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201605136

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UWHC,UWMF,

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

CSC Hem Inpt Outpt R-MAXI CHOP Alternating With R-Cytarabine Ver 2-2-16 (HL 5089)

CSC Hem Inpt Outpt R-MAXI CHOP Alternating With R-Cytarabine Ver 2-2-16 (HL 5089) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Lymphoma


CSC HEM INPT/ OUTPT R-MAXI CHOP ALTERNATING WITH R-CYTARABINE VER: 2-2-16 – Properties
Part A (R-Maxi CHOP) – 2/4/2016 through 2/24/2016 (21 days), Planned
Day 1, Part A (R-Maxi CHOP) – Planned for 2/4/2016
Treatment Plan Information
Reference Information (1)
MANTLE CELL LYMPHOMA: Geisler C, et al. Blood 2008;112(7):2687-93.
Reference Information (2)
MANTLE CELL LYMPHOMA: Geisler C, et al. Br J Haematol 2012;158(3):355-62.
Treatment Plan Summary
For patients less than 60 years of age: DISEASE: Mantle Cell Lymphoma; THERAPY: (Part A - R-Maxi
CHOP) rituximab 375 mg/m2 IV Day 1, doxorubicin 75 mg/m2 IV Day 1, vinCRIStine 2 mg IV Day 1, cyclophosphamide
1200 mg/m2 IV Day 1, prednisone 100 mg by mouth Days 1, 2, 3, 4, 5; GROWTH FACTOR REQUIRED followed by
THERAPY: (Part B - R- high dose cytarabine) rituximab 375 mg/m2 IV Day 1, cytarabine 3000 mg/m2 IV every 12 hours
Days 1 and 2; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 alternating cycles (A-B-A-B-A-
B).
Dose Modifications
For patients 60 years old and greater: decrease the dose of cytarabine to 2000 mg/m2 IV every 12 hours
Days 1 and 2 in R-cytarabine cycles.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis,
hepatic failure, or death. Screen patients for HBV infection prior to rituximab treatment.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S Approximate, Expires-S+397, Routine
GLUCOSE
Expected-S Approximate, Expires-S+397, Routine
BUN
Expected-S Approximate, Expires-S+397, Routine
CREATININE
Expected-S Approximate, Expires-S+397, Routine
CALCIUM
Expected-S Approximate, Expires-S+397, Routine
ALBUMIN
Expected-S Approximate, Expires-S+397, Routine
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Zztestonc,PedsBeiber [2668824]
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Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

PROTEIN, TOTAL
Expected-S Approximate, Expires-S+397, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+397, Routine
AST/SGOT
Expected-S Approximate, Expires-S+397, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+397, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+397, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+365, Routine
URIC ACID
Expected-S Approximate, Expires-S+365, Routine
PHOSPHATE
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
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin, Alkaline Phosphatase.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 75K/µL or Total
Bilirubin greater than ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if
greater than 6 months since last dose. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Meds.
Monitoring Parameters (1)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with
rituximab.
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
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Zztestonc,PedsBeiber [2668824]
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Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 0.5 mg
0.5 mg, Oral, ONCE, 1 dose Starting when released
Premedication for chemotherapy.
prednisone (DELTASONE) tab 100 mg
100 mg, Oral, ONCE, 1 dose Starting when released
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
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Zztestonc,PedsBeiber [2668824]
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Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

rituximab (RITUXAN) 784 mg in sodium chloride 0.9 % 500 mL bag
784 mg (rounded from 783.75 mg = 375 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous,
ONCE, 1 dose Starting when released
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6
months since last dose. For first and second dose patient should be treated in a location to optimize emergency care.
See Emergency Meds. Administer rituximab prior to any chemotherapy. See Note on MAR for infusion rates. If patient
experiences fever accompanied by chills or rigors, shortness of breath, chest pain or hypotension, contact MD. Once the
patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 157 mg
157 mg (rounded from 156.75 mg = 75 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous,
ONCE, 1 dose Starting when released
IV side arm push 3-5 mL/minute into running IV.
vinCRIStine (ONCOVIN) 2 mg in sodium chloride 0.9 % 25 mL bag
2 mg, Intravenous
MUST be administered via gravity through a peripheral IV (not on an infusion pump).
cyclophosphamide (CYTOXAN) 2,508 mg bag
2,508 mg (1,200 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous
Administer over 30 minutes.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone
(Dispensed Day 1 of Cycle 1).
Take Home Medications
prednisone (DELTASONE) 50 MG tab
Take 2 tabs by mouth one time daily. Take on Day 2 through 5., 100 mg, Disp-8 tab, R-2, 1 X DAILY
starting S+1
Day 1 dose given as premedication in clinic.
ranitidine (ZANTAC) 150 MG tab
Take 1 tab by mouth 2 times daily., 150 mg, Disp-60 tab, R-5, 2 X DAILY starting S, Local Printer
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting., 8 mg, Disp-30 tab, R-5, EVERY 8
HOURS PRN starting S, Local Printer
prochlorperazine (COMPAZINE) 10 MG tab
Take 1 tab by mouth every 6 hours as needed for nausea/vomiting., 10 mg, Disp-30 tab, R-5, EVERY 6
HOURS PRN starting S, Local Printer
aprepitant (EMEND) 80 MG cap
Take 1 cap by mouth one time daily. Take Day 2 and Day 3 of each cycle following chemotherapy., 80
mg, Disp-2 cap, R-2, 1 X DAILY starting S
sulfamethoxazole-trimethoprim (BACTRIM DS) 800-160 MG per tab
Take 1 tablet by mouth twice daily on Saturday and Sunday., Disp-16 tab, R-5, starting S
acyclovir (ZOVIRAX) 400 MG tab
Take 1 tab by mouth 2 times daily., 400 mg, Disp-60 tab, R-5, 2 X DAILY starting S, Local Printer
Take Home Medications (delete all that do not apply)
TBO-filgrastim (GRANIX) 300 MCG/0.5ML soln prefilled syringe
Inject 300 mcg under skin one time daily in evening. Begin Day 2. Continue until ANC is greater than
1000/uL after nadir., 300 mcg, Disp-10 Syringe, R-0, 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 2. Continue until ANC is greater than
1000/uL after nadir, 480 mcg, Disp-10 Syringe, R-0, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
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Zztestonc,PedsBeiber [2668824]
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Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

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
levofloxacin (LEVAQUIN) 500 MG tab
Take 1 tab by mouth one time daily., 500 mg, Disp-10 tab, R-5, 1 X DAILY starting S
Begin on Day 4 of each Cycle.
fluconazole (DIFLUCAN) 200 MG tab
Take 2 tabs by mouth one time daily., 400 mg, Disp-60 tab, R-5, 1 X DAILY starting S, Local Printer
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC with DIFF
DAY 15 FOLLOW-UP
LABS: CBC with DIFF
DAY 22 FOLLOW-UP
(Day 1 of the next Cycle): Schedule preadmission to B6/6 for chemotherapy administration.
Lab Only - Day 8 , Part A (R-Maxi CHOP) – Planned for 2/11/2016
Treatment Plan Information
Treatment Plan Summary
For patients less than 60 years of age: DISEASE: Mantle Cell Lymphoma; THERAPY: (Part A - R-Maxi
CHOP) rituximab 375 mg/m2 IV Day 1, doxorubicin 75 mg/m2 IV Day 1, vinCRIStine 2 mg IV Day 1, cyclophosphamide
1200 mg/m2 IV Day 1, prednisone 100 mg by mouth Days 1, 2, 3, 4, 5; GROWTH FACTOR REQUIRED followed by
THERAPY: (Part B - R- high dose cytarabine) rituximab 375 mg/m2 IV Day 1, cytarabine 3000 mg/m2 IV every 12 hours
Days 1 and 2; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 alternating cycles (A-B-A-B-A-
B).
Dose Modifications
For patients 60 years old and greater: decrease the dose of cytarabine to 2000 mg/m2 IV every 12 hours
Days 1 and 2 in R-cytarabine cycles.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic
failure, or death. Screen patients for HBV infection prior to rituximab treatment.
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+7 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:44:06 PM Page 5 of 29
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Lab Only - Day 15, Part A (R-Maxi CHOP) – Planned for 2/18/2016
Treatment Plan Information
Treatment Plan Summary
For patients less than 60 years of age: DISEASE: Mantle Cell Lymphoma; THERAPY: (Part A - R-Maxi
CHOP) rituximab 375 mg/m2 IV Day 1, doxorubicin 75 mg/m2 IV Day 1, vinCRIStine 2 mg IV Day 1, cyclophosphamide
1200 mg/m2 IV Day 1, prednisone 100 mg by mouth Days 1, 2, 3, 4, 5; GROWTH FACTOR REQUIRED followed by
THERAPY: (Part B - R- high dose cytarabine) rituximab 375 mg/m2 IV Day 1, cytarabine 3000 mg/m2 IV every 12 hours
Days 1 and 2; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 alternating cycles (A-B-A-B-A-
B).
Dose Modifications
For patients 60 years old and greater: decrease the dose of cytarabine to 2000 mg/m2 IV every 12 hours
Days 1 and 2 in R-cytarabine cycles.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic
failure, or death. Screen patients for HBV infection prior to rituximab treatment.
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+14 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Part B (R-High Dose Cytarabine) – 2/25/2016 through 3/16/2016 (21 days), Planned
Day 1 (Inpatient) , Part B (R-High Dose Cytarabine) – Planned for 2/25/2016
Treatment Plan Information
Treatment Plan Summary
For patients less than 60 years of age: DISEASE: Mantle Cell Lymphoma; THERAPY: (Part A - R-Maxi
CHOP) rituximab 375 mg/m2 IV Day 1, doxorubicin 75 mg/m2 IV Day 1, vinCRIStine 2 mg IV Day 1, cyclophosphamide
1200 mg/m2 IV Day 1, prednisone 100 mg by mouth Days 1, 2, 3, 4, 5; GROWTH FACTOR REQUIRED followed by
THERAPY: (Part B - R- high dose cytarabine) rituximab 375 mg/m2 IV Day 1, cytarabine 3000 mg/m2 IV every 12 hours
Days 1 and 2; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 alternating cycles (A-B-A-B-A-
B).
Dose Modifications
For patients 60 years old and greater: decrease the dose of cytarabine to 2000 mg/m2 IV every 12 hours
Days 1 and 2 in R-cytarabine cycles.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic
failure, or death. Screen patients for HBV infection prior to rituximab treatment.
Consent
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Zztestonc,PedsBeiber [2668824]
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Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
ONCE Starting when released, Routine
ELECTROLYTES
ONCE Starting when released
GLUCOSE
ONCE Starting when released
BUN
ONCE Starting when released
CREATININE
ONCE Starting when released, Routine
CALCIUM
ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALT/SGPT
ONCE Starting when released
ALKALINE PHOSPHATASE
ONCE Starting when released, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, AST, ALT, Alkaline
Phosphatase, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 75K/µL or
Creatinine Clearance less than 60 mL/min or Total Bilirubin greater than 2 mg/dL or AST greater than or equal to 2.5 X
ULN or ALT greater than or equal to 2.5 X ULN or Alkaline Phosphatase greater than 3 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if
greater than 6 months since last dose. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Meds.
Monitoring Parameters (1)
Assess patient for signs of cerebellar toxicity (incoordination, slurred speech) with neurochecks prior to
each dose of cytarabine. Hold and notify MD for any concerns of toxicity.
Monitoring Parameters (2)
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,PedsBeiber [2668824]
2/4/2016 12:44:06 PM Page 7 of 29
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, EVERY 24 HOURS, 2 doses Starting when released
Day 1 and Day 2: Administer 30 minutes prior to chemotherapy. If unable to tolerate PO may give IV.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, nausea/vomiting
Day 1 and Day 2: Administer 30 minutes prior to chemotherapy. Administer if unable to tolerate oral tablets.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, EVERY 24 HOURS, 2 doses Starting when released
Day 1 and Day 2: Administer 30 minutes prior to chemotherapy. If unable to tolerate PO may give IV.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, EVERY 24 HOURS PRN, 2 doses Starting when released, nausea/vomiting
Day 1 and Day 2: Administer 30 minutes prior to chemotherapy. Administer if unable to tolerate oral tablets.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
pyridoxine (VITAMIN B-6) tab 100 mg
100 mg, Oral, EVERY 12 HOURS, 4 doses Starting when released
Day 1 to 2: Administer prior to each dose of cytarabine.
prednisolone (PRED FORTE) 1 % ophthalmic susp 1 drop
1 drop, Eyes (Each), 4 X DAILY, 8 doses Starting when released
Give prior to cytarabine. May use patient's own supply.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:44:06 PM Page 8 of 29
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
rituximab (RITUXAN) 784 mg in sodium chloride 0.9 % 500 mL bag
784 mg (rounded from 783.75 mg = 375 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous,
ONCE, 1 dose Starting when released
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6
months since last dose. For first and second dose patient should be treated in a location to optimize emergency care.
See Emergency Meds. Administer rituximab prior to any chemotherapy. See Note on MAR for infusion rates. If patient
experiences fever accompanied by chills or rigors, shortness of breath, chest pain or hypotension, contact MD. Once the
patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
cytarabine PF (CYTOSAR) in sodium chloride 0.9 % 250 mL bag
Intravenous
For patients less than 60 years of age, administer 3000 mg/m2. For patients 60 years old and greater, administer 2000
mg/m2. Administer over 180 minutes. Neurology checks prior to each cytarabine dose.
Supportive Care Medications
fluconazole (DIFLUCAN) tab 400 mg
400 mg, Oral, 1 X DAILY, 2 doses Starting when released
acyclovir (ZOVIRAX) tab 400 mg
400 mg, Oral, 2 X DAILY, 4 doses Starting when released
sulfamethoxazole-trimethoprim (BACTRIM DS) 800-160 MG per tab 1 tab
1 tab, Oral, 2 X DAILY, 4 doses Starting when released
ranitidine (ZANTAC) tab 150 mg
150 mg, Oral, 2 X DAILY, 4 doses Starting when released
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 3. Continue until ANC is greater than
1000/uL after nadir., 300 mcg, Disp-10 Syringe, R-0, 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 3. Continue until ANC is greater than
1000/uL after nadir, 480 mcg, Disp-10 Syringe, R-0, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
levofloxacin (LEVAQUIN) 500 MG tab
Take 1 tab by mouth one time daily., 500 mg, Disp-10 tab, R-5, 1 X DAILY starting S
Follow-Up
MULTIPLE DAY FOLLOW-UP (1)
INTERIM LAB APPOINTMENTS: CBC with DIFF every Monday and Thursday starting ***.
DAY 8 FOLLOW-UP
LABS: CBC with DIFF.
DAY 15 FOLLOW-UP
LABS: CBC with DIFF.
DAY 22 FOLLOW-UP
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:44:06 PM Page 9 of 29
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose,
BUN, Creatinine, Calcium, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: rituximab, cyclophosphamide,
doxorubicin, vinCRIStine for 180 minutes.
Lab Only - Day 8, Part B (R-High Dose Cytarabine) – Planned for 3/3/2016
Treatment Plan Information
Treatment Plan Summary
For patients less than 60 years of age: DISEASE: Mantle Cell Lymphoma; THERAPY: (Part A - R-Maxi
CHOP) rituximab 375 mg/m2 IV Day 1, doxorubicin 75 mg/m2 IV Day 1, vinCRIStine 2 mg IV Day 1, cyclophosphamide
1200 mg/m2 IV Day 1, prednisone 100 mg by mouth Days 1, 2, 3, 4, 5; GROWTH FACTOR REQUIRED followed by
THERAPY: (Part B - R- high dose cytarabine) rituximab 375 mg/m2 IV Day 1, cytarabine 3000 mg/m2 IV every 12 hours
Days 1 and 2; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 alternating cycles (A-B-A-B-A-
B).
Dose Modifications
For patients 60 years old and greater: decrease the dose of cytarabine to 2000 mg/m2 IV every 12 hours
Days 1 and 2 in R-cytarabine cycles.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic
failure, or death. Screen patients for HBV infection prior to rituximab treatment.
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+4 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Part B (R-High Dose Cytarabine) – Planned for 3/10/2016
Treatment Plan Information
Treatment Plan Summary
For patients less than 60 years of age: DISEASE: Mantle Cell Lymphoma; THERAPY: (Part A - R-Maxi
CHOP) rituximab 375 mg/m2 IV Day 1, doxorubicin 75 mg/m2 IV Day 1, vinCRIStine 2 mg IV Day 1, cyclophosphamide
1200 mg/m2 IV Day 1, prednisone 100 mg by mouth Days 1, 2, 3, 4, 5; GROWTH FACTOR REQUIRED followed by
THERAPY: (Part B - R- high dose cytarabine) rituximab 375 mg/m2 IV Day 1, cytarabine 3000 mg/m2 IV every 12 hours
Days 1 and 2; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 alternating cycles (A-B-A-B-A-
B).
Dose Modifications
For patients 60 years old and greater: decrease the dose of cytarabine to 2000 mg/m2 IV every 12 hours
Days 1 and 2 in R-cytarabine cycles.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic
failure, or death. Screen patients for HBV infection prior to rituximab treatment.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:44:06 PM Page 10 of 29
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+13 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Part A (R-Maxi CHOP) – 3/17/2016 through 4/6/2016 (21 days), Planned
Day 1, Part A (R-Maxi CHOP) – Planned for 3/17/2016
Treatment Plan Information
Treatment Plan Summary
For patients less than 60 years of age: DISEASE: Mantle Cell Lymphoma; THERAPY: (Part A - R-Maxi
CHOP) rituximab 375 mg/m2 IV Day 1, doxorubicin 75 mg/m2 IV Day 1, vinCRIStine 2 mg IV Day 1, cyclophosphamide
1200 mg/m2 IV Day 1, prednisone 100 mg by mouth Days 1, 2, 3, 4, 5; GROWTH FACTOR REQUIRED followed by
THERAPY: (Part B - R- high dose cytarabine) rituximab 375 mg/m2 IV Day 1, cytarabine 3000 mg/m2 IV every 12 hours
Days 1 and 2; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 alternating cycles (A-B-A-B-A-
B).
Dose Modifications
For patients 60 years old and greater: decrease the dose of cytarabine to 2000 mg/m2 IV every 12 hours
Days 1 and 2 in R-cytarabine cycles.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic
failure, or death. Screen patients for HBV infection prior to rituximab treatment.
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+20 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+20 Approximate, Expires-S+365, Routine
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Zztestonc,PedsBeiber [2668824]
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

GLUCOSE
Expected-S+20 Approximate, Expires-S+365, Routine
BUN
Expected-S+20 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+20 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+20 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+20 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 75K/µL or Total
Bilirubin greater than ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if
greater than 6 months since last dose. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Meds.
Monitoring Parameters (1)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with
rituximab.
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 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:44:06 PM Page 12 of 29
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Infuse 1000 mL throughout treatment.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 0.5 mg
0.5 mg, Oral, ONCE, 1 dose Starting when released
Premedication for chemotherapy.
prednisone (DELTASONE) tab 100 mg
100 mg, Oral, ONCE, 1 dose Starting when released
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
rituximab (RITUXAN) 784 mg in sodium chloride 0.9 % 500 mL bag
784 mg (rounded from 783.75 mg = 375 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous,
ONCE, 1 dose Starting when released
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6
months since last dose. For first and second dose patient should be treated in a location to optimize emergency care.
See Emergency Meds. Administer rituximab prior to any chemotherapy. See Note on MAR for infusion rates. If patient
experiences fever accompanied by chills or rigors, shortness of breath, chest pain or hypotension, contact MD. Once the
patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 157 mg
157 mg (rounded from 156.75 mg = 75 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous,
ONCE, 1 dose Starting when released
IV side arm push 3-5 mL/minute into running IV.
vinCRIStine (ONCOVIN) 2 mg in sodium chloride 0.9 % 25 mL bag
2 mg, Intravenous
MUST be administered via gravity through a peripheral IV (not on an infusion pump).
cyclophosphamide (CYTOXAN) 2,508 mg bag
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Zztestonc,PedsBeiber [2668824]
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Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

2,508 mg (1,200 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous
Administer over 30 minutes.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone
(Dispensed Day 1 of Cycle 1).
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 2. Continue until ANC is greater than
1000/uL after nadir., 300 mcg, Disp-10 Syringe, R-0, 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 2. Continue until ANC is greater than
1000/uL after nadir, 480 mcg, Disp-10 Syringe, R-0, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC with DIFF
DAY 15 FOLLOW-UP
LABS: CBC with DIFF
DAY 22 FOLLOW-UP
(Day 1 of the next Cycle): Schedule preadmission to B6/6 for chemotherapy administration.
Lab Only - Day 8, Part A (R-Maxi CHOP) – Planned for 3/24/2016
Treatment Plan Information
Treatment Plan Summary
For patients less than 60 years of age: DISEASE: Mantle Cell Lymphoma; THERAPY: (Part A - R-Maxi
CHOP) rituximab 375 mg/m2 IV Day 1, doxorubicin 75 mg/m2 IV Day 1, vinCRIStine 2 mg IV Day 1, cyclophosphamide
1200 mg/m2 IV Day 1, prednisone 100 mg by mouth Days 1, 2, 3, 4, 5; GROWTH FACTOR REQUIRED followed by
THERAPY: (Part B - R- high dose cytarabine) rituximab 375 mg/m2 IV Day 1, cytarabine 3000 mg/m2 IV every 12 hours
Days 1 and 2; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 alternating cycles (A-B-A-B-A-
B).
Dose Modifications
For patients 60 years old and greater: decrease the dose of cytarabine to 2000 mg/m2 IV every 12 hours
Days 1 and 2 in R-cytarabine cycles.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic
failure, or death. Screen patients for HBV infection prior to rituximab treatment.
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+7 Approximate, Expires-S+365, Routine
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:44:06 PM Page 14 of 29
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Part A (R-Maxi CHOP) – Planned for 3/31/2016
Treatment Plan Information
Treatment Plan Summary
For patients less than 60 years of age: DISEASE: Mantle Cell Lymphoma; THERAPY: (Part A - R-Maxi
CHOP) rituximab 375 mg/m2 IV Day 1, doxorubicin 75 mg/m2 IV Day 1, vinCRIStine 2 mg IV Day 1, cyclophosphamide
1200 mg/m2 IV Day 1, prednisone 100 mg by mouth Days 1, 2, 3, 4, 5; GROWTH FACTOR REQUIRED followed by
THERAPY: (Part B - R- high dose cytarabine) rituximab 375 mg/m2 IV Day 1, cytarabine 3000 mg/m2 IV every 12 hours
Days 1 and 2; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 alternating cycles (A-B-A-B-A-
B).
Dose Modifications
For patients 60 years old and greater: decrease the dose of cytarabine to 2000 mg/m2 IV every 12 hours
Days 1 and 2 in R-cytarabine cycles.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic
failure, or death. Screen patients for HBV infection prior to rituximab treatment.
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+14 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Part B (R-High Dose Cytarabine) – 4/7/2016 through 4/27/2016 (21 days), Planned
Day 1 (Inpatient) , Part B (R-High Dose Cytarabine) – Planned for 4/7/2016
Treatment Plan Information
Treatment Plan Summary
For patients less than 60 years of age: DISEASE: Mantle Cell Lymphoma; THERAPY: (Part A - R-Maxi
CHOP) rituximab 375 mg/m2 IV Day 1, doxorubicin 75 mg/m2 IV Day 1, vinCRIStine 2 mg IV Day 1, cyclophosphamide
1200 mg/m2 IV Day 1, prednisone 100 mg by mouth Days 1, 2, 3, 4, 5; GROWTH FACTOR REQUIRED followed by
THERAPY: (Part B - R- high dose cytarabine) rituximab 375 mg/m2 IV Day 1, cytarabine 3000 mg/m2 IV every 12 hours
Days 1 and 2; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 alternating cycles (A-B-A-B-A-
B).
Dose Modifications
For patients 60 years old and greater: decrease the dose of cytarabine to 2000 mg/m2 IV every 12 hours
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:44:06 PM Page 15 of 29
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Days 1 and 2 in R-cytarabine cycles.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic
failure, or death. Screen patients for HBV infection prior to rituximab treatment.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
ONCE Starting when released, Routine
ELECTROLYTES
ONCE Starting when released
GLUCOSE
ONCE Starting when released
BUN
ONCE Starting when released
CREATININE
ONCE Starting when released, Routine
CALCIUM
ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALT/SGPT
ONCE Starting when released
ALKALINE PHOSPHATASE
ONCE Starting when released, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, AST, ALT, Alkaline
Phosphatase, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 75K/µL or
Creatinine Clearance less than 60 mL/min or Total Bilirubin greater than 2 mg/dL or AST greater than or equal to 2.5 X
ULN or ALT greater than or equal to 2.5 X ULN or Alkaline Phosphatase greater than 3 X ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if
greater than 6 months since last dose. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Meds.
Monitoring Parameters (1)
Assess patient for signs of cerebellar toxicity (incoordination, slurred speech) with neurochecks prior to
each dose of cytarabine. Hold and notify MD for any concerns of toxicity.
Monitoring Parameters (2)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with
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Zztestonc,PedsBeiber [2668824]
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

rituximab.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Vital Signs every 15 minutes for the first 60 minutes and then every 30 minutes until rituximab infusion complete.
If patient experiences fever accompanied by chills or rigors, shortness of breath, chest pain, or hypotension, stop infusion
and contact MD. Once the patient returns to baseline, infusion may be restarted at half the rate during which the reaction
occurred.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, EVERY 24 HOURS, 2 doses Starting when released
Day 1 and Day 2: Administer 30 minutes prior to chemotherapy. If unable to tolerate PO may give IV.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, nausea/vomiting
Day 1 and Day 2: Administer 30 minutes prior to chemotherapy. Administer if unable to tolerate oral tablets.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, EVERY 24 HOURS, 2 doses Starting when released
Day 1 and Day 2: Administer 30 minutes prior to chemotherapy. If unable to tolerate PO may give IV.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, EVERY 24 HOURS PRN, 2 doses Starting when released, nausea/vomiting
Day 1 and Day 2: Administer 30 minutes prior to chemotherapy. Administer if unable to tolerate oral tablets.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
pyridoxine (VITAMIN B-6) tab 100 mg
100 mg, Oral, EVERY 12 HOURS, 4 doses Starting when released
Day 1 to 2: Administer prior to each dose of cytarabine.
prednisolone (PRED FORTE) 1 % ophthalmic susp 1 drop
1 drop, Eyes (Each), 4 X DAILY, 8 doses Starting when released
Give prior to cytarabine. May use patient's own supply.
Emergency Medications
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:44:06 PM Page 17 of 29
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
rituximab (RITUXAN) 784 mg in sodium chloride 0.9 % 500 mL bag
784 mg (rounded from 783.75 mg = 375 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous,
ONCE, 1 dose Starting when released
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6
months since last dose. For first and second dose patient should be treated in a location to optimize emergency care.
See Emergency Meds. Administer rituximab prior to any chemotherapy. See Note on MAR for infusion rates. If patient
experiences fever accompanied by chills or rigors, shortness of breath, chest pain or hypotension, contact MD. Once the
patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
cytarabine PF (CYTOSAR) in sodium chloride 0.9 % 250 mL bag
Intravenous
For patients less than 60 years of age, administer 3000 mg/m2. For patients 60 years old and greater, administer 2000
mg/m2. Administer over 180 minutes. Neurology checks prior to each cytarabine dose.
Supportive Care Medications
fluconazole (DIFLUCAN) tab 400 mg
400 mg, Oral, 1 X DAILY, 2 doses Starting when released
acyclovir (ZOVIRAX) tab 400 mg
400 mg, Oral, 2 X DAILY, 4 doses Starting when released
sulfamethoxazole-trimethoprim (BACTRIM DS) 800-160 MG per tab 1 tab
1 tab, Oral, 2 X DAILY, 4 doses Starting when released
ranitidine (ZANTAC) tab 150 mg
150 mg, Oral, 2 X DAILY, 4 doses Starting when released
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 3. Continue until ANC is greater than
1000/uL after nadir., 300 mcg, Disp-10 Syringe, R-0, 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 3. Continue until ANC is greater than
1000/uL after nadir, 480 mcg, Disp-10 Syringe, R-0, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
levofloxacin (LEVAQUIN) 500 MG tab
Take 1 tab by mouth one time daily., 500 mg, Disp-10 tab, R-5, 1 X DAILY starting S
Follow-Up
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:44:06 PM Page 18 of 29
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

MULTIPLE DAY FOLLOW-UP (1)
INTERIM LAB APPOINTMENTS: CBC with DIFF every Monday and Thursday starting ***.
DAY 8 FOLLOW-UP
LABS: CBC with DIFF.
DAY 15 FOLLOW-UP
LABS: CBC with DIFF.
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF,
Electrolytes, Glucose, BUN, Creatinine, Calcium, Total Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: rituximab,
cyclophosphamide, doxorubicin, vinCRIStine for 180 minutes.
Lab Only - Day 8, Part B (R-High Dose Cytarabine) – Planned for 4/14/2016
Treatment Plan Information
Treatment Plan Summary
For patients less than 60 years of age: DISEASE: Mantle Cell Lymphoma; THERAPY: (Part A - R-Maxi
CHOP) rituximab 375 mg/m2 IV Day 1, doxorubicin 75 mg/m2 IV Day 1, vinCRIStine 2 mg IV Day 1, cyclophosphamide
1200 mg/m2 IV Day 1, prednisone 100 mg by mouth Days 1, 2, 3, 4, 5; GROWTH FACTOR REQUIRED followed by
THERAPY: (Part B - R- high dose cytarabine) rituximab 375 mg/m2 IV Day 1, cytarabine 3000 mg/m2 IV every 12 hours
Days 1 and 2; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 alternating cycles (A-B-A-B-A-
B).
Dose Modifications
For patients 60 years old and greater: decrease the dose of cytarabine to 2000 mg/m2 IV every 12 hours
Days 1 and 2 in R-cytarabine cycles.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic
failure, or death. Screen patients for HBV infection prior to rituximab treatment.
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+7 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Part B (R-High Dose Cytarabine) – Planned for 4/21/2016
Treatment Plan Information
Treatment Plan Summary
For patients less than 60 years of age: DISEASE: Mantle Cell Lymphoma; THERAPY: (Part A - R-Maxi
CHOP) rituximab 375 mg/m2 IV Day 1, doxorubicin 75 mg/m2 IV Day 1, vinCRIStine 2 mg IV Day 1, cyclophosphamide
1200 mg/m2 IV Day 1, prednisone 100 mg by mouth Days 1, 2, 3, 4, 5; GROWTH FACTOR REQUIRED followed by
THERAPY: (Part B - R- high dose cytarabine) rituximab 375 mg/m2 IV Day 1, cytarabine 3000 mg/m2 IV every 12 hours
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:44:06 PM Page 19 of 29
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Days 1 and 2; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 alternating cycles (A-B-A-B-A-
B).
Dose Modifications
For patients 60 years old and greater: decrease the dose of cytarabine to 2000 mg/m2 IV every 12 hours
Days 1 and 2 in R-cytarabine cycles.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic
failure, or death. Screen patients for HBV infection prior to rituximab treatment.
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+13 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Part A (R-Maxi CHOP) – 4/28/2016 through 5/18/2016 (21 days), Planned
Day 1, Part A (R-Maxi CHOP) – Planned for 4/28/2016
Treatment Plan Information
Treatment Plan Summary
For patients less than 60 years of age: DISEASE: Mantle Cell Lymphoma; THERAPY: (Part A - R-Maxi
CHOP) rituximab 375 mg/m2 IV Day 1, doxorubicin 75 mg/m2 IV Day 1, vinCRIStine 2 mg IV Day 1, cyclophosphamide
1200 mg/m2 IV Day 1, prednisone 100 mg by mouth Days 1, 2, 3, 4, 5; GROWTH FACTOR REQUIRED followed by
THERAPY: (Part B - R- high dose cytarabine) rituximab 375 mg/m2 IV Day 1, cytarabine 3000 mg/m2 IV every 12 hours
Days 1 and 2; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 alternating cycles (A-B-A-B-A-
B).
Dose Modifications
For patients 60 years old and greater: decrease the dose of cytarabine to 2000 mg/m2 IV every 12 hours
Days 1 and 2 in R-cytarabine cycles.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic
failure, or death. Screen patients for HBV infection prior to rituximab treatment.
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
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:44:06 PM Page 20 of 29
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+20 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+20 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+20 Approximate, Expires-S+365, Routine
BUN
Expected-S+20 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+20 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+20 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+20 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 75K/µL or Total
Bilirubin greater than ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if
greater than 6 months since last dose. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Meds.
Monitoring Parameters (1)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with
rituximab.
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 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:44:06 PM Page 21 of 29
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
dexamethasone (DECADRON) tab 0.5 mg
0.5 mg, Oral, ONCE, 1 dose Starting when released
Premedication for chemotherapy.
prednisone (DELTASONE) tab 100 mg
100 mg, Oral, ONCE, 1 dose Starting when released
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to rituximab.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
rituximab (RITUXAN) 784 mg in sodium chloride 0.9 % 500 mL bag
784 mg (rounded from 783.75 mg = 375 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous,
ONCE, 1 dose Starting when released
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6
months since last dose. For first and second dose patient should be treated in a location to optimize emergency care.
See Emergency Meds. Administer rituximab prior to any chemotherapy. See Note on MAR for infusion rates. If patient
experiences fever accompanied by chills or rigors, shortness of breath, chest pain or hypotension, contact MD. Once the
patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:44:06 PM Page 22 of 29
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 157 mg
157 mg (rounded from 156.75 mg = 75 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous,
ONCE, 1 dose Starting when released
IV side arm push 3-5 mL/minute into running IV.
vinCRIStine (ONCOVIN) 2 mg in sodium chloride 0.9 % 25 mL bag
2 mg, Intravenous
MUST be administered via gravity through a peripheral IV (not on an infusion pump).
cyclophosphamide (CYTOXAN) 2,508 mg bag
2,508 mg (1,200 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous
Administer over 30 minutes.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): prednisone
(Dispensed Day 1 of Cycle 1).
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 2. Continue until ANC is greater than
1000/uL after nadir., 300 mcg, Disp-10 Syringe, R-0, 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 2. Continue until ANC is greater than
1000/uL after nadir, 480 mcg, Disp-10 Syringe, R-0, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC with DIFF
DAY 15 FOLLOW-UP
LABS: CBC with DIFF
DAY 22 FOLLOW-UP
(Day 1 of the next Cycle): Schedule preadmission to B6/6 for chemotherapy administration.
Lab Only - Day 8 , Part A (R-Maxi CHOP) – Planned for 5/5/2016
Treatment Plan Information
Treatment Plan Summary
For patients less than 60 years of age: DISEASE: Mantle Cell Lymphoma; THERAPY: (Part A - R-Maxi
CHOP) rituximab 375 mg/m2 IV Day 1, doxorubicin 75 mg/m2 IV Day 1, vinCRIStine 2 mg IV Day 1, cyclophosphamide
1200 mg/m2 IV Day 1, prednisone 100 mg by mouth Days 1, 2, 3, 4, 5; GROWTH FACTOR REQUIRED followed by
THERAPY: (Part B - R- high dose cytarabine) rituximab 375 mg/m2 IV Day 1, cytarabine 3000 mg/m2 IV every 12 hours
Days 1 and 2; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 alternating cycles (A-B-A-B-A-
B).
Dose Modifications
For patients 60 years old and greater: decrease the dose of cytarabine to 2000 mg/m2 IV every 12 hours
Days 1 and 2 in R-cytarabine cycles.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic
failure, or death. Screen patients for HBV infection prior to rituximab treatment.
IV Access
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:44:06 PM Page 23 of 29
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

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+7 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Part A (R-Maxi CHOP) – Planned for 5/12/2016
Treatment Plan Information
Treatment Plan Summary
For patients less than 60 years of age: DISEASE: Mantle Cell Lymphoma; THERAPY: (Part A - R-Maxi
CHOP) rituximab 375 mg/m2 IV Day 1, doxorubicin 75 mg/m2 IV Day 1, vinCRIStine 2 mg IV Day 1, cyclophosphamide
1200 mg/m2 IV Day 1, prednisone 100 mg by mouth Days 1, 2, 3, 4, 5; GROWTH FACTOR REQUIRED followed by
THERAPY: (Part B - R- high dose cytarabine) rituximab 375 mg/m2 IV Day 1, cytarabine 3000 mg/m2 IV every 12 hours
Days 1 and 2; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 alternating cycles (A-B-A-B-A-
B).
Dose Modifications
For patients 60 years old and greater: decrease the dose of cytarabine to 2000 mg/m2 IV every 12 hours
Days 1 and 2 in R-cytarabine cycles.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic
failure, or death. Screen patients for HBV infection prior to rituximab treatment.
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+14 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Part B (R-High Dose Cytarabine) – 5/19/2016 through 6/8/2016 (21 days), Planned
Day 1 (Inpatient) , Part B (R-High Dose Cytarabine) – Planned for 5/19/2016
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:44:06 PM Page 24 of 29
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
For patients less than 60 years of age: DISEASE: Mantle Cell Lymphoma; THERAPY: (Part A - R-Maxi
CHOP) rituximab 375 mg/m2 IV Day 1, doxorubicin 75 mg/m2 IV Day 1, vinCRIStine 2 mg IV Day 1, cyclophosphamide
1200 mg/m2 IV Day 1, prednisone 100 mg by mouth Days 1, 2, 3, 4, 5; GROWTH FACTOR REQUIRED followed by
THERAPY: (Part B - R- high dose cytarabine) rituximab 375 mg/m2 IV Day 1, cytarabine 3000 mg/m2 IV every 12 hours
Days 1 and 2; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 alternating cycles (A-B-A-B-A-
B).
Dose Modifications
For patients 60 years old and greater: decrease the dose of cytarabine to 2000 mg/m2 IV every 12 hours
Days 1 and 2 in R-cytarabine cycles.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic
failure, or death. Screen patients for HBV infection prior to rituximab treatment.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
ONCE Starting when released, Routine
ELECTROLYTES
ONCE Starting when released
GLUCOSE
ONCE Starting when released
BUN
ONCE Starting when released
CREATININE
ONCE Starting when released, Routine
CALCIUM
ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALT/SGPT
ONCE Starting when released
ALKALINE PHOSPHATASE
ONCE Starting when released, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, AST, ALT, Alkaline
Phosphatase, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 75K/µL or
Creatinine Clearance less than 60 mL/min or Total Bilirubin greater than 2 mg/dL or AST greater than or equal to 2.5 X
ULN or ALT greater than or equal to 2.5 X ULN or Alkaline Phosphatase greater than 3 X ULN.
Nursing Procedure, Assessment and Monitoring
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:44:06 PM Page 25 of 29
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

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)
Assess patient for signs of cerebellar toxicity (incoordination, slurred speech) with neurochecks prior to
each dose of cytarabine. Hold and notify MD for any concerns of toxicity.
Monitoring Parameters (2)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with
rituximab.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Vital Signs every 15 minutes for the first 60 minutes and then every 30 minutes until rituximab infusion complete.
If patient experiences fever accompanied by chills or rigors, shortness of breath, chest pain, or hypotension, stop infusion
and contact MD. Once the patient returns to baseline, infusion may be restarted at half the rate during which the reaction
occurred.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, EVERY 24 HOURS, 2 doses Starting when released
Day 1 and Day 2: Administer 30 minutes prior to chemotherapy. If unable to tolerate PO may give IV.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, nausea/vomiting
Day 1 and Day 2: Administer 30 minutes prior to chemotherapy. Administer if unable to tolerate oral tablets.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, EVERY 24 HOURS, 2 doses Starting when released
Day 1 and Day 2: Administer 30 minutes prior to chemotherapy. If unable to tolerate PO may give IV.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, EVERY 24 HOURS PRN, 2 doses Starting when released, nausea/vomiting
Day 1 and Day 2: Administer 30 minutes prior to chemotherapy. Administer if unable to tolerate oral tablets.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
diphenhydramine (BENADRYL) cap 25 mg
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:44:06 PM Page 26 of 29
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

25 mg, Oral, ONCE, 1 dose Starting when released
Administer prior to chemotherapy.
pyridoxine (VITAMIN B-6) tab 100 mg
100 mg, Oral, EVERY 12 HOURS, 4 doses Starting when released
Day 1 to 2: Administer prior to each dose of cytarabine.
prednisolone (PRED FORTE) 1 % ophthalmic susp 1 drop
1 drop, Eyes (Each), 4 X DAILY, 8 doses Starting when released
Give prior to cytarabine. May use patient's own supply.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
rituximab (RITUXAN) 784 mg in sodium chloride 0.9 % 500 mL bag
784 mg (rounded from 783.75 mg = 375 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous,
ONCE, 1 dose Starting when released
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose or if greater than 6
months since last dose. For first and second dose patient should be treated in a location to optimize emergency care.
See Emergency Meds. Administer rituximab prior to any chemotherapy. See Note on MAR for infusion rates. If patient
experiences fever accompanied by chills or rigors, shortness of breath, chest pain or hypotension, contact MD. Once the
patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.
cytarabine PF (CYTOSAR) in sodium chloride 0.9 % 250 mL bag
Intravenous
For patients less than 60 years of age, administer 3000 mg/m2. For patients 60 years old and greater, administer 2000
mg/m2. Administer over 180 minutes. Neurology checks prior to each cytarabine dose.
Supportive Care Medications
fluconazole (DIFLUCAN) tab 400 mg
400 mg, Oral, 1 X DAILY, 2 doses Starting when released
acyclovir (ZOVIRAX) tab 400 mg
400 mg, Oral, 2 X DAILY, 4 doses Starting when released
sulfamethoxazole-trimethoprim (BACTRIM DS) 800-160 MG per tab 1 tab
1 tab, Oral, 2 X DAILY, 4 doses Starting when released
ranitidine (ZANTAC) tab 150 mg
150 mg, Oral, 2 X DAILY, 4 doses Starting when released
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 3. Continue until ANC is greater than
1000/uL after nadir., 300 mcg, Disp-10 Syringe, R-0, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:44:06 PM Page 27 of 29
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

TBO-filgrastim (GRANIX) 480 MCG/0.8ML soln prefilled syringe
Inject 480 mcg under skin one time daily in evening. Begin Day 3. Continue until ANC is greater than
1000/uL after nadir, 480 mcg, Disp-10 Syringe, R-0, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
levofloxacin (LEVAQUIN) 500 MG tab
Take 1 tab by mouth one time daily., 500 mg, Disp-10 tab, R-5, 1 X DAILY starting S
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC with DIFF.
DAY 15 FOLLOW-UP
LABS: CBC with DIFF.
DAY 22 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose, BUN,
Creatinine, Calcium, Total Bilirubin.
Lab Only - Day 8, Part B (R-High Dose Cytarabine) – Planned for 5/26/2016
Treatment Plan Information
Treatment Plan Summary
For patients less than 60 years of age: DISEASE: Mantle Cell Lymphoma; THERAPY: (Part A - R-Maxi
CHOP) rituximab 375 mg/m2 IV Day 1, doxorubicin 75 mg/m2 IV Day 1, vinCRIStine 2 mg IV Day 1, cyclophosphamide
1200 mg/m2 IV Day 1, prednisone 100 mg by mouth Days 1, 2, 3, 4, 5; GROWTH FACTOR REQUIRED followed by
THERAPY: (Part B - R- high dose cytarabine) rituximab 375 mg/m2 IV Day 1, cytarabine 3000 mg/m2 IV every 12 hours
Days 1 and 2; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 alternating cycles (A-B-A-B-A-
B).
Dose Modifications
For patients 60 years old and greater: decrease the dose of cytarabine to 2000 mg/m2 IV every 12 hours
Days 1 and 2 in R-cytarabine cycles.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic
failure, or death. Screen patients for HBV infection prior to rituximab treatment.
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+4 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org

Lab Only - Day 15, Part B (R-High Dose Cytarabine) – Planned for 6/2/2016
Treatment Plan Information
Treatment Plan Summary
For patients less than 60 years of age: DISEASE: Mantle Cell Lymphoma; THERAPY: (Part A - R-Maxi
CHOP) rituximab 375 mg/m2 IV Day 1, doxorubicin 75 mg/m2 IV Day 1, vinCRIStine 2 mg IV Day 1, cyclophosphamide
1200 mg/m2 IV Day 1, prednisone 100 mg by mouth Days 1, 2, 3, 4, 5; GROWTH FACTOR REQUIRED followed by
THERAPY: (Part B - R- high dose cytarabine) rituximab 375 mg/m2 IV Day 1, cytarabine 3000 mg/m2 IV every 12 hours
Days 1 and 2; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 alternating cycles (A-B-A-B-A-
B).
Dose Modifications
For patients 60 years old and greater: decrease the dose of cytarabine to 2000 mg/m2 IV every 12 hours
Days 1 and 2 in R-cytarabine cycles.
Note to All Staff (1)
Reactivation of hepatitis B virus (HBV) may occur and in some cases result in fulminant hepatitis, hepatic
failure, or death. Screen patients for HBV infection prior to rituximab treatment.
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+13 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 12:44:06 PM Page 29 of 29
Copyright © 201�University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2016Lee Vermeulen, CCKM@uwhealth.org