM Page 27 of 43
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Intrathecal Procedure Orders (delete all that do not apply)
LEUKEMIA/LYMPHOMA SCREEN, CSF
ONCE Starting when released
methotrexate PF 12 mg in sodium chloride 0.9 % 2.4 mL intraTHECAL injection
12 mg, Intrathecal, ONCE, 1 dose Starting when released
Indication: prophylactic CSF treatment. Dose to be given by provider.
Treatment Medications
Pump Disconnection Procedures
Disconnect pump upon completion of 96-hour home infusion.
cyclophosphamide (CYTOXAN) in sodium chloride 0.9 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer on Day 5.
Cyclophosphamide dose less than 2000 mg infuse IV over 30 minutes.
Cyclophosphamide dose 2000 mg to 3999 mg infuse IV over 90 minutes.
Cyclophosphamide dose greater than 4000 mg infuse IV over 120 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 – 3/7/2017 through 3/27/2017 (21 days), Planned
Day 1, Cycle 6 – Planned for 3/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma/ Burkitts Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, prednisone 60 mg/m2 by
mouth twice daily Day 1 through 5, etoposide 50 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 200 mg/m2), vinCRIStine 0.4 mg/m2/day IV continous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 1.6 mg/m2), doxorubicin 10 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 40 mg/m2), cyclophosphamide 750 mg/m2 IV Day 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21
days; COURSE: 4 to 8 cycles. Note: CSF negative patients receive methotrexate 12 mg IT Days 1 and 5 of Cycles 3, 4, 5 and 6.
NOTE : Doses listed above are for cycle 1. For subsequent cycles of doxorubicin, etoposide, and cyclophosphamide see dose
calculation instructions below. Doses are not adjusted per protocol for prednisone, rituximab and vinCRIStine.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
Dose Calculation Instructions
All patients will be started on dose level 1 for cycle 1. If ANC nadir is greater than or equal to 500/uL increase one dose level. If ANC
nadir less than 500/uL for 1 or 2 measurements maintain the same dose level. If ANC nadir less than 500/uL on at least 3
measurements decrease one dose level. OR if the platelet count is less than 25/uL on one measurement decrease one dose level
Dose Calculation Instructions (2)
DOXOrubicin dose adjustment: Dose Level (Dose): -3(10 mg/m2/day), -2(10 mg/m2/day), -1(10 mg/m2/day), 1(10
mg/m2/day), 2(12 mg/m2/day), 3(14.4 mg/m2/day), 4(17.3 mg/m2/day), 5(20.7 mg/m2/day), 6(24.8 mg/m2/day), 7(29.8
mg/m2/day)
Dose Calculation Instructions (3)
Etoposide dose adjustment: Dose Level (Dose): -3(50 mg/m2/day), -2(50 mg/m2/day), -1(50 mg/m2/day), 1(50 mg/m2/day), 2
(60 mg/m2/day), 3(72 mg/m2/day), 4(86.4 mg/m2/day), 5(103.7 mg/m2/day), 6(124.4 mg/m2/day), 7(149.3 mg/m2/day),
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ZZtestonc,Andrew [2428787]
11/22/2016 12:28:19 PM Page 28 of 43
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Dose Calculation Instructions (4)
Cyclophosphamide dose adjustment: Dose Level (Dose): -3(384 mg/m2), -2(480 mg/m2), -1(600 mg/m2), 1(750 mg/m2), 2
(900 mg/m2), 3(1080 mg/m2), 4(1296 mg/m2), 5(1555 mg/m2), 6(1866 mg/m2), 7(2239 mg/m2)
Dose Per Protocol
Dose level per protocol for current cycle: DOXOrubicin {Hit F2 to choose- DOXOrubicin Dose Level:22169}, Etoposide {Hit F2 to
choose- Etoposide Dose Level:22173}, Cyclophosphamide {Hit F2 to choose- Cyclophosphamide Dose Level:7700138}. Date of
Current Cycle *** . DO NOT PROPAGATE THIS ORDER BEYOND THE CURRENT CYCLE.
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+17 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+17 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+17 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin
Treatment Parameters
Hold treatment and notify authorizing prescriber for: ANC less than 1000/µL or Platelets less than 75K/µL or Total Bilirubin greater
than 1.8 mg/dL
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
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.
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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:28:19 PM Page 29 of 43
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
prednisone (DELTASONE) tab 107.5 mg
107.5 mg (rounded from 107.4 mg = 60 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Intrathecal Procedure Orders (delete all that do not apply)
LEUKEMIA/LYMPHOMA SCREEN, CSF
ONCE Starting when released
methotrexate PF 12 mg in sodium chloride 0.9 % 2.4 mL intraTHECAL injection
12 mg, Intrathecal, ONCE, 1 dose Starting when released
Indication: prophylactic CSF treatment. Dose to be given by provider.
Treatment Medications
rituximab (RITUXAN) 671 mg in sodium chloride 0.9 % 500 mL bag
671 mg (rounded from 671.25 mg = 375 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Day 1: Hypersensitivity Risk. See Emergency Medications. Administer rituximab prior to any chemotherapy. See Note on MAR for
infusion rates. If patient experiences fever accompanied by chills or rigors, shortness of breath, chest pain or hypotension, contact
MD. Once the patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
etoposide (VEPESID) 179 mg, vinCRIStine (ONCOVIN) 1.4 mg, doxorubicin CONVENTIONAL (ADRIAMYCIN) 36
mg home infusion bag
Intravenous, EVERY 48 HOURS, 1 dose Starting when released
Home infusion company to supply for continuous infusion over 48 hours (Bag 1 of 2).
Take Home Medications
prednisone (DELTASONE) 20 MG tab
Take 5.5 tabs by mouth 2 times daily at mealtime. Take on Days 1 through 5., 110 mg (rounded from 107.4 mg = 60 mg/m2 ×
1.79 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY (AT MEALTIME) starting S, Local Printer
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ZZtestonc,Andrew [2428787]
11/22/2016 12:28:19 PM Page 30 of 43
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Follow-Up
MULTIPLE DAY FOLLOW-UP (1)
INTERIM LAB APPOINTMENTS: CBC with DIFF every Monday and Thursday starting ***
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: Home infusion bag change for 60 minutes
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: Discontinue home infusion and cyclophosphamide for 150 minutes
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, DIFF, Hemoglobin, Creatinine Total Bilirubin;
CHEMOTHERAPY ROOM APPOINTMENT: riTUXimab and home infusion set up for 180 minutes
Day 3 (Home Infusion Bag Change), Cycle 6 – Planned for 3/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma/ Burkitts Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, prednisone 60 mg/m2 by
mouth twice daily Day 1 through 5, etoposide 50 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 200 mg/m2), vinCRIStine 0.4 mg/m2/day IV continous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 1.6 mg/m2), doxorubicin 10 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 40 mg/m2), cyclophosphamide 750 mg/m2 IV Day 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21
days; COURSE: 4 to 8 cycles. Note: CSF negative patients receive methotrexate 12 mg IT Days 1 and 5 of Cycles 3, 4, 5 and 6.
NOTE : Doses listed above are for cycle 1. For subsequent cycles of doxorubicin, etoposide, and cyclophosphamide see dose
calculation instructions below. Doses are not adjusted per protocol for prednisone, rituximab and vinCRIStine.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
Dose Calculation Instructions
All patients will be started on dose level 1 for cycle 1. If ANC nadir is greater than or equal to 500/uL increase one dose level. If ANC
nadir less than 500/uL for 1 or 2 measurements maintain the same dose level. If ANC nadir less than 500/uL on at least 3
measurements decrease one dose level. OR if the platelet count is less than 25/uL on one measurement decrease one dose level
Dose Calculation Instructions (2)
DOXOrubicin dose adjustment: Dose Level (Dose): -3(10 mg/m2/day), -2(10 mg/m2/day), -1(10 mg/m2/day), 1(10
mg/m2/day), 2(12 mg/m2/day), 3(14.4 mg/m2/day), 4(17.3 mg/m2/day), 5(20.7 mg/m2/day), 6(24.8 mg/m2/day), 7(29.8
mg/m2/day)
Dose Calculation Instructions (3)
Etoposide dose adjustment: Dose Level (Dose): -3(50 mg/m2/day), -2(50 mg/m2/day), -1(50 mg/m2/day), 1(50 mg/m2/day), 2
(60 mg/m2/day), 3(72 mg/m2/day), 4(86.4 mg/m2/day), 5(103.7 mg/m2/day), 6(124.4 mg/m2/day), 7(149.3 mg/m2/day),
Dose Calculation Instructions (4)
Cyclophosphamide dose adjustment: Dose Level (Dose): -3(384 mg/m2), -2(480 mg/m2), -1(600 mg/m2), 1(750 mg/m2), 2
(900 mg/m2), 3(1080 mg/m2), 4(1296 mg/m2), 5(1555 mg/m2), 6(1866 mg/m2), 7(2239 mg/m2)
Dose Per Protocol
Dose level per protocol for current cycle: DOXOrubicin {Hit F2 to choose- DOXOrubicin Dose Level:22169}, Etoposide {Hit F2 to
choose- Etoposide Dose Level:22173}, Cyclophosphamide {Hit F2 to choose- Cyclophosphamide Dose Level:7700138}. Date of
Current Cycle *** . DO NOT PROPAGATE THIS ORDER BEYOND THE CURRENT CYCLE.
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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:28:19 PM Page 31 of 43
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
etoposide (VEPESID) 179 mg, vinCRIStine (ONCOVIN) 1.4 mg, doxorubicin CONVENTIONAL (ADRIAMYCIN) 36
mg home infusion bag
Intravenous, EVERY 48 HOURS, 1 dose Starting when released
Home infusion company to supply for continuous infusion over 48 hours (Bag 2 of 2).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 6 – Planned for 3/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma/ Burkitts Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, prednisone 60 mg/m2 by
mouth twice daily Day 1 through 5, etoposide 50 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 200 mg/m2), vinCRIStine 0.4 mg/m2/day IV continous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 1.6 mg/m2), doxorubicin 10 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 40 mg/m2), cyclophosphamide 750 mg/m2 IV Day 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21
days; COURSE: 4 to 8 cycles. Note: CSF negative patients receive methotrexate 12 mg IT Days 1 and 5 of Cycles 3, 4, 5 and 6.
NOTE : Doses listed above are for cycle 1. For subsequent cycles of doxorubicin, etoposide, and cyclophosphamide see dose
calculation instructions below. Doses are not adjusted per protocol for prednisone, rituximab and vinCRIStine.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
Dose Calculation Instructions
All patients will be started on dose level 1 for cycle 1. If ANC nadir is greater than or equal to 500/uL increase one dose level. If ANC
nadir less than 500/uL for 1 or 2 measurements maintain the same dose level. If ANC nadir less than 500/uL on at least 3
measurements decrease one dose level. OR if the platelet count is less than 25/uL on one measurement decrease one dose level
Dose Calculation Instructions (2)
DOXOrubicin dose adjustment: Dose Level (Dose): -3(10 mg/m2/day), -2(10 mg/m2/day), -1(10 mg/m2/day), 1(10
mg/m2/day), 2(12 mg/m2/day), 3(14.4 mg/m2/day), 4(17.3 mg/m2/day), 5(20.7 mg/m2/day), 6(24.8 mg/m2/day), 7(29.8
mg/m2/day)
Dose Calculation Instructions (3)
Etoposide dose adjustment: Dose Level (Dose): -3(50 mg/m2/day), -2(50 mg/m2/day), -1(50 mg/m2/day), 1(50 mg/m2/day), 2
(60 mg/m2/day), 3(72 mg/m2/day), 4(86.4 mg/m2/day), 5(103.7 mg/m2/day), 6(124.4 mg/m2/day), 7(149.3 mg/m2/day),
Dose Calculation Instructions (4)
Cyclophosphamide dose adjustment: Dose Level (Dose): -3(384 mg/m2), -2(480 mg/m2), -1(600 mg/m2), 1(750 mg/m2), 2
(900 mg/m2), 3(1080 mg/m2), 4(1296 mg/m2), 5(1555 mg/m2), 6(1866 mg/m2), 7(2239 mg/m2)
Dose Per Protocol
Dose level per protocol for current cycle: DOXOrubicin {Hit F2 to choose- DOXOrubicin Dose Level:22169}, Etoposide {Hit F2 to
choose- Etoposide Dose Level:22173}, Cyclophosphamide {Hit F2 to choose- Cyclophosphamide Dose Level:7700138}. Date of
Current Cycle *** . DO NOT PROPAGATE THIS ORDER BEYOND THE CURRENT CYCLE.
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.
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.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:28:19 PM Page 32 of 43
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@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 lock flush 10 UNIT/ML 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
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Intrathecal Procedure Orders (delete all that do not apply)
LEUKEMIA/LYMPHOMA SCREEN, CSF
ONCE Starting when released
methotrexate PF 12 mg in sodium chloride 0.9 % 2.4 mL intraTHECAL injection
12 mg, Intrathecal, ONCE, 1 dose Starting when released
Indication: prophylactic CSF treatment. Dose to be given by provider.
Treatment Medications
Pump Disconnection Procedures
Disconnect pump upon completion of 96-hour home infusion.
cyclophosphamide (CYTOXAN) in sodium chloride 0.9 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer on Day 5.
Cyclophosphamide dose less than 2000 mg infuse IV over 30 minutes.
Cyclophosphamide dose 2000 mg to 3999 mg infuse IV over 90 minutes.
Cyclophosphamide dose greater than 4000 mg infuse IV over 120 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 7 – 3/28/2017 through 4/17/2017 (21 days), Planned
Day 1, Cycle 7 – Planned for 3/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma/ Burkitts Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, prednisone 60 mg/m2 by
mouth twice daily Day 1 through 5, etoposide 50 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 200 mg/m2), vinCRIStine 0.4 mg/m2/day IV continous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 1.6 mg/m2), doxorubicin 10 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 40 mg/m2), cyclophosphamide 750 mg/m2 IV Day 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21
days; COURSE: 4 to 8 cycles. Note: CSF negative patients receive methotrexate 12 mg IT Days 1 and 5 of Cycles 3, 4, 5 and 6.
NOTE : Doses listed above are for cycle 1. For subsequent cycles of doxorubicin, etoposide, and cyclophosphamide see dose
calculation instructions below. Doses are not adjusted per protocol for prednisone, rituximab and vinCRIStine.
Note to All Staff (1)
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ZZtestonc,Andrew [2428787]
11/22/2016 12:28:19 PM Page 33 of 43
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
Dose Calculation Instructions
All patients will be started on dose level 1 for cycle 1. If ANC nadir is greater than or equal to 500/uL increase one dose level. If ANC
nadir less than 500/uL for 1 or 2 measurements maintain the same dose level. If ANC nadir less than 500/uL on at least 3
measurements decrease one dose level. OR if the platelet count is less than 25/uL on one measurement decrease one dose level
Dose Calculation Instructions (2)
DOXOrubicin dose adjustment: Dose Level (Dose): -3(10 mg/m2/day), -2(10 mg/m2/day), -1(10 mg/m2/day), 1(10
mg/m2/day), 2(12 mg/m2/day), 3(14.4 mg/m2/day), 4(17.3 mg/m2/day), 5(20.7 mg/m2/day), 6(24.8 mg/m2/day), 7(29.8
mg/m2/day)
Dose Calculation Instructions (3)
Etoposide dose adjustment: Dose Level (Dose): -3(50 mg/m2/day), -2(50 mg/m2/day), -1(50 mg/m2/day), 1(50 mg/m2/day), 2
(60 mg/m2/day), 3(72 mg/m2/day), 4(86.4 mg/m2/day), 5(103.7 mg/m2/day), 6(124.4 mg/m2/day), 7(149.3 mg/m2/day),
Dose Calculation Instructions (4)
Cyclophosphamide dose adjustment: Dose Level (Dose): -3(384 mg/m2), -2(480 mg/m2), -1(600 mg/m2), 1(750 mg/m2), 2
(900 mg/m2), 3(1080 mg/m2), 4(1296 mg/m2), 5(1555 mg/m2), 6(1866 mg/m2), 7(2239 mg/m2)
Dose Per Protocol
Dose level per protocol for current cycle: DOXOrubicin {Hit F2 to choose- DOXOrubicin Dose Level:22169}, Etoposide {Hit F2 to
choose- Etoposide Dose Level:22173}, Cyclophosphamide {Hit F2 to choose- Cyclophosphamide Dose Level:7700138}. Date of
Current Cycle *** . DO NOT PROPAGATE THIS ORDER BEYOND THE CURRENT CYCLE.
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+17 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+17 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+17 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin
Treatment Parameters
Hold treatment and notify authorizing prescriber for: ANC less than 1000/µL or Platelets less than 75K/µL or Total Bilirubin greater
than 1.8 mg/dL
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
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
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ZZtestonc,Andrew [2428787]
11/22/2016 12:28:19 PM Page 34 of 43
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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.
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 lock flush 10 UNIT/ML 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 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
prednisone (DELTASONE) tab 107.5 mg
107.5 mg (rounded from 107.4 mg = 60 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 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) 671 mg in sodium chloride 0.9 % 500 mL bag
671 mg (rounded from 671.25 mg = 375 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Day 1: Hypersensitivity Risk. See Emergency Medications. Administer rituximab prior to any chemotherapy. See Note on MAR for
infusion rates. If patient experiences fever accompanied by chills or rigors, shortness of breath, chest pain or hypotension, contact
MD. Once the patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
etoposide (VEPESID) 179 mg, vinCRIStine (ONCOVIN) 1.4 mg, doxorubicin CONVENTIONAL (ADRIAMYCIN) 36
mg home infusion bag
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ZZtestonc,Andrew [2428787]
11/22/2016 12:28:19 PM Page 35 of 43
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Intravenous, EVERY 48 HOURS, 1 dose Starting when released
Home infusion company to supply for continuous infusion over 48 hours (Bag 1 of 2).
Take Home Medications
prednisone (DELTASONE) 20 MG tab
Take 5.5 tabs by mouth 2 times daily at mealtime. Take on Days 1 through 5., 110 mg (rounded from 107.4 mg = 60 mg/m2 ×
1.79 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY (AT MEALTIME) starting S, Local Printer
Follow-Up
MULTIPLE DAY FOLLOW-UP (1)
INTERIM LAB APPOINTMENTS: CBC with DIFF every Monday and Thursday starting ***
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: Home infusion bag change for 60 minutes
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: Discontinue home infusion and cyclophosphamide for 150 minutes
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, DIFF, Hemoglobin, Creatinine Total Bilirubin;
CHEMOTHERAPY ROOM APPOINTMENT: riTUXimab and home infusion set up for 180 minutes
Day 3 (Home Infusion Bag Change), Cycle 7 – Planned for 3/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma/ Burkitts Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, prednisone 60 mg/m2 by
mouth twice daily Day 1 through 5, etoposide 50 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 200 mg/m2), vinCRIStine 0.4 mg/m2/day IV continous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 1.6 mg/m2), doxorubicin 10 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 40 mg/m2), cyclophosphamide 750 mg/m2 IV Day 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21
days; COURSE: 4 to 8 cycles. Note: CSF negative patients receive methotrexate 12 mg IT Days 1 and 5 of Cycles 3, 4, 5 and 6.
NOTE : Doses listed above are for cycle 1. For subsequent cycles of doxorubicin, etoposide, and cyclophosphamide see dose
calculation instructions below. Doses are not adjusted per protocol for prednisone, rituximab and vinCRIStine.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
Dose Calculation Instructions
All patients will be started on dose level 1 for cycle 1. If ANC nadir is greater than or equal to 500/uL increase one dose level. If ANC
nadir less than 500/uL for 1 or 2 measurements maintain the same dose level. If ANC nadir less than 500/uL on at least 3
measurements decrease one dose level. OR if the platelet count is less than 25/uL on one measurement decrease one dose level
Dose Calculation Instructions (2)
DOXOrubicin dose adjustment: Dose Level (Dose): -3(10 mg/m2/day), -2(10 mg/m2/day), -1(10 mg/m2/day), 1(10
mg/m2/day), 2(12 mg/m2/day), 3(14.4 mg/m2/day), 4(17.3 mg/m2/day), 5(20.7 mg/m2/day), 6(24.8 mg/m2/day), 7(29.8
mg/m2/day)
Dose Calculation Instructions (3)
Etoposide dose adjustment: Dose Level (Dose): -3(50 mg/m2/day), -2(50 mg/m2/day), -1(50 mg/m2/day), 1(50 mg/m2/day), 2
(60 mg/m2/day), 3(72 mg/m2/day), 4(86.4 mg/m2/day), 5(103.7 mg/m2/day), 6(124.4 mg/m2/day), 7(149.3 mg/m2/day),
Dose Calculation Instructions (4)
Cyclophosphamide dose adjustment: Dose Level (Dose): -3(384 mg/m2), -2(480 mg/m2), -1(600 mg/m2), 1(750 mg/m2), 2
(900 mg/m2), 3(1080 mg/m2), 4(1296 mg/m2), 5(1555 mg/m2), 6(1866 mg/m2), 7(2239 mg/m2)
Dose Per Protocol
Dose level per protocol for current cycle: DOXOrubicin {Hit F2 to choose- DOXOrubicin Dose Level:22169}, Etoposide {Hit F2 to
choose- Etoposide Dose Level:22173}, Cyclophosphamide {Hit F2 to choose- Cyclophosphamide Dose Level:7700138}. Date of
Current Cycle *** . DO NOT PROPAGATE THIS ORDER BEYOND THE CURRENT CYCLE.
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
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ZZtestonc,Andrew [2428787]
11/22/2016 12:28:19 PM Page 36 of 43
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@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 lock flush 10 UNIT/ML 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.
Treatment Medications
etoposide (VEPESID) 179 mg, vinCRIStine (ONCOVIN) 1.4 mg, doxorubicin CONVENTIONAL (ADRIAMYCIN) 36
mg home infusion bag
Intravenous, EVERY 48 HOURS, 1 dose Starting when released
Home infusion company to supply for continuous infusion over 48 hours (Bag 2 of 2).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 7 – Planned for 4/1/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma/ Burkitts Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, prednisone 60 mg/m2 by
mouth twice daily Day 1 through 5, etoposide 50 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 200 mg/m2), vinCRIStine 0.4 mg/m2/day IV continous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 1.6 mg/m2), doxorubicin 10 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 40 mg/m2), cyclophosphamide 750 mg/m2 IV Day 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21
days; COURSE: 4 to 8 cycles. Note: CSF negative patients receive methotrexate 12 mg IT Days 1 and 5 of Cycles 3, 4, 5 and 6.
NOTE : Doses listed above are for cycle 1. For subsequent cycles of doxorubicin, etoposide, and cyclophosphamide see dose
calculation instructions below. Doses are not adjusted per protocol for prednisone, rituximab and vinCRIStine.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
Dose Calculation Instructions
All patients will be started on dose level 1 for cycle 1. If ANC nadir is greater than or equal to 500/uL increase one dose level. If ANC
nadir less than 500/uL for 1 or 2 measurements maintain the same dose level. If ANC nadir less than 500/uL on at least 3
measurements decrease one dose level. OR if the platelet count is less than 25/uL on one measurement decrease one dose level
Dose Calculation Instructions (2)
DOXOrubicin dose adjustment: Dose Level (Dose): -3(10 mg/m2/day), -2(10 mg/m2/day), -1(10 mg/m2/day), 1(10
mg/m2/day), 2(12 mg/m2/day), 3(14.4 mg/m2/day), 4(17.3 mg/m2/day), 5(20.7 mg/m2/day), 6(24.8 mg/m2/day), 7(29.8
mg/m2/day)
Dose Calculation Instructions (3)
Etoposide dose adjustment: Dose Level (Dose): -3(50 mg/m2/day), -2(50 mg/m2/day), -1(50 mg/m2/day), 1(50 mg/m2/day), 2
(60 mg/m2/day), 3(72 mg/m2/day), 4(86.4 mg/m2/day), 5(103.7 mg/m2/day), 6(124.4 mg/m2/day), 7(149.3 mg/m2/day),
Dose Calculation Instructions (4)
Cyclophosphamide dose adjustment: Dose Level (Dose): -3(384 mg/m2), -2(480 mg/m2), -1(600 mg/m2), 1(750 mg/m2), 2
(900 mg/m2), 3(1080 mg/m2), 4(1296 mg/m2), 5(1555 mg/m2), 6(1866 mg/m2), 7(2239 mg/m2)
Dose Per Protocol
Dose level per protocol for current cycle: DOXOrubicin {Hit F2 to choose- DOXOrubicin Dose Level:22169}, Etoposide {Hit F2 to
choose- Etoposide Dose Level:22173}, Cyclophosphamide {Hit F2 to choose- Cyclophosphamide Dose Level:7700138}. Date of
Current Cycle *** . DO NOT PROPAGATE THIS ORDER BEYOND THE CURRENT CYCLE.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/22/2016 12:28:19 PM Page 37 of 43
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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.
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 lock flush 10 UNIT/ML 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
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
Pump Disconnection Procedures
Disconnect pump upon completion of 96-hour home infusion.
cyclophosphamide (CYTOXAN) in sodium chloride 0.9 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer on Day 5.
Cyclophosphamide dose less than 2000 mg infuse IV over 30 minutes.
Cyclophosphamide dose 2000 mg to 3999 mg infuse IV over 90 minutes.
Cyclophosphamide dose greater than 4000 mg infuse IV over 120 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 8 – 4/18/2017 through 5/8/2017 (21 days), Planned
Day 1, Cycle 8 – Planned for 4/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma/ Burkitts Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, prednisone 60 mg/m2 by
mouth twice daily Day 1 through 5, etoposide 50 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 200 mg/m2), vinCRIStine 0.4 mg/m2/day IV continous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 1.6 mg/m2), doxorubicin 10 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 40 mg/m2), cyclophosphamide 750 mg/m2 IV Day 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21
days; COURSE: 4 to 8 cycles. Note: CSF negative patients receive methotrexate 12 mg IT Days 1 and 5 of Cycles 3, 4, 5 and 6.
NOTE : Doses listed above are for cycle 1. For subsequent cycles of doxorubicin, etoposide, and cyclophosphamide see dose
calculation instructions below. Doses are not adjusted per protocol for prednisone, rituximab and vinCRIStine.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:28:19 PM Page 38 of 43
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Dose Calculation Instructions
All patients will be started on dose level 1 for cycle 1. If ANC nadir is greater than or equal to 500/uL increase one dose level. If ANC
nadir less than 500/uL for 1 or 2 measurements maintain the same dose level. If ANC nadir less than 500/uL on at least 3
measurements decrease one dose level. OR if the platelet count is less than 25/uL on one measurement decrease one dose level
Dose Calculation Instructions (2)
DOXOrubicin dose adjustment: Dose Level (Dose): -3(10 mg/m2/day), -2(10 mg/m2/day), -1(10 mg/m2/day), 1(10
mg/m2/day), 2(12 mg/m2/day), 3(14.4 mg/m2/day), 4(17.3 mg/m2/day), 5(20.7 mg/m2/day), 6(24.8 mg/m2/day), 7(29.8
mg/m2/day)
Dose Calculation Instructions (3)
Etoposide dose adjustment: Dose Level (Dose): -3(50 mg/m2/day), -2(50 mg/m2/day), -1(50 mg/m2/day), 1(50 mg/m2/day), 2
(60 mg/m2/day), 3(72 mg/m2/day), 4(86.4 mg/m2/day), 5(103.7 mg/m2/day), 6(124.4 mg/m2/day), 7(149.3 mg/m2/day),
Dose Calculation Instructions (4)
Cyclophosphamide dose adjustment: Dose Level (Dose): -3(384 mg/m2), -2(480 mg/m2), -1(600 mg/m2), 1(750 mg/m2), 2
(900 mg/m2), 3(1080 mg/m2), 4(1296 mg/m2), 5(1555 mg/m2), 6(1866 mg/m2), 7(2239 mg/m2)
Dose Per Protocol
Dose level per protocol for current cycle: DOXOrubicin {Hit F2 to choose- DOXOrubicin Dose Level:22169}, Etoposide {Hit F2 to
choose- Etoposide Dose Level:22173}, Cyclophosphamide {Hit F2 to choose- Cyclophosphamide Dose Level:7700138}. Date of
Current Cycle *** . DO NOT PROPAGATE THIS ORDER BEYOND THE CURRENT CYCLE.
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+17 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+17 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+17 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin
Treatment Parameters
Hold treatment and notify authorizing prescriber for: ANC less than 1000/µL or Platelets less than 75K/µL or Total Bilirubin greater
than 1.8 mg/dL
Nursing Procedure, Assessment and Monitoring
Page Or Call ___________
Notify Home infusion provider.
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,Andrew [2428787]
11/22/2016 12:28:19 PM Page 39 of 43
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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 lock flush 10 UNIT/ML 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 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
diphenhydramine (BENADRYL) cap 50 mg
50 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
prednisone (DELTASONE) tab 107.5 mg
107.5 mg (rounded from 107.4 mg = 60 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 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) 671 mg in sodium chloride 0.9 % 500 mL bag
671 mg (rounded from 671.25 mg = 375 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
Day 1: Hypersensitivity Risk. See Emergency Medications. Administer rituximab prior to any chemotherapy. See Note on MAR for
infusion rates. If patient experiences fever accompanied by chills or rigors, shortness of breath, chest pain or hypotension, contact
MD. Once the patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
etoposide (VEPESID) 179 mg, vinCRIStine (ONCOVIN) 1.4 mg, doxorubicin CONVENTIONAL (ADRIAMYCIN) 36
mg home infusion bag
Intravenous, EVERY 48 HOURS, 1 dose Starting when released
Home infusion company to supply for continuous infusion over 48 hours (Bag 1 of 2).
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ZZtestonc,Andrew [2428787]
11/22/2016 12:28:19 PM Page 40 of 43
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Take Home Medications
prednisone (DELTASONE) 20 MG tab
Take 5.5 tabs by mouth 2 times daily at mealtime. Take on Days 1 through 5., 110 mg (rounded from 107.4 mg = 60 mg/m2 ×
1.79 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY (AT MEALTIME) starting S, Local Printer
Follow-Up
MULTIPLE DAY FOLLOW-UP (1)
INTERIM LAB APPOINTMENTS: CBC with DIFF every Monday and Thursday starting ***
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: Home infusion bag change for 60 minutes
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: Discontinue home infusion and cyclophosphamide for 150 minutes
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, DIFF, Hemoglobin, Creatinine Total Bilirubin;
CHEMOTHERAPY ROOM APPOINTMENT: riTUXimab and home infusion set up for 180 minutes
Day 3 (Home Infusion Bag Change), Cycle 8 – Planned for 4/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma/ Burkitts Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, prednisone 60 mg/m2 by
mouth twice daily Day 1 through 5, etoposide 50 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 200 mg/m2), vinCRIStine 0.4 mg/m2/day IV continous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 1.6 mg/m2), doxorubicin 10 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 40 mg/m2), cyclophosphamide 750 mg/m2 IV Day 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21
days; COURSE: 4 to 8 cycles. Note: CSF negative patients receive methotrexate 12 mg IT Days 1 and 5 of Cycles 3, 4, 5 and 6.
NOTE : Doses listed above are for cycle 1. For subsequent cycles of doxorubicin, etoposide, and cyclophosphamide see dose
calculation instructions below. Doses are not adjusted per protocol for prednisone, rituximab and vinCRIStine.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
Dose Calculation Instructions
All patients will be started on dose level 1 for cycle 1. If ANC nadir is greater than or equal to 500/uL increase one dose level. If ANC
nadir less than 500/uL for 1 or 2 measurements maintain the same dose level. If ANC nadir less than 500/uL on at least 3
measurements decrease one dose level. OR if the platelet count is less than 25/uL on one measurement decrease one dose level
Dose Calculation Instructions (2)
DOXOrubicin dose adjustment: Dose Level (Dose): -3(10 mg/m2/day), -2(10 mg/m2/day), -1(10 mg/m2/day), 1(10
mg/m2/day), 2(12 mg/m2/day), 3(14.4 mg/m2/day), 4(17.3 mg/m2/day), 5(20.7 mg/m2/day), 6(24.8 mg/m2/day), 7(29.8
mg/m2/day)
Dose Calculation Instructions (3)
Etoposide dose adjustment: Dose Level (Dose): -3(50 mg/m2/day), -2(50 mg/m2/day), -1(50 mg/m2/day), 1(50 mg/m2/day), 2
(60 mg/m2/day), 3(72 mg/m2/day), 4(86.4 mg/m2/day), 5(103.7 mg/m2/day), 6(124.4 mg/m2/day), 7(149.3 mg/m2/day),
Dose Calculation Instructions (4)
Cyclophosphamide dose adjustment: Dose Level (Dose): -3(384 mg/m2), -2(480 mg/m2), -1(600 mg/m2), 1(750 mg/m2), 2
(900 mg/m2), 3(1080 mg/m2), 4(1296 mg/m2), 5(1555 mg/m2), 6(1866 mg/m2), 7(2239 mg/m2)
Dose Per Protocol
Dose level per protocol for current cycle: DOXOrubicin {Hit F2 to choose- DOXOrubicin Dose Level:22169}, Etoposide {Hit F2 to
choose- Etoposide Dose Level:22173}, Cyclophosphamide {Hit F2 to choose- Cyclophosphamide Dose Level:7700138}. Date of
Current Cycle *** . DO NOT PROPAGATE THIS ORDER BEYOND THE CURRENT CYCLE.
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
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ZZtestonc,Andrew [2428787]
11/22/2016 12:28:19 PM Page 41 of 43
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML 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.
Treatment Medications
etoposide (VEPESID) 179 mg, vinCRIStine (ONCOVIN) 1.4 mg, doxorubicin CONVENTIONAL (ADRIAMYCIN) 36
mg home infusion bag
Intravenous, EVERY 48 HOURS, 1 dose Starting when released
Home infusion company to supply for continuous infusion over 48 hours (Bag 2 of 2).
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 8 – Planned for 4/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Hodgkin Lymphoma/ Burkitts Lymphoma; THERAPY: rituximab 375 mg/m2 IV Day 1, prednisone 60 mg/m2 by
mouth twice daily Day 1 through 5, etoposide 50 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 200 mg/m2), vinCRIStine 0.4 mg/m2/day IV continous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 1.6 mg/m2), doxorubicin 10 mg/m2/day IV continuous infusion over 24 hours Day 1 through 4 (infuse over 96
hours: Total dose = 40 mg/m2), cyclophosphamide 750 mg/m2 IV Day 5; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21
days; COURSE: 4 to 8 cycles. Note: CSF negative patients receive methotrexate 12 mg IT Days 1 and 5 of Cycles 3, 4, 5 and 6.
NOTE : Doses listed above are for cycle 1. For subsequent cycles of doxorubicin, etoposide, and cyclophosphamide see dose
calculation instructions below. Doses are not adjusted per protocol for prednisone, rituximab and vinCRIStine.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic failure, or death. Screen
patients for HBV infection prior to rituximab treatment and consider prophylaxis against reactivation.
Dose Calculation Instructions
All patients will be started on dose level 1 for cycle 1. If ANC nadir is greater than or equal to 500/uL increase one dose level. If ANC
nadir less than 500/uL for 1 or 2 measurements maintain the same dose level. If ANC nadir less than 500/uL on at least 3
measurements decrease one dose level. OR if the platelet count is less than 25/uL on one measurement decrease one dose level
Dose Calculation Instructions (2)
DOXOrubicin dose adjustment: Dose Level (Dose): -3(10 mg/m2/day), -2(10 mg/m2/day), -1(10 mg/m2/day), 1(10
mg/m2/day), 2(12 mg/m2/day), 3(14.4 mg/m2/day), 4(17.3 mg/m2/day), 5(20.7 mg/m2/day), 6(24.8 mg/m2/day), 7(29.8
mg/m2/day)
Dose Calculation Instructions (3)
Etoposide dose adjustment: Dose Level (Dose): -3(50 mg/m2/day), -2(50 mg/m2/day), -1(50 mg/m2/day), 1(50 mg/m2/day), 2
(60 mg/m2/day), 3(72 mg/m2/day), 4(86.4 mg/m2/day), 5(103.7 mg/m2/day), 6(124.4 mg/m2/day), 7(149.3 mg/m2/day),
Dose Calculation Instructions (4)
Cyclophosphamide dose adjustment: Dose Level (Dose): -3(384 mg/m2), -2(480 mg/m2), -1(600 mg/m2), 1(750 mg/m2), 2
(900 mg/m2), 3(1080 mg/m2), 4(1296 mg/m2), 5(1555 mg/m2), 6(1866 mg/m2), 7(2239 mg/m2)
Dose Per Protocol
Dose level per protocol for current cycle: DOXOrubicin {Hit F2 to choose- DOXOrubicin Dose Level:22169}, Etoposide {Hit F2 to
choose- Etoposide Dose Level:22173}, Cyclophosphamide {Hit F2 to choose- Cyclophosphamide Dose Level:7700138}. Date of
Current Cycle *** . DO NOT PROPAGATE THIS ORDER BEYOND THE CURRENT CYCLE.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/22/2016 12:28:19 PM Page 42 of 43
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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.
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 lock flush 10 UNIT/ML 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
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
Pump Disconnection Procedures
Disconnect pump upon completion of 96-hour home infusion.
cyclophosphamide (CYTOXAN) in sodium chloride 0.9 % 250 mL bag
Intravenous, ONCE, 1 dose Starting when released
Administer on Day 5.
Cyclophosphamide dose less than 2000 mg infuse IV over 30 minutes.
Cyclophosphamide dose 2000 mg to 3999 mg infuse IV over 90 minutes.
Cyclophosphamide dose greater than 4000 mg infuse IV over 120 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:28:19 PM Page 43 of 43
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org