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

CSC Hem PCNSL Inpt Consolidation Cytarabine(4D1-4) Etoposide(4D1-4) Ver 2-2-16 (HL 5331)

CSC Hem PCNSL Inpt Consolidation Cytarabine(4D1-4) Etoposide(4D1-4) Ver 2-2-16 (HL 5331) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Lymphoma


CSC HEM PCNSL INPT CONSOLIDATION CYTARABINE(4D:1-4)/ETOPOSIDE(4D:1-4) VER: 2-2-16 – Properties
Cycle 1 – 2/4/2016, Planned
Day 1 through 4 (Inpatient) , Cycle 1 – Planned for 2/4/2016
Treatment Plan Information
Reference Information (1)
PRIMARY CNS LYMPHOMA: Rubenstein JL, et al. J Clin Onc 2013;31(25):3061-68.
Treatment Plan Summary
DISEASE: Primary CNS Lymphoma; THERAPY (CONSOLIDATION): cytarabine 2,000 mg/m2 IV every
12 hours Days 1 through 4 for 8 doses (total 16,000 mg/m2) , etoposide 5 mg/kg IV every 12 hours Days 1 through 4 for
8 doses (total 40 mg/kg IV continuous over 96 hours); GROWTH FACTOR REQUIRED; CYCLE LENGTH: 4 days;
COURSE: 1 Cycle.
Dose Calculation Instructions
For both cytarabine and etoposide:
If actual weight is less than ideal weight, use actual body weight.
If actual weight is between 100% and 150% of ideal weight, dose should be based on corrected weight, calculated as
ideal body weight +25% of the difference between actual and ideal body weight.
If the patient's actual weight is greater than 150% of ideal, then the corrected weight is ideal body weight x 1.125
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
CALCIUM
ONCE Starting when released
BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALBUMIN
ONCE Starting when released
Pre-Labs (delete all that do not apply)
HCG, QUANTITATIVE
ONCE Starting when released, Routine
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Zztestonc,PedsBeiber [2668824]
2/4/2016 1:12:33 PM Page 1 of 4
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 Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC, Platelets, Creatinine, Total Bilirubin, and AST.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1000/uL, Platelets less
than or equal to 100K/uL, Creatinine greater than or equal to 2.0 mg/dL, Total Bilirubin greater than or equal to 2 X ULN,
AST greater than or equal to 3 X ULN.
Nursing Procedure, Assessment and Monitoring
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.
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, CONTINUOUS Starting when released Until Discontinued
To establish line and for flushing
Pre-Medications
pyridoxine (VITAMIN B-6) tab 100 mg
100 mg, Oral, EVERY 12 HOURS, For 4 days Starting when released
Days 1 through 4. Give prior to cytarabine.
prednisolone (PRED FORTE) 1 % ophthalmic susp 1 drop
1 drop, Eyes (Each), EVERY 6 HOURS, For 6 days Starting when released
Days 1 through 6. Give first dose prior to cytarabine.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, EVERY 24 HOURS, For 4 days Starting when released
Day 1 through 4. Give prior to chemotherapy. May give IV if PO not tolerated.
ondansetron (ZOFRAN) injection 16 mg
16 mg, Intravenous, EVERY 24 HOURS PRN, For 120 hours Starting when released, nausea/vomiting,
for 3 Minutes
Day 1 through 4. Give prior to chemotherapy. May give IV if PO not tolerated.
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, EVERY 24 HOURS, For 4 days Starting when released
Day 1 through 4. Give prior to chemotherapy. May give IV if PO not tolerated.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, EVERY 24 HOURS PRN, For 120 hours Starting when released, nausea/vomiting
Day 1 through 4. Give prior to chemotherapy. May give IV if PO not tolerated.
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Zztestonc,PedsBeiber [2668824]
2/4/2016 1:12:33 PM Page 2 of 4
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 Medications
cytarabine PF (CYTOSAR) 4,180 mg in sodium chloride 0.9 % 250 mL bag
4,180 mg (2,000 mg/m2 × 2.09 m2 Treatment plan actual BSA), Intravenous
Days 1 through 4. Administer each bag over 2 hours x 8 doses. (Total dose of 16,000 mg/m2 IV over 96 hours).
etoposide (VEPESID) 460 mg in sodium chloride 0.9 % 1,000 mL NSS bag
460 mg (5 mg/kg × 92 kg Treatment plan actual weight), Intravenous
Days 1 through 4. Administer each bag over 12 hours x 8 doses. (Total of 40 mg/kg IV continuous over 96 hours).
Supportive Care Medications
acyclovir (ZOVIRAX) tab 400 mg
400 mg, Oral, 2 X DAILY Starting when released
ranitidine (ZANTAC) tab 150 mg
150 mg, Oral, 2 X DAILY Starting when released
sulfamethoxazole-trimethoprim (BACTRIM DS) 800-160 MG per tab 1 tab
1 tab, Oral, 2 X DAILY SAT, SUN Starting when released
fluconazole (DIFLUCAN) tab 400 mg
400 mg, Oral, 1 X DAILY Starting when released
Conditional Orders
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
May give IV if PO not tolerated.
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
IV push slowly, max rate 5 mg/minute. May give IV if PO not tolerated.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
No more than a total of 24 mg of ondansetron doses per 24 hours (scheduled and PRN). May give IV if PO not tolerated.
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting,
for 3 Minutes
No more than a total of 24 mg ondansetron doses per 24 hours (scheduled and PRN). May give IV if PO not tolerated.
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-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 ***. Continue until ANC is greater than
*** 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.
Take Home Medications
levofloxacin (LEVAQUIN) 500 MG tab
Take 1 tablet by mouth once daily starting on Day 7., Disp-10 tab, R-0, starting S, Local Printer
Start on Day 7 until ANC is greater than 2000/uL past nadir. Bacterial prophylaxis.
prednisolone (PRED FORTE) 1 % ophthalmic susp
1 drop in each eye every 6 hours. Days 1 through 6., 1 drop, Disp-1 Bottle, R-0, EVERY 6 HOURS
starting S, Local Printer
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Zztestonc,PedsBeiber [2668824]
2/4/2016 1:12:33 PM Page 3 of 4
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

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
fluconazole (DIFLUCAN) 200 MG tab
Take 2 tabs by mouth one time daily., 400 mg, Disp-60 tab, R-1, 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-1, 2 X DAILY SAT, SUN starting S,
Local Printer
ranitidine (ZANTAC) 150 MG tab
Take 1 tab by mouth 2 times daily., 150 mg, Disp-60 tab, R-5, 2 X DAILY starting S, Local Printer
prochlorperazine (COMPAZINE) 10 MG tab
Take 1 tab by mouth every 6 hours as needed for nausea/vomiting., 10 mg, Disp-30 tab, R-0, EVERY 6
HOURS PRN 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-0, EVERY 8
HOURS PRN starting S, Local Printer
Follow-Up
MULTIPLE DAY FOLLOW-UP (1)
LABS: CBC with DIFF twice weekly; Electrolytes, Glucose, BUN, Creatinine, Calcium, AST, Total
Bilirubin, Magnesium weekly until counts have recovered post-nadir (typically 4-6 weeks).
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Zztestonc,PedsBeiber [2668824]
2/4/2016 1:12:33 PM Page 4 of 4
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