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/clinical/cckm-tools/content/beacon-protocols/hem---lymphoma/name-96904-en.cckm

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 PCNSL Inpt Op Induction Methotrexate Rituximab Temozolomide Ver 3-4-16 (HL 5296)

CSC Hem PCNSL Inpt Op Induction Methotrexate Rituximab Temozolomide Ver 3-4-16 (HL 5296) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Lymphoma


CSC HEM PCNSL INPT/OP INDUCTION METHOTREXATE/RITUXIMAB/TEMOZOLOMIDE VER: 3-4-16 – Properties
Cycle 1 – 3/3/2016 through 3/30/2016 (28 days), Planned
Day 1 through 3 (Inpatient), Cycle 1 – Planned for 3/3/2016
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 (INDUCTION): methotrexate 8000 mg/m2 IV over 4 hours Day 1,15 of Cycles 1 through 3 and Day 1 of
Cycle 4 for total of 7 doses, leucovorin 100 mg/m2 IV starting 24 hours after the start of the methotrexate infusion and
continue every 6 hours until methotrexate level undetectable, rituximab 375 mg/m2 IV Day 3, 10, 17, 24 of Cycle 1 and
Day 3, 10 of Cycle 2 for a total of 6 doses, temozolomide 150 mg/m2 by mouth daily Days 7 through 11.
CYCLE LENGTH: 28 days.
COURSE LENGTH: 4 Cycles, followed by restaging. Patients achieving a complete/unconfirmed complete response
may continue to Cycle 5.
THERAPY (INDUCTION AFTER RESTAGING): methotrexate 8000 mg/m2 IV over 4 hours Day 1 for one
dose, leucovorin 100 mg/m2 IV starting 24 hours after the start of the methotrexate infusion and continue every 6 hours
until methotrexate level undetectable, temozolomide 150 mg/m2 by mouth daily Days 7 through 11.
CYCLE LENGTH: 28 days.
COURSE LENGTH: 1 Cycle.
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.
NOTE:
ONCE, 1 dose Starting when released
Hold TMP/SMX during infusion and until methotrexate level is undetectable.
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
ALBUMIN
ONCE Starting when released
PROTEIN, TOTAL
ONCE Starting when released
Actions
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3/3/2016 11:55:18 AM Page 1 of 54
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BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALT/SGPT
ONCE Starting when released
ALKALINE PHOSPHATASE
ONCE Starting when released
HEPATITIS B CORE AB, TOTAL
ONCE Starting when released
HEPATITIS B SURFACE AG
ONCE Starting when released
HEPATITIS B SURFACE AB
ONCE Starting when released
Pre-Labs (delete all that do not apply)
HEPATITIS B DNA, ULTRA QUANT, PCR
ONCE Starting when released
Draw if Hepatitis B Core AB is positive.
HCG, QUANTITATIVE
ONCE Starting when released, Routine
Additional Labs
PH, URINE (METHOTREXATE PROTOCOL)
ONCE Starting when released
Obtain pH, Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 2 HOURS Starting when released for 2 occurrences
Obtain pH, Urine (Methotrexate Protocol) at 2 hours and 4 hours after start of Methotrexate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting when released for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is
undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting S+8 at 0000 for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is
undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
CONDITIONAL - RN COLLECT Starting when released until S+7 for 7 days
If Urine pH falls below 7, obtain pH, Urine (Methotrexate Protocol) every 2 hours as needed until Urine pH is greater than
or equal to 7 for two consecutive occurrences.
METHOTREXATE
ONCE Starting when released
Obtain methotrexate level 24 hours after the start of methotrexate infusion.
METHOTREXATE
NEXT AM Starting S+2 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate
levels when drug level is undetectable.
METHOTREXATE
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3/3/2016 11:55:18 AM Page 2 of 54
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NEXT AM Starting S+9 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate
levels when drug level is undetectable.
CREATININE
ONCE Starting when released
Obtain creatinine at 24 hours after the start of methotrexate infusion.
CREATININE
NEXT AM Starting S+2 As Scheduled for 7 days
CREATININE
NEXT AM Starting S+9 As Scheduled for 7 days
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total Bilirubin, AST, ALT, Alkaline
Phosphatase, Creatinine, pH Urine (Methotrexate Protocol).
Verify Labs (2)
Verify ongoing treatment labs: Creatinine, pH, Urine (Methotrexate Protocol) and
Methotrexate levels.
Treatment Parameters
Hold treatment and notify authorizing prescriber for: Creatinine greater than 1.5 mg/dL or
Creatinine Clearance less than 60 mL/min or Total bilirubin greater than or equal to 2 mg/dL or AST greater than 2.5 X
ULN or ALT greater than 2.5 X ULN or Alkaline Phosphatase greater than 2.5 X ULN.
Treatment Parameters (2)
Do not administer methotrexate until urine pH is greater than or equal to 7.
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)
Check pH Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate
infusion. If less than 7, give sodium bicarbonate 50 mEq IV. See Conditional Medications.
Monitoring Parameters (2)
Check pH Urine (Methotrexate Protocol) at 2 hours, 4 hours, and 8 hours after start of
methotrexate and then every 8 hours until methotrexate level is undetectable. If less than 7, give sodium bicarbonate 50
mEq IV and check urine pH every 2 hours until urine pH is greater than or equal to 7. See Conditional Medications and
Additional Labs.
Monitoring Parameters (3)
Educate patients regarding the potential of occurence for severe mucocutaneous
reactions with rituximab.
Nursing Communication
CONTINUOUS Starting when released Until Specified
If sodium bicarbonate bolus given, recheck Urine pH in 2 hours. If two boluses of sodium bicarbonate have been given in
8 hours or three boluses in 24 hours, notify pharmacy and provider to review IV fluid orders.
Vital Signs
SEE COMMENTS Starting S+2 at 0000 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
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Zztestonc,Edward E [2435061]
3/3/2016 11:55:18 AM Page 3 of 54
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2016CCKM@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 bicarbonate 100 mEq in dextrose 5 % 1,000 mL infusion
Intravenous, CONTINUOUS Starting when released Until Discontinued
Begin 4 hours prior to start of methotrexate. May discontinue when methotrexate level is undetectable. Sodium
Bicarbonate infusion must NOT be interrupted for any reason without an order from the attending physician or fellow.
NOTE:
EVERY 6 HOURS Starting when released
Sodium Bicarbonate infusion must NOT be interrupted for any reason without an order from the attending physician or
fellow.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
May give IV if unable to tolerate oral dose.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, EVERY 24 HOURS PRN, For 48 hours Starting when released,
nausea/vomiting, if unable to tolerate PO
If unable to tolerate the oral dose
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Once prior to methotrexate. If unable to give PO may give IV.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, EVERY 24 HOURS PRN, For 48 hours Starting when released,
nausea/vomiting
Administer prior to methotrexate. If unable to give PO may give IV.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting S+2 at 0000
Administer prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting S+2 at 0000
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
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3/3/2016 11:55:18 AM Page 4 of 54
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2016CCKM@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
methotrexate PF 16,080 mg in dextrose 5 % 1,000 mL bag
16,080 mg (8,000 mg/m2 × 2.01 m2 Treatment plan actual BSA), Intravenous, ONCE, 1
dose Starting when released
Day 1. Administer over 4 hours. Do not start until Urine pH is greater than or equal to 7.
leucovorin 20 MG/ML injection 201 mg
201 mg (100 mg/m2 × 2.01 m2 Treatment plan actual BSA), Intravenous, EVERY 6
HOURS Starting S+1 at 0000, for 3 Minutes
Day 2. Administer over 3 to 5 minutes. Start 24 hours after the START of methotrexate infusion. May discontinue when
methotrexate level is undetectable.
rituximab (RITUXAN) 754 mg in sodium chloride 0.9 % 500 mL bag
754 mg (rounded from 753.75 mg = 375 mg/m2 × 2.01 m2 Treatment plan actual BSA),
Intravenous, ONCE, 1 dose Starting S+2 at 0000
Day 3. 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.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s):
temozolomide (Dispensed on Day 1 of each cycle)
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
Supportive Care Medications (delete all that do not apply)
Note to All Staff (1)
Delete fungal prophylaxis if patient is not on continuous steroids.
clotrimazole (MYCELEX) troche 10 mg
10 mg, Oral, 2 X DAILY Starting when released
For patients on continuous steroids. Dissolve in mouth. Do not chew.
fluconazole (DIFLUCAN) tab 400 mg
400 mg, Oral, 1 X DAILY Starting when released
For patients on continuous steroids
Conditional Orders
sodium bicarbonate 8.4 % injection 50 mEq
50 mEq, Intravenous, EVERY 2 HOURS PRN, For 7 days Starting when released until
S+7, For urine pH less than 7, for 1 Minutes
Administer over 1 to 2 minutes. Give if urine pH is less than 7. May discontinue when methotrexate level is undetectable.
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued,
nausea/vomiting
If unable to take PO, may give IV.
prochlorperazine (COMPAZINE) injection 10 mg
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3/3/2016 11:55:18 AM Page 5 of 54
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
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10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued,
nausea/vomiting, If unable to tolerate PO.
IV push slowly, max rate 5 mg/minute.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, EVERY 8 HOURS PRN Starting when released Until Discontinued,
nausea/vomiting
Do not exceed total of 24 mg ondansetron per 24 hours (scheduled and PRN)
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued,
nausea/vomiting, If unable to tolerate PO., for 3 Minutes
Do not exceed total of 24 mg of ondansetron per 24 hours (scheduled and PRN). Administer over 3 to 5 minutes
Take Home Medications (delete all that do not apply)
temozolomide (TEMODAR) 250 MG cap
On Days 7 through 11, take *** caps by mouth one time daily at bedtime. Total daily
dose is *** mg., R-0, starting S, Local Printer
Temozolomide dose is 150 mg/m2/day, based on *** m2
temozolomide (TEMODAR) 180 MG cap
On Days 7 through 11, take *** caps by mouth one time daily at bedtime. Total daily
dose is *** mg., R-0, starting S, Local Printer
Temozolomide dose is 150 mg/m2/day, based on *** m2
temozolomide (TEMODAR) 140 MG cap
On Days 7 through 11, take *** caps by mouth one time daily at bedtime. Total daily
dose is *** mg., R-0, starting S, Local Printer
Temozolomide dose is 150 mg/m2/day, based on *** m2
temozolomide (TEMODAR) 100 MG cap
On Days 7 through 11, take *** caps by mouth one time daily at bedtime. Total daily
dose is *** mg., R-0, starting S
Temozolomide dose is 150 mg/m2/day, based on *** m2
temozolomide (TEMODAR) 20 MG cap
On Days 7 through 11, take *** caps by mouth one time daily at bedtime. Total daily
dose is *** mg., R-0, starting S
Temozolomide dose is 150 mg/m2/day, based on *** m2
Note to All Staff (1)
Delete fungal and PJP prophylaxis if patient is not on continuous steroids.
clotrimazole (MYCELEX) 10 MG lozenge
Take 1 tab by mouth 2 times daily., 10 mg, Disp-60 lozenge, R-5, 2 X DAILY starting S,
Local Printer
Dissolve in mouth. Do not chew.
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
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-5, 2 X DAILY SAT,
SUN starting S
Hold TMP/Sulfa during methotrexate infusion and until methotrexate level is undetectable.
Take Home Medications
leucovorin 15 MG tab
Take 1 tab by mouth every 6 hours. Take until seen in clinic for follow up appt to confirm
methotrexate level undetectable, 15 mg, Disp-16 tab, R-0, EVERY 6 HOURS starting S
sodium bicarbonate oral powder
Mix 1/2 teaspoon sodium bicarbonate oral powder (baking soda) in 6-8 ounces of a non-
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Zztestonc,Edward E [2435061]
3/3/2016 11:55:18 AM Page 6 of 54
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
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acidic fluid and drink by mouth at 8 AM, 12 PM, 4 PM, 10 PM the day before methotrexate treatment and at 8 AM the
morning of methotrexate treatment., Disp-1 Bottle, R-0, starting S, No Print
acyclovir (ZOVIRAX) 400 MG tab
Take 1 tab by mouth 2 times daily., 400 mg, Disp-60 tab, R-6, 2 X DAILY starting S, Local
Printer
ranitidine (ZANTAC) 150 MG tab
Take 1 tab by mouth 2 times daily., 150 mg, Disp-60 tab, R-6, 2 X DAILY starting S, Local
Printer
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth prior to each dose of temozolomide, and may take 1 tab by mouth
every 8 hours as needed for nausea and vomiting., Disp-30 tab, R-5, 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
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC with DIFF, Creatinine; CHEMOTHERAPY ROOM APPOINTMENT: rituximab
for 180 minutes.
DAY 15 FOLLOW-UP
Schedule B6/6 admission for chemotherapy administration.
DAY 24 FOLLOW-UP
LABS: CBC with DIFF, Creatinine. CHEMOTHERAPY ROOM APPOINTMENT: rituximab
for 180 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) Schedule B6/6 admission for chemotherapy administration.
Day 10 (Outpatient), Cycle 1 – Planned for 3/12/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Primary CNS Lymphoma.
THERAPY (INDUCTION): methotrexate 8000 mg/m2 IV over 4 hours Day 1,15 of Cycles 1 through 3 and Day 1 of Cycle
4 for total of 7 doses, leucovorin 100 mg/m2 IV starting 24 hours after the start of the methotrexate infusion and continue
every 6 hours until methotrexate level undetectable, rituximab 375 mg/m2 IV Day 3, 10, 17, 24 of Cycle 1 and Day 3, 10
of Cycle 2 for a total of 6 doses, temozolomide 150 mg/m2 by mouth daily Days 7 through 11.
CYCLE LENGTH: 28 days.
COURSE LENGTH: 4 Cycles, followed by restaging. Patients achieving a complete/unconfirmed complete response may
continue to Cycle 5.
THERAPY (INDUCTION AFTER RESTAGING): methotrexate 8000 mg/m2 IV over 4 hours Day 1 for one
dose, leucovorin 100 mg/m2 IV starting 24 hours after the start of the methotrexate infusion and continue every 6 hours
until methotrexate level undetectable, temozolomide 150 mg/m2 by mouth daily Days 7 through 11.
CYCLE LENGTH: 28 days.
COURSE LENGTH: 1 Cycle.
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.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
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Zztestonc,Edward E [2435061]
3/3/2016 11:55:18 AM Page 7 of 54
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
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Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose
or if greater than 6 months since last dose. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Meds.
Monitoring Parameters (1)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with
rituximab.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Vital Signs every 15 minutes for the first 60 minutes and then every 30 minutes until rituximab infusion complete.
If patient experiences fever accompanied by chills or rigors, shortness of breath, chest pain, or hypotension, stop infusion
and contact MD. Once the patient returns to baseline, infusion may be restarted at half the rate during which the reaction
occurred.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 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
Give 30 minutes prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to rituximab.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
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Zztestonc,Edward E [2435061]
3/3/2016 11:55:18 AM Page 8 of 54
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2016CCKM@uwhealth.org

diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
rituximab (RITUXAN) 754 mg in sodium chloride 0.9 % 500 mL bag
754 mg (rounded from 753.75 mg = 375 mg/m2 × 2.01 m2 Treatment plan actual BSA),
Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity 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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15 through 17 (Inpatient), Cycle 1 – Planned for 3/17/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Primary CNS Lymphoma.
THERAPY (INDUCTION): methotrexate 8000 mg/m2 IV over 4 hours Day 1,15 of Cycles 1 through 3 and Day 1 of Cycle
4 for total of 7 doses, leucovorin 100 mg/m2 IV starting 24 hours after the start of the methotrexate infusion and continue
every 6 hours until methotrexate level undetectable, rituximab 375 mg/m2 IV Day 3, 10, 17, 24 of Cycle 1 and Day 3, 10
of Cycle 2 for a total of 6 doses, temozolomide 150 mg/m2 by mouth daily Days 7 through 11.
CYCLE LENGTH: 28 days.
COURSE LENGTH: 4 Cycles, followed by restaging. Patients achieving a complete/unconfirmed complete response may
continue to Cycle 5.
THERAPY (INDUCTION AFTER RESTAGING): methotrexate 8000 mg/m2 IV over 4 hours Day 1 for one
dose, leucovorin 100 mg/m2 IV starting 24 hours after the start of the methotrexate infusion and continue every 6 hours
until methotrexate level undetectable, temozolomide 150 mg/m2 by mouth daily Days 7 through 11.
CYCLE LENGTH: 28 days.
COURSE LENGTH: 1 Cycle.
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.
NOTE:
ONCE, 1 dose Starting when released
Hold TMP/SMX during infusion and until methotrexate level is undetectable.
Pre-Labs
CBC WITH DIFFERENTIAL
ONCE Starting when released, Routine
ELECTROLYTES
ONCE Starting when released
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Zztestonc,Edward E [2435061]
3/3/2016 11:55:18 AM Page 9 of 54
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GLUCOSE
ONCE Starting when released
BUN
ONCE Starting when released
CREATININE
ONCE Starting when released
CALCIUM
ONCE Starting when released
ALBUMIN
ONCE Starting when released
PROTEIN, TOTAL
ONCE Starting when released
BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALT/SGPT
ONCE Starting when released
ALKALINE PHOSPHATASE
ONCE Starting when released
Pre-Labs (delete all that do not apply)
HCG, QUANTITATIVE
ONCE Starting when released, Routine
Additional Labs
PH, URINE (METHOTREXATE PROTOCOL)
ONCE Starting when released
Obtain pH, Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 2 HOURS Starting when released for 2 occurrences
Obtain pH, Urine (Methotrexate Protocol) at 2 hours and 4 hours after start of Methotrexate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting when released for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is
undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting S+8 at 0000 for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is
undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
CONDITIONAL - RN COLLECT Starting when released until S+7 for 7 days
If Urine pH falls below 7, obtain pH, Urine (Methotrexate Protocol) every 2 hours as needed until Urine pH is greater than
or equal to 7 for two consecutive occurrences.
METHOTREXATE
ONCE Starting when released
Obtain methotrexate level 24 hours after the start of methotrexate infusion.
METHOTREXATE
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Zztestonc,Edward E [2435061]
3/3/2016 11:55:18 AM Page 10 of 54
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NEXT AM Starting S+2 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate
levels when drug level is undetectable.
METHOTREXATE
NEXT AM Starting S+9 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate
levels when drug level is undetectable.
CREATININE
ONCE Starting when released
Obtain creatinine at 24 hours after the start of methotrexate infusion.
CREATININE
NEXT AM Starting S+2 As Scheduled for 7 days
CREATININE
NEXT AM Starting S+9 As Scheduled for 7 days
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total Bilirubin, AST, ALT, Alkaline Phosphatase,
Creatinine, pH Urine (Methotrexate Protocol).
Verify Labs (2)
Verify ongoing treatment labs: Creatinine, pH, Urine (Methotrexate Protocol) and Methotrexate
levels.
Treatment Parameters
Hold treatment and notify authorizing prescriber for: Creatinine greater than 1.5 mg/dL or
Creatinine Clearance less than 60 mL/min or Total bilirubin greater than or equal to 2 mg/dL or AST greater than 2.5 X
ULN or ALT greater than 2.5 X ULN or Alkaline Phosphatase greater than 2.5 X ULN.
Treatment Parameters (2)
Do not administer methotrexate until urine pH is greater than or equal to 7.
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)
Check pH Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion. If
less than 7, give sodium bicarbonate 50 mEq IV. See Conditional Medications.
Monitoring Parameters (2)
Check pH Urine (Methotrexate Protocol) at 2 hours, 4 hours, and 8 hours after start of methotrexate
and then every 8 hours until methotrexate level is undetectable. If less than 7, give sodium bicarbonate 50 mEq IV and
check urine pH every 2 hours until urine pH is greater than or equal to 7. See Conditional Medications and Additional
Labs.
Monitoring Parameters (3)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with
rituximab.
Nursing Communication
CONTINUOUS Starting when released Until Specified
If sodium bicarbonate bolus given, recheck Urine pH in 2 hours. If two boluses of sodium bicarbonate have been given in
8 hours or three boluses in 24 hours, notify pharmacy and provider to review IV fluid orders.
Vital Signs
SEE COMMENTS Starting S+2 at 0000 Until Specified
Monitor Vital Signs every 15 minutes for the first 60 minutes and then every 30 minutes until rituximab infusion complete.
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Zztestonc,Edward E [2435061]
3/3/2016 11:55:18 AM Page 11 of 54
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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 bicarbonate 100 mEq in dextrose 5 % 1,000 mL infusion
Intravenous, CONTINUOUS Starting when released Until Discontinued
Begin 4 hours prior to start of methotrexate. May discontinue when methotrexate level is undetectable. Sodium
Bicarbonate infusion must NOT be interrupted for any reason without an order from the attending physician or fellow.
NOTE:
EVERY 6 HOURS Starting when released
Sodium Bicarbonate infusion must NOT be interrupted for any reason without an order from the attending physician or
fellow.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
May give IV if unable to tolerate oral dose.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, EVERY 24 HOURS PRN, For 48 hours Starting when released,
nausea/vomiting, if unable to tolerate PO
If unable to tolerate the oral dose
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Once prior to methotrexate. If unable to give PO may give IV.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, EVERY 24 HOURS PRN, For 48 hours Starting when released,
nausea/vomiting
Administer prior to methotrexate. If unable to give PO may give IV.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting S+2 at 0000
Administer prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting S+2 at 0000
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
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Zztestonc,Edward E [2435061]
3/3/2016 11:55:18 AM Page 12 of 54
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2016CCKM@uwhealth.org

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
methotrexate PF 16,080 mg in dextrose 5 % 1,000 mL bag
16,080 mg (8,000 mg/m2 × 2.01 m2 Treatment plan actual BSA), Intravenous, ONCE, 1 dose
Starting when released
Day 15. Administer over 4 hours. Do not start until Urine pH is greater than or equal to 7.
leucovorin 20 MG/ML injection 201 mg
201 mg (100 mg/m2 × 2.01 m2 Treatment plan actual BSA), Intravenous, EVERY 6 HOURS
Starting S+1 at 0000, for 3 Minutes
Day 16. Administer over 3 to 5 minutes. Start 24 hours after the START of methotrexate infusion. May discontinue when
methotrexate level is undetectable.
rituximab (RITUXAN) 754 mg in sodium chloride 0.9 % 500 mL bag
754 mg (rounded from 753.75 mg = 375 mg/m2 × 2.01 m2 Treatment plan actual BSA),
Intravenous, ONCE, 1 dose Starting S+2 at 0000
Day 17. 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.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s):
temozolomide (Dispensed on Day 1 of each cycle)
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
Supportive Care Medications (delete all that do not apply)
Note to All Staff (1)
Delete fungal prophylaxis if patient is not on continuous steroids.
clotrimazole (MYCELEX) troche 10 mg
10 mg, Oral, 2 X DAILY Starting when released
For patients on continuous steroids. Dissolve in mouth. Do not chew.
fluconazole (DIFLUCAN) tab 400 mg
400 mg, Oral, 1 X DAILY Starting when released
For patients on continuous steroids
Conditional Orders
sodium bicarbonate 8.4 % injection 50 mEq
50 mEq, Intravenous, EVERY 2 HOURS PRN, For 7 days Starting when released until S+7, For
urine pH less than 7, for 1 Minutes
Administer over 1 to 2 minutes. Give if urine pH is less than 7. May discontinue when methotrexate level is undetectable.
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Zztestonc,Edward E [2435061]
3/3/2016 11:55:18 AM Page 13 of 54
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2016CCKM@uwhealth.org

prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
If unable to take PO, may give IV.
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued,
nausea/vomiting, If unable to tolerate PO.
IV push slowly, max rate 5 mg/minute.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
Do not exceed total of 24 mg ondansetron per 24 hours (scheduled and PRN)
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued,
nausea/vomiting, If unable to tolerate PO., for 3 Minutes
Do not exceed total of 24 mg of ondansetron per 24 hours (scheduled and PRN). Administer over 3 to 5 minutes
Take Home Medications
leucovorin 15 MG tab
Take 1 tab by mouth every 6 hours. Take until seen in clinic for follow up appt to confirm
methotrexate level undetectable, 15 mg, Disp-16 tab, R-0, EVERY 6 HOURS starting S
sodium bicarbonate oral powder
Mix 1/2 teaspoon sodium bicarbonate oral powder (baking soda) in 6-8 ounces of a non-acidic fluid
and drink by mouth at 8 AM, 12 PM, 4 PM, 10 PM the day before methotrexate treatment and at 8 AM the morning of
methotrexate treatment., Disp-1 Bottle, R-0, starting S, No Print
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 24 (Outpatient), Cycle 1 – Planned for 3/26/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Primary CNS Lymphoma.
THERAPY (INDUCTION): methotrexate 8000 mg/m2 IV over 4 hours Day 1,15 of Cycles 1 through 3 and Day 1 of Cycle
4 for total of 7 doses, leucovorin 100 mg/m2 IV starting 24 hours after the start of the methotrexate infusion and continue
every 6 hours until methotrexate level undetectable, rituximab 375 mg/m2 IV Day 3, 10, 17, 24 of Cycle 1 and Day 3, 10
of Cycle 2 for a total of 6 doses, temozolomide 150 mg/m2 by mouth daily Days 7 through 11.
CYCLE LENGTH: 28 days.
COURSE LENGTH: 4 Cycles, followed by restaging. Patients achieving a complete/unconfirmed complete response may
continue to Cycle 5.
THERAPY (INDUCTION AFTER RESTAGING): methotrexate 8000 mg/m2 IV over 4 hours Day 1 for one
dose, leucovorin 100 mg/m2 IV starting 24 hours after the start of the methotrexate infusion and continue every 6 hours
until methotrexate level undetectable, temozolomide 150 mg/m2 by mouth daily Days 7 through 11.
CYCLE LENGTH: 28 days.
COURSE LENGTH: 1 Cycle.
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.
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.
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Zztestonc,Edward E [2435061]
3/3/2016 11:55:18 AM Page 14 of 54
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2016CCKM@uwhealth.org

Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to rituximab can occur and is most common with the first or second dose
or if greater than 6 months since last dose. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Meds.
Monitoring Parameters (1)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with
rituximab.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor Vital Signs every 15 minutes for the first 60 minutes and then every 30 minutes until rituximab infusion complete.
If patient experiences fever accompanied by chills or rigors, shortness of breath, chest pain, or hypotension, stop infusion
and contact MD. Once the patient returns to baseline, infusion may be restarted at half the rate during which the reaction
occurred.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 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
Give 30 minutes prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes 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
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Zztestonc,Edward E [2435061]
3/3/2016 11:55:18 AM Page 15 of 54
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2016CCKM@uwhealth.org

50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, for 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
rituximab (RITUXAN) 754 mg in sodium chloride 0.9 % 500 mL bag
754 mg (rounded from 753.75 mg = 375 mg/m2 × 2.01 m2 Treatment plan actual BSA),
Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity 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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 3/31/2016 through 4/27/2016 (28 days), Planned
Day 1 through 3 (Inpatient), Cycle 2 – Planned for 3/31/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Primary CNS Lymphoma.
THERAPY (INDUCTION): methotrexate 8000 mg/m2 IV over 4 hours Day 1,15 of Cycles 1 through 3 and Day 1 of Cycle
4 for total of 7 doses, leucovorin 100 mg/m2 IV starting 24 hours after the start of the methotrexate infusion and continue
every 6 hours until methotrexate level undetectable, rituximab 375 mg/m2 IV Day 3, 10, 17, 24 of Cycle 1 and Day 3, 10
of Cycle 2 for a total of 6 doses, temozolomide 150 mg/m2 by mouth daily Days 7 through 11.
CYCLE LENGTH: 28 days.
COURSE LENGTH: 4 Cycles, followed by restaging. Patients achieving a complete/unconfirmed complete response may
continue to Cycle 5.
THERAPY (INDUCTION AFTER RESTAGING): methotrexate 8000 mg/m2 IV over 4 hours Day 1 for one
dose, leucovorin 100 mg/m2 IV starting 24 hours after the start of the methotrexate infusion and continue every 6 hours
until methotrexate level undetectable, temozolomide 150 mg/m2 by mouth daily Days 7 through 11.
CYCLE LENGTH: 28 days.
COURSE LENGTH: 1 Cycle.
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.
NOTE:
ONCE, 1 dose Starting when released
Hold TMP/SMX during infusion and until methotrexate level is undetectable.
Consent
Verify Consent
Verify informed consent has been obtained.
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Zztestonc,Edward E [2435061]
3/3/2016 11:55:18 AM Page 16 of 54
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2016CCKM@uwhealth.org

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
ALBUMIN
ONCE Starting when released
PROTEIN, TOTAL
ONCE Starting when released
BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALT/SGPT
ONCE Starting when released
ALKALINE PHOSPHATASE
ONCE Starting when released
Pre-Labs (delete all that do not apply)
HCG, QUANTITATIVE
ONCE Starting when released, Routine
Additional Labs
PH, URINE (METHOTREXATE PROTOCOL)
ONCE Starting when released
Obtain pH, Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 2 HOURS Starting when released for 2 occurrences
Obtain pH, Urine (Methotrexate Protocol) at 2 hours and 4 hours after start of Methotrexate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting when released for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is
undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting S+8 at 0000 for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is
undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
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Zztestonc,Edward E [2435061]
3/3/2016 11:55:18 AM Page 17 of 54
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2016CCKM@uwhealth.org

CONDITIONAL - RN COLLECT Starting when released until S+7 for 7 days
If Urine pH falls below 7, obtain pH, Urine (Methotrexate Protocol) every 2 hours as needed until Urine pH is greater than
or equal to 7 for two consecutive occurrences.
METHOTREXATE
ONCE Starting when released
Obtain methotrexate level 24 hours after the start of methotrexate infusion.
METHOTREXATE
NEXT AM Starting S+2 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate
levels when drug level is undetectable.
METHOTREXATE
NEXT AM Starting S+9 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate
levels when drug level is undetectable.
CREATININE
ONCE Starting when released
Obtain creatinine at 24 hours after the start of methotrexate infusion.
CREATININE
NEXT AM Starting S+2 As Scheduled for 7 days
CREATININE
NEXT AM Starting S+9 As Scheduled for 7 days
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total Bilirubin, AST, ALT, Alkaline Phosphatase,
Creatinine, pH Urine (Methotrexate Protocol).
Verify Labs (2)
Verify ongoing treatment labs: Creatinine, pH, Urine (Methotrexate Protocol) and Methotrexate
levels.
Treatment Parameters
Hold treatment and notify authorizing prescriber for: Creatinine greater than 1.5 mg/dL or
Creatinine Clearance less than 60 mL/min or Total bilirubin greater than or equal to 2 mg/dL or AST greater than 2.5 X
ULN or ALT greater than 2.5 X ULN or Alkaline Phosphatase greater than 2.5 X ULN.
Treatment Parameters (2)
Do not administer methotrexate until urine pH is greater than or equal to 7.
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)
Check pH Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion. If
less than 7, give sodium bicarbonate 50 mEq IV. See Conditional Medications.
Monitoring Parameters (2)
Check pH Urine (Methotrexate Protocol) at 2 hours, 4 hours, and 8 hours after start of methotrexate
and then every 8 hours until methotrexate level is undetectable. If less than 7, give sodium bicarbonate 50 mEq IV and
check urine pH every 2 hours until urine pH is greater than or equal to 7. See Conditional Medications and Additional
Labs.
Monitoring Parameters (3)
Educate patients regarding the potential of occurence for severe mucocutaneous reactions with
rituximab.
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Zztestonc,Edward E [2435061]
3/3/2016 11:55:18 AM Page 18 of 54
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Nursing Communication
CONTINUOUS Starting when released Until Specified
If sodium bicarbonate bolus given, recheck Urine pH in 2 hours. If two boluses of sodium bicarbonate have been given in
8 hours or three boluses in 24 hours, notify pharmacy and provider to review IV fluid orders.
Vital Signs
SEE COMMENTS Starting S+2 at 0000 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 bicarbonate 100 mEq in dextrose 5 % 1,000 mL infusion
Intravenous, CONTINUOUS Starting when released Until Discontinued
Begin 4 hours prior to start of methotrexate. May discontinue when methotrexate level is undetectable. Sodium
Bicarbonate infusion must NOT be interrupted for any reason without an order from the attending physician or fellow.
NOTE:
EVERY 6 HOURS Starting when released
Sodium Bicarbonate infusion must NOT be interrupted for any reason without an order from the attending physician or
fellow.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
May give IV if unable to tolerate oral dose.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, EVERY 24 HOURS PRN, For 48 hours Starting when released,
nausea/vomiting, if unable to tolerate PO
If unable to tolerate the oral dose
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Once prior to methotrexate. If unable to give PO may give IV.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, EVERY 24 HOURS PRN, For 48 hours Starting when released,
nausea/vomiting
Administer prior to methotrexate. If unable to give PO may give IV.
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting S+2 at 0000
Administer prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting S+2 at 0000
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Zztestonc,Edward E [2435061]
3/3/2016 11:55:18 AM Page 19 of 54
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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
methotrexate PF 16,080 mg in dextrose 5 % 1,000 mL bag
16,080 mg (8,000 mg/m2 × 2.01 m2 Treatment plan actual BSA), Intravenous, ONCE, 1 dose
Starting when released
Day 1. Administer over 4 hours. Do not start until Urine pH is greater than or equal to 7.
leucovorin 20 MG/ML injection 201 mg
201 mg (100 mg/m2 × 2.01 m2 Treatment plan actual BSA), Intravenous, EVERY 6 HOURS
Starting S+1 at 0000, for 3 Minutes
Day 2. Administer over 3 to 5 minutes. Start 24 hours after the START of methotrexate infusion. May discontinue when
methotrexate level is undetectable.
rituximab (RITUXAN) 754 mg in sodium chloride 0.9 % 500 mL bag
754 mg (rounded from 753.75 mg = 375 mg/m2 × 2.01 m2 Treatment plan actual BSA),
Intravenous, ONCE, 1 dose Starting S+2 at 0000
Day 3. 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.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s):
temozolomide (Dispensed on Day 1 of each cycle)
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
Supportive Care Medications (delete all that do not apply)
Note to All Staff (1)
Delete fungal prophylaxis if patient is not on continuous steroids.
clotrimazole (MYCELEX) troche 10 mg
10 mg, Oral, 2 X DAILY Starting when released
For patients on continuous steroids. Dissolve in mouth. Do not chew.
fluconazole (DIFLUCAN) tab 400 mg
400 mg, Oral, 1 X DAILY Starting when released
For patients on continuous steroids
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Zztestonc,Edward E [2435061]
3/3/2016 11:55:18 AM Page 20 of 54
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2016CCKM@uwhealth.org

Conditional Orders
sodium bicarbonate 8.4 % injection 50 mEq
50 mEq, Intravenous, EVERY 2 HOURS PRN, For 7 days Starting when released until S+7, For
urine pH less than 7, for 1 Minutes
Administer over 1 to 2 minutes. Give if urine pH is less than 7. May discontinue when methotrexate level is undetectable.
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
If unable to take PO, may give IV.
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued,
nausea/vomiting, If unable to tolerate PO.
IV push slowly, max rate 5 mg/minute.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
Do not exceed total of 24 mg ondansetron per 24 hours (scheduled and PRN)
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued,
nausea/vomiting, If unable to tolerate PO., for 3 Minutes
Do not exceed total of 24 mg of ondansetron per 24 hours (scheduled and PRN). Administer over 3 to 5 minutes
Take Home Medications (delete all that do not apply)
temozolomide (TEMODAR) 250 MG cap
On Days 7 through 11, take *** caps by mouth one time daily at bedtime. Total daily dose is ***
mg., R-0, starting S, Local Printer
Temozolomide dose is 150 mg/m2/day, based on *** m2
temozolomide (TEMODAR) 180 MG cap
On Days 7 through 11, take *** caps by mouth one time daily at bedtime. Total daily dose is ***
mg., R-0, starting S, Local Printer
Temozolomide dose is 150 mg/m2/day, based on *** m2
temozolomide (TEMODAR) 140 MG cap
On Days 7 through 11, take *** caps by mouth one time daily at bedtime. Total daily dose is ***
mg., R-0, starting S, Local Printer
Temozolomide dose is 150 mg/m2/day, based on *** m2
temozolomide (TEMODAR) 100 MG cap
On Days 7 through 11, take *** caps by mouth one time daily at bedtime. Total daily dose is ***
mg., R-0, starting S
Temozolomide dose is 150 mg/m2/day, based on *** m2
temozolomide (TEMODAR) 20 MG cap
On Days 7 through 11, take *** caps by mouth one time daily at bedtime. Total daily dose is ***
mg., R-0, starting S
Temozolomide dose is 150 mg/m2/day, based on *** m2
Take Home Medications
leucovorin 15 MG tab
Take 1 tab by mouth every 6 hours. Take until seen in clinic for follow up appt to confirm
methotrexate level undetectable, 15 mg, Disp-16 tab, R-0, EVERY 6 HOURS starting S
sodium bicarbonate oral powder
Mix 1/2 teaspoon sodium bicarbonate oral powder (baking soda) in 6-8 ounces of a non-acidic fluid
and drink by mouth at 8 AM, 12 PM, 4 PM, 10 PM the day before methotrexate treatment and at 8 AM the morning of
methotrexate treatment., Disp-1 Bottle, R-0, starting S, No Print
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Zztestonc,Edward E [2435061]
3/3/2016 11:55:18 AM Page 21 of 54
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2016CCKM@uwhealth.org

Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC with DIFF, Creatinine; CHEMOTHERAPY ROOM APPOINTMENT: rituximab 180
minutes.
DAY 15 FOLLOW-UP
Schedule B6/6 admission for chemotherapy administration.
DAY 24 FOLLOW-UP
LABS: CBC with DIFF, Creatinine.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) Schedule B6/6 admission for chemotherapy administration.
Day 10 (Outpatient), Cycle 2 – Planned for 4/9/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Primary CNS Lymphoma.
THERAPY (INDUCTION): methotrexate 8000 mg/m2 IV over 4 hours Day 1,15 of Cycles 1 through 3 and Day 1 of Cycle
4 for total of 7 doses, leucovorin 100 mg/m2 IV starting 24 hours after the start of the methotrexate infusion and continue
every 6 hours until methotrexate level undetectable, rituximab 375 mg/m2 IV Day 3, 10, 17, 24 of Cycle 1 and Day 3, 10
of Cycle 2 for a total of 6 doses, temozolomide 150 mg/m2 by mouth daily Days 7 through 11.
CYCLE LENGTH: 28 days.
COURSE LENGTH: 4 Cycles, followed by restaging. Patients achieving a complete/unconfirmed complete response may
continue to Cycle 5.
THERAPY (INDUCTION AFTER RESTAGING): methotrexate 8000 mg/m2 IV over 4 hours Day 1 for one
dose, leucovorin 100 mg/m2 IV starting 24 hours after the start of the methotrexate infusion and continue every 6 hours
until methotrexate level undetectable, temozolomide 150 mg/m2 by mouth daily Days 7 through 11.
CYCLE LENGTH: 28 days.
COURSE LENGTH: 1 Cycle.
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.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
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.
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Zztestonc,Edward E [2435061]
3/3/2016 11:55:18 AM Page 22 of 54
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2016CCKM@uwhealth.org

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
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to rituximab.
diphenhydramine (BENADRYL) cap 25 mg
25 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes 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) 754 mg in sodium chloride 0.9 % 500 mL bag
754 mg (rounded from 753.75 mg = 375 mg/m2 × 2.01 m2 Treatment plan actual BSA),
Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity 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
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Zztestonc,Edward E [2435061]
3/3/2016 11:55:18 AM Page 23 of 54
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2016CCKM@uwhealth.org

reaction occurred.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15 through 17 (Inpatient), Cycle 2 – Planned for 4/14/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Primary CNS Lymphoma.
THERAPY (INDUCTION): methotrexate 8000 mg/m2 IV over 4 hours Day 1,15 of Cycles 1 through 3 and Day 1 of Cycle
4 for total of 7 doses, leucovorin 100 mg/m2 IV starting 24 hours after the start of the methotrexate infusion and continue
every 6 hours until methotrexate level undetectable, rituximab 375 mg/m2 IV Day 3, 10, 17, 24 of Cycle 1 and Day 3, 10
of Cycle 2 for a total of 6 doses, temozolomide 150 mg/m2 by mouth daily Days 7 through 11.
CYCLE LENGTH: 28 days.
COURSE LENGTH: 4 Cycles, followed by restaging. Patients achieving a complete/unconfirmed complete response may
continue to Cycle 5.
THERAPY (INDUCTION AFTER RESTAGING): methotrexate 8000 mg/m2 IV over 4 hours Day 1 for one
dose, leucovorin 100 mg/m2 IV starting 24 hours after the start of the methotrexate infusion and continue every 6 hours
until methotrexate level undetectable, temozolomide 150 mg/m2 by mouth daily Days 7 through 11.
CYCLE LENGTH: 28 days.
COURSE LENGTH: 1 Cycle.
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.
NOTE:
ONCE, 1 dose Starting when released
Hold TMP/SMX during infusion and until methotrexate level is undetectable.
Pre-Labs
CBC WITH DIFFERENTIAL
ONCE Starting when released, Routine
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
ALBUMIN
ONCE Starting when released
PROTEIN, TOTAL
ONCE Starting when released
BILIRUBIN, TOTAL
ONCE Starting when released
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Zztestonc,Edward E [2435061]
3/3/2016 11:55:18 AM Page 24 of 54
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
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AST/SGOT
ONCE Starting when released
ALT/SGPT
ONCE Starting when released
ALKALINE PHOSPHATASE
ONCE Starting when released
Pre-Labs (delete all that do not apply)
HCG, QUANTITATIVE
ONCE Starting when released, Routine
Additional Labs
PH, URINE (METHOTREXATE PROTOCOL)
ONCE Starting when released
Obtain pH, Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 2 HOURS Starting when released for 2 occurrences
Obtain pH, Urine (Methotrexate Protocol) at 2 hours and 4 hours after start of Methotrexate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting when released for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is
undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting S+8 at 0000 for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is
undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
CONDITIONAL - RN COLLECT Starting when released until S+7 for 7 days
If Urine pH falls below 7, obtain pH, Urine (Methotrexate Protocol) every 2 hours as needed until Urine pH is greater than
or equal to 7 for two consecutive occurrences.
METHOTREXATE
ONCE Starting when released
Obtain methotrexate level 24 hours after the start of methotrexate infusion.
METHOTREXATE
NEXT AM Starting S+2 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate
levels when drug level is undetectable.
METHOTREXATE
NEXT AM Starting S+9 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate
levels when drug level is undetectable.
CREATININE
ONCE Starting when released
Obtain creatinine at 24 hours after the start of methotrexate infusion.
CREATININE
NEXT AM Starting S+2 As Scheduled for 7 days
CREATININE
NEXT AM Starting S+9 As Scheduled for 7 days
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Zztestonc,Edward E [2435061]
3/3/2016 11:55:18 AM Page 25 of 54
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2016CCKM@uwhealth.org

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total Bilirubin, AST, ALT, Alkaline Phosphatase,
Creatinine, pH Urine (Methotrexate Protocol).
Verify Labs (2)
Verify ongoing treatment labs: Creatinine, pH, Urine (Methotrexate Protocol) and Methotrexate
levels.
Treatment Parameters
Hold treatment and notify authorizing prescriber for: Creatinine greater than 1.5 mg/dL or Creatinine
Clearance less than 60 mL/min or Total bilirubin greater than or equal to 2 mg/dL or AST greater than 2.5 X ULN or ALT
greater than 2.5 X ULN or Alkaline Phosphatase greater than 2.5 X ULN.
Treatment Parameters (2)
Do not administer methotrexate until urine pH is greater than or equal to 7.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Check pH Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion. If less
than 7, give sodium bicarbonate 50 mEq IV. See Conditional Medications.
Monitoring Parameters (2)
Check pH Urine (Methotrexate Protocol) at 2 hours, 4 hours, and 8 hours after start of methotrexate
and then every 8 hours until methotrexate level is undetectable. If less than 7, give sodium bicarbonate 50 mEq IV and
check urine pH every 2 hours until urine pH is greater than or equal to 7. See Conditional Medications and Additional
Labs.
Nursing Communication
CONTINUOUS Starting when released Until Specified
If sodium bicarbonate bolus given, recheck Urine pH in 2 hours. If two boluses of sodium bicarbonate have been given in
8 hours or three boluses in 24 hours, notify pharmacy and provider to review IV fluid orders.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium bicarbonate 100 mEq in dextrose 5 % 1,000 mL infusion
Intravenous, CONTINUOUS Starting when released Until Discontinued
Begin 4 hours prior to start of methotrexate. May discontinue when methotrexate level is undetectable. Sodium
Bicarbonate infusion must NOT be interrupted for any reason without an order from the attending physician or fellow.
NOTE:
EVERY 6 HOURS Starting when released
Sodium Bicarbonate infusion must NOT be interrupted for any reason without an order from the attending physician or
fellow.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
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Zztestonc,Edward E [2435061]
3/3/2016 11:55:18 AM Page 26 of 54
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May give IV if unable to tolerate oral dose.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, EVERY 24 HOURS PRN, For 48 hours Starting when released,
nausea/vomiting, if unable to tolerate PO
If unable to tolerate the oral dose
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Once prior to methotrexate. If unable to give PO may give IV.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, EVERY 24 HOURS PRN, For 48 hours Starting when released,
nausea/vomiting
Administer prior to methotrexate. If unable to give PO may give IV.
Treatment Medications
methotrexate PF 16,080 mg in dextrose 5 % 1,000 mL bag
16,080 mg (8,000 mg/m2 × 2.01 m2 Treatment plan actual BSA), Intravenous, ONCE, 1 dose
Starting when released
Day 15. Administer over 4 hours. Do not start until Urine pH is greater than or equal to 7.
leucovorin 20 MG/ML injection 201 mg
201 mg (100 mg/m2 × 2.01 m2 Treatment plan actual BSA), Intravenous, EVERY 6 HOURS
Starting S+1 at 0000, for 3 Minutes
Day 16. Administer over 3 to 5 minutes. Start 24 hours after the START of methotrexate infusion. May discontinue when
methotrexate level is undetectable.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s):
temozolomide (Dispensed on Day 1 of each cycle)
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
Supportive Care Medications (delete all that do not apply)
Note to All Staff (1)
Delete fungal prophylaxis if patient is not on continuous steroids.
clotrimazole (MYCELEX) troche 10 mg
10 mg, Oral, 2 X DAILY Starting when released
For patients on continuous steroids. Dissolve in mouth. Do not chew.
fluconazole (DIFLUCAN) tab 400 mg
400 mg, Oral, 1 X DAILY Starting when released
For patients on continuous steroids
Conditional Orders
sodium bicarbonate 8.4 % injection 50 mEq
50 mEq, Intravenous, EVERY 2 HOURS PRN, For 7 days Starting when released until S+7, For
urine pH less than 7, for 1 Minutes
Administer over 1 to 2 minutes. Give if urine pH is less than 7. May discontinue when methotrexate level is undetectable.
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
If unable to take PO, may give IV.
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Zztestonc,Edward E [2435061]
3/3/2016 11:55:18 AM Page 27 of 54
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2016CCKM@uwhealth.org

prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued,
nausea/vomiting, If unable to tolerate PO.
IV push slowly, max rate 5 mg/minute.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
Do not exceed total of 24 mg ondansetron per 24 hours (scheduled and PRN)
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued,
nausea/vomiting, If unable to tolerate PO., for 3 Minutes
Do not exceed total of 24 mg of ondansetron per 24 hours (scheduled and PRN). Administer over 3 to 5 minutes
Take Home Medications
leucovorin 15 MG tab
Take 1 tab by mouth every 6 hours. Take until seen in clinic for follow up appt to confirm
methotrexate level undetectable, 15 mg, Disp-16 tab, R-0, EVERY 6 HOURS starting S
sodium bicarbonate oral powder
Mix 1/2 teaspoon sodium bicarbonate oral powder (baking soda) in 6-8 ounces of a non-acidic fluid
and drink by mouth at 8 AM, 12 PM, 4 PM, 10 PM the day before methotrexate treatment and at 8 AM the morning of
methotrexate treatment., Disp-1 Bottle, R-0, starting S, No Print
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 24 (Lab Day Only), Cycle 2 – Planned for 4/23/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Primary CNS Lymphoma.
THERAPY (INDUCTION): methotrexate 8000 mg/m2 IV over 4 hours Day 1,15 of Cycles 1 through 3 and Day 1 of Cycle
4 for total of 7 doses, leucovorin 100 mg/m2 IV starting 24 hours after the start of the methotrexate infusion and continue
every 6 hours until methotrexate level undetectable, rituximab 375 mg/m2 IV Day 3, 10, 17, 24 of Cycle 1 and Day 3, 10
of Cycle 2 for a total of 6 doses, temozolomide 150 mg/m2 by mouth daily Days 7 through 11.
CYCLE LENGTH: 28 days.
COURSE LENGTH: 4 Cycles, followed by restaging. Patients achieving a complete/unconfirmed complete response may
continue to Cycle 5.
THERAPY (INDUCTION AFTER RESTAGING): methotrexate 8000 mg/m2 IV over 4 hours Day 1 for one
dose, leucovorin 100 mg/m2 IV starting 24 hours after the start of the methotrexate infusion and continue every 6 hours
until methotrexate level undetectable, temozolomide 150 mg/m2 by mouth daily Days 7 through 11.
CYCLE LENGTH: 28 days.
COURSE LENGTH: 1 Cycle.
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.
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
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Zztestonc,Edward E [2435061]
3/3/2016 11:55:18 AM Page 28 of 54
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CBC WITH DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 4/28/2016 through 5/25/2016 (28 days), Planned
Day 1 through 3 (Inpatient), Cycle 3 – Planned for 4/28/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Primary CNS Lymphoma.
THERAPY (INDUCTION): methotrexate 8000 mg/m2 IV over 4 hours Day 1,15 of Cycles 1 through 3 and Day 1 of Cycle
4 for total of 7 doses, leucovorin 100 mg/m2 IV starting 24 hours after the start of the methotrexate infusion and continue
every 6 hours until methotrexate level undetectable, rituximab 375 mg/m2 IV Day 3, 10, 17, 24 of Cycle 1 and Day 3, 10
of Cycle 2 for a total of 6 doses, temozolomide 150 mg/m2 by mouth daily Days 7 through 11.
CYCLE LENGTH: 28 days.
COURSE LENGTH: 4 Cycles, followed by restaging. Patients achieving a complete/unconfirmed complete response may
continue to Cycle 5.
THERAPY (INDUCTION AFTER RESTAGING): methotrexate 8000 mg/m2 IV over 4 hours Day 1 for one
dose, leucovorin 100 mg/m2 IV starting 24 hours after the start of the methotrexate infusion and continue every 6 hours
until methotrexate level undetectable, temozolomide 150 mg/m2 by mouth daily Days 7 through 11.
CYCLE LENGTH: 28 days.
COURSE LENGTH: 1 Cycle.
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.
NOTE:
ONCE, 1 dose Starting when released
Hold TMP/SMX during infusion and until methotrexate level is undetectable.
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
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3/3/2016 11:55:18 AM Page 29 of 54
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ONCE Starting when released
CALCIUM
ONCE Starting when released
ALBUMIN
ONCE Starting when released
PROTEIN, TOTAL
ONCE Starting when released
BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALT/SGPT
ONCE Starting when released
ALKALINE PHOSPHATASE
ONCE Starting when released
Pre-Labs (delete all that do not apply)
HCG, QUANTITATIVE
ONCE Starting when released, Routine
Additional Labs
PH, URINE (METHOTREXATE PROTOCOL)
ONCE Starting when released
Obtain pH, Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 2 HOURS Starting when released for 2 occurrences
Obtain pH, Urine (Methotrexate Protocol) at 2 hours and 4 hours after start of Methotrexate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting when released for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is
undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting S+8 at 0000 for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is
undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
CONDITIONAL - RN COLLECT Starting when released until S+7 for 7 days
If Urine pH falls below 7, obtain pH, Urine (Methotrexate Protocol) every 2 hours as needed until Urine pH is greater than
or equal to 7 for two consecutive occurrences.
METHOTREXATE
ONCE Starting when released
Obtain methotrexate level 24 hours after the start of methotrexate infusion.
METHOTREXATE
NEXT AM Starting S+2 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate
levels when drug level is undetectable.
METHOTREXATE
NEXT AM Starting S+9 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate
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3/3/2016 11:55:18 AM Page 30 of 54
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levels when drug level is undetectable.
CREATININE
ONCE Starting when released
Obtain creatinine at 24 hours after the start of methotrexate infusion.
CREATININE
NEXT AM Starting S+2 As Scheduled for 7 days
CREATININE
NEXT AM Starting S+9 As Scheduled for 7 days
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total Bilirubin, AST, ALT, Alkaline Phosphatase,
Creatinine, pH Urine (Methotrexate Protocol).
Verify Labs (2)
Verify ongoing treatment labs: Creatinine, pH, Urine (Methotrexate Protocol) and Methotrexate
levels.
Treatment Parameters
Hold treatment and notify authorizing prescriber for: Creatinine greater than 1.5 mg/dL or
Creatinine Clearance less than 60 mL/min or Total bilirubin greater than or equal to 2 mg/dL or AST greater than 2.5 X
ULN or ALT greater than 2.5 X ULN or Alkaline Phosphatase greater than 2.5 X ULN.
Treatment Parameters (2)
Do not administer methotrexate until urine pH is greater than or equal to 7.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Check pH Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion. If
less than 7, give sodium bicarbonate 50 mEq IV. See Conditional Medications.
Monitoring Parameters (2)
Check pH Urine (Methotrexate Protocol) at 2 hours, 4 hours, and 8 hours after start of methotrexate
and then every 8 hours until methotrexate level is undetectable. If less than 7, give sodium bicarbonate 50 mEq IV and
check urine pH every 2 hours until urine pH is greater than or equal to 7. See Conditional Medications and Additional
Labs.
Nursing Communication
CONTINUOUS Starting when released Until Specified
If sodium bicarbonate bolus given, recheck Urine pH in 2 hours. If two boluses of sodium bicarbonate have been given in
8 hours or three boluses in 24 hours, notify pharmacy and provider to review IV fluid orders.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium bicarbonate 100 mEq in dextrose 5 % 1,000 mL infusion
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3/3/2016 11:55:18 AM Page 31 of 54
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Intravenous, CONTINUOUS Starting when released Until Discontinued
Begin 4 hours prior to start of methotrexate. May discontinue when methotrexate level is undetectable. Sodium
Bicarbonate infusion must NOT be interrupted for any reason without an order from the attending physician or fellow.
NOTE:
EVERY 6 HOURS Starting when released
Sodium Bicarbonate infusion must NOT be interrupted for any reason without an order from the attending physician or
fellow.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
May give IV if unable to tolerate oral dose.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, EVERY 24 HOURS PRN, For 48 hours Starting when released,
nausea/vomiting, if unable to tolerate PO
If unable to tolerate the oral dose
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Once prior to methotrexate. If unable to give PO may give IV.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, EVERY 24 HOURS PRN, For 48 hours Starting when released,
nausea/vomiting
Administer prior to methotrexate. If unable to give PO may give IV.
Treatment Medications
methotrexate PF 16,080 mg in dextrose 5 % 1,000 mL bag
16,080 mg (8,000 mg/m2 × 2.01 m2 Treatment plan actual BSA), Intravenous, ONCE, 1 dose
Starting when released
Day 1. Administer over 4 hours. Do not start until Urine pH is greater than or equal to 7.
leucovorin 20 MG/ML injection 201 mg
201 mg (100 mg/m2 × 2.01 m2 Treatment plan actual BSA), Intravenous, EVERY 6 HOURS
Starting S+1 at 0000, for 3 Minutes
Day 2. Administer over 3 to 5 minutes. Start 24 hours after the START of methotrexate infusion. May discontinue when
methotrexate level is undetectable.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s):
temozolomide (Dispensed on Day 1 of each cycle)
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
Supportive Care Medications (delete all that do not apply)
Note to All Staff (1)
Delete fungal prophylaxis if patient is not on continuous steroids.
clotrimazole (MYCELEX) troche 10 mg
10 mg, Oral, 2 X DAILY Starting when released
For patients on continuous steroids. Dissolve in mouth. Do not chew.
fluconazole (DIFLUCAN) tab 400 mg
400 mg, Oral, 1 X DAILY Starting when released
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3/3/2016 11:55:18 AM Page 32 of 54
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For patients on continuous steroids
Conditional Orders
sodium bicarbonate 8.4 % injection 50 mEq
50 mEq, Intravenous, EVERY 2 HOURS PRN, For 7 days Starting when released until S+7, For
urine pH less than 7, for 1 Minutes
Administer over 1 to 2 minutes. Give if urine pH is less than 7. May discontinue when methotrexate level is undetectable.
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
If unable to take PO, may give IV.
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued,
nausea/vomiting, If unable to tolerate PO.
IV push slowly, max rate 5 mg/minute.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
Do not exceed total of 24 mg ondansetron per 24 hours (scheduled and PRN)
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued,
nausea/vomiting, If unable to tolerate PO., for 3 Minutes
Do not exceed total of 24 mg of ondansetron per 24 hours (scheduled and PRN). Administer over 3 to 5 minutes
Take Home Medications (delete all that do not apply)
temozolomide (TEMODAR) 250 MG cap
On Days 7 through 11, take *** caps by mouth one time daily at bedtime. Total daily dose is ***
mg., R-0, starting S, Local Printer
Temozolomide dose is 150 mg/m2/day, based on *** m2
temozolomide (TEMODAR) 180 MG cap
On Days 7 through 11, take *** caps by mouth one time daily at bedtime. Total daily dose is ***
mg., R-0, starting S, Local Printer
Temozolomide dose is 150 mg/m2/day, based on *** m2
temozolomide (TEMODAR) 140 MG cap
On Days 7 through 11, take *** caps by mouth one time daily at bedtime. Total daily dose is ***
mg., R-0, starting S, Local Printer
Temozolomide dose is 150 mg/m2/day, based on *** m2
temozolomide (TEMODAR) 100 MG cap
On Days 7 through 11, take *** caps by mouth one time daily at bedtime. Total daily dose is ***
mg., R-0, starting S
Temozolomide dose is 150 mg/m2/day, based on *** m2
temozolomide (TEMODAR) 20 MG cap
On Days 7 through 11, take *** caps by mouth one time daily at bedtime. Total daily dose is ***
mg., R-0, starting S
Temozolomide dose is 150 mg/m2/day, based on *** m2
Take Home Medications
leucovorin 15 MG tab
Take 1 tab by mouth every 6 hours. Take until seen in clinic for follow up appt to confirm
methotrexate level undetectable, 15 mg, Disp-16 tab, R-0, EVERY 6 HOURS starting S
sodium bicarbonate oral powder
Mix 1/2 teaspoon sodium bicarbonate oral powder (baking soda) in 6-8 ounces of a non-acidic fluid
and drink by mouth at 8 AM, 12 PM, 4 PM, 10 PM the day before methotrexate treatment and at 8 AM the morning of
methotrexate treatment., Disp-1 Bottle, R-0, starting S, No Print
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Zztestonc,Edward E [2435061]
3/3/2016 11:55:18 AM Page 33 of 54
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Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC with DIFF, Creatinine.
DAY 15 FOLLOW-UP
Schedule B6/6 admission for chemotherapy administration.
DAY 24 FOLLOW-UP
LABS: CBC with DIFF, Creatinine.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) Schedule B6/6 admission for chemotherapy administration.
Day 10 (Lab Day Only), Cycle 3 – Planned for 5/7/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Primary CNS Lymphoma.
THERAPY (INDUCTION): methotrexate 8000 mg/m2 IV over 4 hours Day 1,15 of Cycles 1 through 3 and Day 1 of Cycle
4 for total of 7 doses, leucovorin 100 mg/m2 IV starting 24 hours after the start of the methotrexate infusion and continue
every 6 hours until methotrexate level undetectable, rituximab 375 mg/m2 IV Day 3, 10, 17, 24 of Cycle 1 and Day 3, 10
of Cycle 2 for a total of 6 doses, temozolomide 150 mg/m2 by mouth daily Days 7 through 11.
CYCLE LENGTH: 28 days.
COURSE LENGTH: 4 Cycles, followed by restaging. Patients achieving a complete/unconfirmed complete response may
continue to Cycle 5.
THERAPY (INDUCTION AFTER RESTAGING): methotrexate 8000 mg/m2 IV over 4 hours Day 1 for one
dose, leucovorin 100 mg/m2 IV starting 24 hours after the start of the methotrexate infusion and continue every 6 hours
until methotrexate level undetectable, temozolomide 150 mg/m2 by mouth daily Days 7 through 11.
CYCLE LENGTH: 28 days.
COURSE LENGTH: 1 Cycle.
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.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15 through 17 (Inpatient), Cycle 3 – Planned for 5/12/2016
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3/3/2016 11:55:18 AM Page 34 of 54
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Treatment Plan Information
Treatment Plan Summary
DISEASE: Primary CNS Lymphoma.
THERAPY (INDUCTION): methotrexate 8000 mg/m2 IV over 4 hours Day 1,15 of Cycles 1 through 3 and Day 1 of Cycle
4 for total of 7 doses, leucovorin 100 mg/m2 IV starting 24 hours after the start of the methotrexate infusion and continue
every 6 hours until methotrexate level undetectable, rituximab 375 mg/m2 IV Day 3, 10, 17, 24 of Cycle 1 and Day 3, 10
of Cycle 2 for a total of 6 doses, temozolomide 150 mg/m2 by mouth daily Days 7 through 11.
CYCLE LENGTH: 28 days.
COURSE LENGTH: 4 Cycles, followed by restaging. Patients achieving a complete/unconfirmed complete response may
continue to Cycle 5.
THERAPY (INDUCTION AFTER RESTAGING): methotrexate 8000 mg/m2 IV over 4 hours Day 1 for one
dose, leucovorin 100 mg/m2 IV starting 24 hours after the start of the methotrexate infusion and continue every 6 hours
until methotrexate level undetectable, temozolomide 150 mg/m2 by mouth daily Days 7 through 11.
CYCLE LENGTH: 28 days.
COURSE LENGTH: 1 Cycle.
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.
NOTE:
ONCE, 1 dose Starting when released
Hold TMP/SMX during infusion and until methotrexate level is undetectable.
Pre-Labs
CBC WITH DIFFERENTIAL
ONCE Starting when released, Routine
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
ALBUMIN
ONCE Starting when released
PROTEIN, TOTAL
ONCE Starting when released
BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALT/SGPT
ONCE Starting when released
ALKALINE PHOSPHATASE
ONCE Starting when released
Pre-Labs (delete all that do not apply)
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Zztestonc,Edward E [2435061]
3/3/2016 11:55:18 AM Page 35 of 54
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HCG, QUANTITATIVE
ONCE Starting when released, Routine
Additional Labs
PH, URINE (METHOTREXATE PROTOCOL)
ONCE Starting when released
Obtain pH, Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 2 HOURS Starting when released for 2 occurrences
Obtain pH, Urine (Methotrexate Protocol) at 2 hours and 4 hours after start of Methotrexate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting when released for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is
undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting S+8 at 0000 for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is
undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
CONDITIONAL - RN COLLECT Starting when released until S+7 for 7 days
If Urine pH falls below 7, obtain pH, Urine (Methotrexate Protocol) every 2 hours as needed until Urine pH is greater than
or equal to 7 for two consecutive occurrences.
METHOTREXATE
ONCE Starting when released
Obtain methotrexate level 24 hours after the start of methotrexate infusion.
METHOTREXATE
NEXT AM Starting S+2 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate
levels when drug level is undetectable.
METHOTREXATE
NEXT AM Starting S+9 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate
levels when drug level is undetectable.
CREATININE
ONCE Starting when released
Obtain creatinine at 24 hours after the start of methotrexate infusion.
CREATININE
NEXT AM Starting S+2 As Scheduled for 7 days
CREATININE
NEXT AM Starting S+9 As Scheduled for 7 days
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total Bilirubin, AST, ALT, Alkaline Phosphatase,
Creatinine, pH Urine (Methotrexate Protocol).
Verify Labs (2)
Verify ongoing treatment labs: Creatinine, pH, Urine (Methotrexate Protocol) and Methotrexate
levels.
Treatment Parameters
Hold treatment and notify authorizing prescriber for: Creatinine greater than 1.5 mg/dL or
Creatinine Clearance less than 60 mL/min or Total bilirubin greater than or equal to 2 mg/dL or AST greater than 2.5 X
ULN or ALT greater than 2.5 X ULN or Alkaline Phosphatase greater than 2.5 X ULN.
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3/3/2016 11:55:18 AM Page 36 of 54
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Treatment Parameters (2)
Do not administer methotrexate until urine pH is greater than or equal to 7.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Check pH Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion. If
less than 7, give sodium bicarbonate 50 mEq IV. See Conditional Medications.
Monitoring Parameters (2)
Check pH Urine (Methotrexate Protocol) at 2 hours, 4 hours, and 8 hours after start of methotrexate
and then every 8 hours until methotrexate level is undetectable. If less than 7, give sodium bicarbonate 50 mEq IV and
check urine pH every 2 hours until urine pH is greater than or equal to 7. See Conditional Medications and Additional
Labs.
Nursing Communication
CONTINUOUS Starting when released Until Specified
If sodium bicarbonate bolus given, recheck Urine pH in 2 hours. If two boluses of sodium bicarbonate have been given in
8 hours or three boluses in 24 hours, notify pharmacy and provider to review IV fluid orders.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium bicarbonate 100 mEq in dextrose 5 % 1,000 mL infusion
Intravenous, CONTINUOUS Starting when released Until Discontinued
Begin 4 hours prior to start of methotrexate. May discontinue when methotrexate level is undetectable. Sodium
Bicarbonate infusion must NOT be interrupted for any reason without an order from the attending physician or fellow.
NOTE:
EVERY 6 HOURS Starting when released
Sodium Bicarbonate infusion must NOT be interrupted for any reason without an order from the attending physician or
fellow.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
May give IV if unable to tolerate oral dose.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, EVERY 24 HOURS PRN, For 48 hours Starting when released,
nausea/vomiting, if unable to tolerate PO
If unable to tolerate the oral dose
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Once prior to methotrexate. If unable to give PO may give IV.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, EVERY 24 HOURS PRN, For 48 hours Starting when released,
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Zztestonc,Edward E [2435061]
3/3/2016 11:55:18 AM Page 37 of 54
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nausea/vomiting
Administer prior to methotrexate. If unable to give PO may give IV.
Treatment Medications
methotrexate PF 16,080 mg in dextrose 5 % 1,000 mL bag
16,080 mg (8,000 mg/m2 × 2.01 m2 Treatment plan actual BSA), Intravenous, ONCE, 1 dose
Starting when released
Day 15. Administer over 4 hours. Do not start until Urine pH is greater than or equal to 7.
leucovorin 20 MG/ML injection 201 mg
201 mg (100 mg/m2 × 2.01 m2 Treatment plan actual BSA), Intravenous, EVERY 6 HOURS
Starting S+1 at 0000, for 3 Minutes
Day 16. Administer over 3 to 5 minutes. Start 24 hours after the START of methotrexate infusion. May discontinue when
methotrexate level is undetectable.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s):
temozolomide (Dispensed on Day 1 of each cycle)
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
Supportive Care Medications (delete all that do not apply)
Note to All Staff (1)
Delete fungal prophylaxis if patient is not on continuous steroids.
clotrimazole (MYCELEX) troche 10 mg
10 mg, Oral, 2 X DAILY Starting when released
For patients on continuous steroids. Dissolve in mouth. Do not chew.
fluconazole (DIFLUCAN) tab 400 mg
400 mg, Oral, 1 X DAILY Starting when released
For patients on continuous steroids
Conditional Orders
sodium bicarbonate 8.4 % injection 50 mEq
50 mEq, Intravenous, EVERY 2 HOURS PRN, For 7 days Starting when released until S+7, For
urine pH less than 7, for 1 Minutes
Administer over 1 to 2 minutes. Give if urine pH is less than 7. May discontinue when methotrexate level is undetectable.
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
If unable to take PO, may give IV.
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued,
nausea/vomiting, If unable to tolerate PO.
IV push slowly, max rate 5 mg/minute.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
Do not exceed total of 24 mg ondansetron per 24 hours (scheduled and PRN)
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued,
nausea/vomiting, If unable to tolerate PO., for 3 Minutes
Do not exceed total of 24 mg of ondansetron per 24 hours (scheduled and PRN). Administer over 3 to 5 minutes
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3/3/2016 11:55:18 AM Page 38 of 54
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Take Home Medications
leucovorin 15 MG tab
Take 1 tab by mouth every 6 hours. Take until seen in clinic for follow up appt to confirm
methotrexate level undetectable, 15 mg, Disp-16 tab, R-0, EVERY 6 HOURS starting S
sodium bicarbonate oral powder
Mix 1/2 teaspoon sodium bicarbonate oral powder (baking soda) in 6-8 ounces of a non-acidic fluid
and drink by mouth at 8 AM, 12 PM, 4 PM, 10 PM the day before methotrexate treatment and at 8 AM the morning of
methotrexate treatment., Disp-1 Bottle, R-0, starting S, No Print
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 24 (Lab Day Only), Cycle 3 – Planned for 5/21/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Primary CNS Lymphoma.
THERAPY (INDUCTION): methotrexate 8000 mg/m2 IV over 4 hours Day 1,15 of Cycles 1 through 3 and Day 1 of Cycle
4 for total of 7 doses, leucovorin 100 mg/m2 IV starting 24 hours after the start of the methotrexate infusion and continue
every 6 hours until methotrexate level undetectable, rituximab 375 mg/m2 IV Day 3, 10, 17, 24 of Cycle 1 and Day 3, 10
of Cycle 2 for a total of 6 doses, temozolomide 150 mg/m2 by mouth daily Days 7 through 11.
CYCLE LENGTH: 28 days.
COURSE LENGTH: 4 Cycles, followed by restaging. Patients achieving a complete/unconfirmed complete response may
continue to Cycle 5.
THERAPY (INDUCTION AFTER RESTAGING): methotrexate 8000 mg/m2 IV over 4 hours Day 1 for one
dose, leucovorin 100 mg/m2 IV starting 24 hours after the start of the methotrexate infusion and continue every 6 hours
until methotrexate level undetectable, temozolomide 150 mg/m2 by mouth daily Days 7 through 11.
CYCLE LENGTH: 28 days.
COURSE LENGTH: 1 Cycle.
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.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Edward E [2435061]
3/3/2016 11:55:18 AM Page 39 of 54
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2016CCKM@uwhealth.org

Cycle 4 – 5/26/2016 through 6/22/2016 (28 days), Planned
Day 1 through 3 (Inpatient), Cycle 4 – Planned for 5/26/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Primary CNS Lymphoma.
THERAPY (INDUCTION): methotrexate 8000 mg/m2 IV over 4 hours Day 1,15 of Cycles 1 through 3 and Day 1 of Cycle
4 for total of 7 doses, leucovorin 100 mg/m2 IV starting 24 hours after the start of the methotrexate infusion and continue
every 6 hours until methotrexate level undetectable, rituximab 375 mg/m2 IV Day 3, 10, 17, 24 of Cycle 1 and Day 3, 10
of Cycle 2 for a total of 6 doses, temozolomide 150 mg/m2 by mouth daily Days 7 through 11.
CYCLE LENGTH: 28 days.
COURSE LENGTH: 4 Cycles, followed by restaging. Patients achieving a complete/unconfirmed complete response may
continue to Cycle 5.
THERAPY (INDUCTION AFTER RESTAGING): methotrexate 8000 mg/m2 IV over 4 hours Day 1 for one
dose, leucovorin 100 mg/m2 IV starting 24 hours after the start of the methotrexate infusion and continue every 6 hours
until methotrexate level undetectable, temozolomide 150 mg/m2 by mouth daily Days 7 through 11.
CYCLE LENGTH: 28 days.
COURSE LENGTH: 1 Cycle.
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.
NOTE:
ONCE, 1 dose Starting when released
Hold TMP/SMX during infusion and until methotrexate level is undetectable.
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
ALBUMIN
ONCE Starting when released
PROTEIN, TOTAL
ONCE Starting when released
BILIRUBIN, TOTAL
ONCE Starting when released
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Zztestonc,Edward E [2435061]
3/3/2016 11:55:18 AM Page 40 of 54
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AST/SGOT
ONCE Starting when released
ALT/SGPT
ONCE Starting when released
ALKALINE PHOSPHATASE
ONCE Starting when released
Pre-Labs (delete all that do not apply)
HCG, QUANTITATIVE
ONCE Starting when released, Routine
Additional Labs
PH, URINE (METHOTREXATE PROTOCOL)
ONCE Starting when released
Obtain pH, Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 2 HOURS Starting when released for 2 occurrences
Obtain pH, Urine (Methotrexate Protocol) at 2 hours and 4 hours after start of Methotrexate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting when released for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is
undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting S+8 at 0000 for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is
undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
CONDITIONAL - RN COLLECT Starting when released until S+7 for 7 days
If Urine pH falls below 7, obtain pH, Urine (Methotrexate Protocol) every 2 hours as needed until Urine pH is greater than
or equal to 7 for two consecutive occurrences.
METHOTREXATE
ONCE Starting when released
Obtain methotrexate level 24 hours after the start of methotrexate infusion.
METHOTREXATE
NEXT AM Starting S+2 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate
levels when drug level is undetectable.
METHOTREXATE
NEXT AM Starting S+9 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate
levels when drug level is undetectable.
CREATININE
ONCE Starting when released
Obtain creatinine at 24 hours after the start of methotrexate infusion.
CREATININE
NEXT AM Starting S+2 As Scheduled for 7 days
CREATININE
NEXT AM Starting S+9 As Scheduled for 7 days
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Zztestonc,Edward E [2435061]
3/3/2016 11:55:18 AM Page 41 of 54
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Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total Bilirubin, AST, ALT, Alkaline Phosphatase,
Creatinine, pH Urine (Methotrexate Protocol).
Verify Labs (2)
Verify ongoing treatment labs: Creatinine, pH, Urine (Methotrexate Protocol) and Methotrexate
levels.
Treatment Parameters
Hold treatment and notify authorizing prescriber for: Creatinine greater than 1.5 mg/dL or Creatinine
Clearance less than 60 mL/min or Total bilirubin greater than or equal to 2 mg/dL or AST greater than 2.5 X ULN or ALT
greater than 2.5 X ULN or Alkaline Phosphatase greater than 2.5 X ULN.
Treatment Parameters (2)
Do not administer methotrexate until urine pH is greater than or equal to 7.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Check pH Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion. If less
than 7, give sodium bicarbonate 50 mEq IV. See Conditional Medications.
Monitoring Parameters (2)
Check pH Urine (Methotrexate Protocol) at 2 hours, 4 hours, and 8 hours after start of methotrexate
and then every 8 hours until methotrexate level is undetectable. If less than 7, give sodium bicarbonate 50 mEq IV and
check urine pH every 2 hours until urine pH is greater than or equal to 7. See Conditional Medications and Additional
Labs.
Nursing Communication
CONTINUOUS Starting when released Until Specified
If sodium bicarbonate bolus given, recheck Urine pH in 2 hours. If two boluses of sodium bicarbonate have been given in
8 hours or three boluses in 24 hours, notify pharmacy and provider to review IV fluid orders.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium bicarbonate 100 mEq in dextrose 5 % 1,000 mL infusion
Intravenous, CONTINUOUS Starting when released Until Discontinued
Begin 4 hours prior to start of methotrexate. May discontinue when methotrexate level is undetectable. Sodium
Bicarbonate infusion must NOT be interrupted for any reason without an order from the attending physician or fellow.
NOTE:
EVERY 6 HOURS Starting when released
Sodium Bicarbonate infusion must NOT be interrupted for any reason without an order from the attending physician or
fellow.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
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Zztestonc,Edward E [2435061]
3/3/2016 11:55:18 AM Page 42 of 54
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2016CCKM@uwhealth.org

May give IV if unable to tolerate oral dose.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, EVERY 24 HOURS PRN, For 48 hours Starting when released,
nausea/vomiting, if unable to tolerate PO
If unable to tolerate the oral dose
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Once prior to methotrexate. If unable to give PO may give IV.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, EVERY 24 HOURS PRN, For 48 hours Starting when released,
nausea/vomiting
Administer prior to methotrexate. If unable to give PO may give IV.
Treatment Medications
methotrexate PF 16,080 mg in dextrose 5 % 1,000 mL bag
16,080 mg (8,000 mg/m2 × 2.01 m2 Treatment plan actual BSA), Intravenous, ONCE, 1 dose
Starting when released
Day 1. Administer over 4 hours. Do not start until Urine pH is greater than or equal to 7.
leucovorin 20 MG/ML injection 201 mg
201 mg (100 mg/m2 × 2.01 m2 Treatment plan actual BSA), Intravenous, EVERY 6 HOURS
Starting S+1 at 0000, for 3 Minutes
Day 2. Administer over 3 to 5 minutes. Start 24 hours after the START of methotrexate infusion. May discontinue when
methotrexate level is undetectable.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s):
temozolomide (Dispensed on Day 1 of each cycle)
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
Supportive Care Medications (delete all that do not apply)
Note to All Staff (1)
Delete fungal prophylaxis if patient is not on continuous steroids.
clotrimazole (MYCELEX) troche 10 mg
10 mg, Oral, 2 X DAILY Starting when released
For patients on continuous steroids. Dissolve in mouth. Do not chew.
fluconazole (DIFLUCAN) tab 400 mg
400 mg, Oral, 1 X DAILY Starting when released
For patients on continuous steroids
Conditional Orders
sodium bicarbonate 8.4 % injection 50 mEq
50 mEq, Intravenous, EVERY 2 HOURS PRN, For 7 days Starting when released until S+7, For
urine pH less than 7, for 1 Minutes
Administer over 1 to 2 minutes. Give if urine pH is less than 7. May discontinue when methotrexate level is undetectable.
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
If unable to take PO, may give IV.
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Zztestonc,Edward E [2435061]
3/3/2016 11:55:18 AM Page 43 of 54
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2016CCKM@uwhealth.org

prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued,
nausea/vomiting, If unable to tolerate PO.
IV push slowly, max rate 5 mg/minute.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
Do not exceed total of 24 mg ondansetron per 24 hours (scheduled and PRN)
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued,
nausea/vomiting, If unable to tolerate PO., for 3 Minutes
Do not exceed total of 24 mg of ondansetron per 24 hours (scheduled and PRN). Administer over 3 to 5 minutes
Take Home Medications (delete all that do not apply)
temozolomide (TEMODAR) 250 MG cap
On Days 7 through 11, take *** caps by mouth one time daily at bedtime. Total daily dose is ***
mg., R-0, starting S, Local Printer
Temozolomide dose is 150 mg/m2/day, based on *** m2
temozolomide (TEMODAR) 180 MG cap
On Days 7 through 11, take *** caps by mouth one time daily at bedtime. Total daily dose is ***
mg., R-0, starting S, Local Printer
Temozolomide dose is 150 mg/m2/day, based on *** m2
temozolomide (TEMODAR) 140 MG cap
On Days 7 through 11, take *** caps by mouth one time daily at bedtime. Total daily dose is ***
mg., R-0, starting S, Local Printer
Temozolomide dose is 150 mg/m2/day, based on *** m2
temozolomide (TEMODAR) 100 MG cap
On Days 7 through 11, take *** caps by mouth one time daily at bedtime. Total daily dose is ***
mg., R-0, starting S
Temozolomide dose is 150 mg/m2/day, based on *** m2
temozolomide (TEMODAR) 20 MG cap
On Days 7 through 11, take *** caps by mouth one time daily at bedtime. Total daily dose is ***
mg., R-0, starting S
Temozolomide dose is 150 mg/m2/day, based on *** m2
Take Home Medications
leucovorin 15 MG tab
Take 1 tab by mouth every 6 hours. Take until seen in clinic for follow up appt to confirm
methotrexate level undetectable, 15 mg, Disp-16 tab, R-0, EVERY 6 HOURS starting S
sodium bicarbonate oral powder
Mix 1/2 teaspoon sodium bicarbonate oral powder (baking soda) in 6-8 ounces of a non-acidic fluid
and drink by mouth at 8 AM, 12 PM, 4 PM, 10 PM the day before methotrexate treatment and at 8 AM the morning of
methotrexate treatment., Disp-1 Bottle, R-0, starting S, No Print
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC with DIFF, Creatinine.
DAY 17 FOLLOW-UP
LABS: CBC with DIFF, Creatinine.
DAY 24 FOLLOW-UP
LABS: CBC with DIFF, Creatinine.
DAY 29 FOLLOW-UP
Schedule provider visit for follow up.
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Zztestonc,Edward E [2435061]
3/3/2016 11:55:18 AM Page 44 of 54
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2016CCKM@uwhealth.org

Day 10 (Lab Day Only), Cycle 4 – Planned for 6/4/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Primary CNS Lymphoma.
THERAPY (INDUCTION): methotrexate 8000 mg/m2 IV over 4 hours Day 1,15 of Cycles 1 through 3 and Day 1 of Cycle
4 for total of 7 doses, leucovorin 100 mg/m2 IV starting 24 hours after the start of the methotrexate infusion and continue
every 6 hours until methotrexate level undetectable, rituximab 375 mg/m2 IV Day 3, 10, 17, 24 of Cycle 1 and Day 3, 10
of Cycle 2 for a total of 6 doses, temozolomide 150 mg/m2 by mouth daily Days 7 through 11.
CYCLE LENGTH: 28 days.
COURSE LENGTH: 4 Cycles, followed by restaging. Patients achieving a complete/unconfirmed complete response may
continue to Cycle 5.
THERAPY (INDUCTION AFTER RESTAGING): methotrexate 8000 mg/m2 IV over 4 hours Day 1 for one
dose, leucovorin 100 mg/m2 IV starting 24 hours after the start of the methotrexate infusion and continue every 6 hours
until methotrexate level undetectable, temozolomide 150 mg/m2 by mouth daily Days 7 through 11.
CYCLE LENGTH: 28 days.
COURSE LENGTH: 1 Cycle.
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.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 17 ( Lab Day Only) , Cycle 4 – Planned for 6/11/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Primary CNS Lymphoma.
THERAPY (INDUCTION): methotrexate 8000 mg/m2 IV over 4 hours Day 1,15 of Cycles 1 through 3 and Day 1 of Cycle
4 for total of 7 doses, leucovorin 100 mg/m2 IV starting 24 hours after the start of the methotrexate infusion and continue
every 6 hours until methotrexate level undetectable, rituximab 375 mg/m2 IV Day 3, 10, 17, 24 of Cycle 1 and Day 3, 10
of Cycle 2 for a total of 6 doses, temozolomide 150 mg/m2 by mouth daily Days 7 through 11.
CYCLE LENGTH: 28 days.
COURSE LENGTH: 4 Cycles, followed by restaging. Patients achieving a complete/unconfirmed complete response may
continue to Cycle 5.
THERAPY (INDUCTION AFTER RESTAGING): methotrexate 8000 mg/m2 IV over 4 hours Day 1 for one
dose, leucovorin 100 mg/m2 IV starting 24 hours after the start of the methotrexate infusion and continue every 6 hours
until methotrexate level undetectable, temozolomide 150 mg/m2 by mouth daily Days 7 through 11.
CYCLE LENGTH: 28 days.
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3/3/2016 11:55:18 AM Page 45 of 54
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COURSE LENGTH: 1 Cycle.
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.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 24 (Lab Day Only), Cycle 4 – Planned for 6/18/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Primary CNS Lymphoma.
THERAPY (INDUCTION): methotrexate 8000 mg/m2 IV over 4 hours Day 1,15 of Cycles 1 through 3 and Day 1 of Cycle
4 for total of 7 doses, leucovorin 100 mg/m2 IV starting 24 hours after the start of the methotrexate infusion and continue
every 6 hours until methotrexate level undetectable, rituximab 375 mg/m2 IV Day 3, 10, 17, 24 of Cycle 1 and Day 3, 10
of Cycle 2 for a total of 6 doses, temozolomide 150 mg/m2 by mouth daily Days 7 through 11.
CYCLE LENGTH: 28 days.
COURSE LENGTH: 4 Cycles, followed by restaging. Patients achieving a complete/unconfirmed complete response may
continue to Cycle 5.
THERAPY (INDUCTION AFTER RESTAGING): methotrexate 8000 mg/m2 IV over 4 hours Day 1 for one
dose, leucovorin 100 mg/m2 IV starting 24 hours after the start of the methotrexate infusion and continue every 6 hours
until methotrexate level undetectable, temozolomide 150 mg/m2 by mouth daily Days 7 through 11.
CYCLE LENGTH: 28 days.
COURSE LENGTH: 1 Cycle.
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.
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
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Zztestonc,Edward E [2435061]
3/3/2016 11:55:18 AM Page 46 of 54
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CREATININE
Expected-S Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 – 6/23/2016 through 7/20/2016 (28 days), Planned
Day 1 through 3 (Inpatient), Cycle 5 – Planned for 6/23/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Primary CNS Lymphoma.
THERAPY (INDUCTION): methotrexate 8000 mg/m2 IV over 4 hours Day 1,15 of Cycles 1 through 3 and Day 1 of Cycle
4 for total of 7 doses, leucovorin 100 mg/m2 IV starting 24 hours after the start of the methotrexate infusion and continue
every 6 hours until methotrexate level undetectable, rituximab 375 mg/m2 IV Day 3, 10, 17, 24 of Cycle 1 and Day 3, 10
of Cycle 2 for a total of 6 doses, temozolomide 150 mg/m2 by mouth daily Days 7 through 11.
CYCLE LENGTH: 28 days.
COURSE LENGTH: 4 Cycles, followed by restaging. Patients achieving a complete/unconfirmed complete response may
continue to Cycle 5.
THERAPY (INDUCTION AFTER RESTAGING): methotrexate 8000 mg/m2 IV over 4 hours Day 1 for one
dose, leucovorin 100 mg/m2 IV starting 24 hours after the start of the methotrexate infusion and continue every 6 hours
until methotrexate level undetectable, temozolomide 150 mg/m2 by mouth daily Days 7 through 11.
CYCLE LENGTH: 28 days.
COURSE LENGTH: 1 Cycle.
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.
NOTE:
ONCE, 1 dose Starting when released
Hold TMP/SMX during infusion and until methotrexate level is undetectable.
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
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3/3/2016 11:55:18 AM Page 47 of 54
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CALCIUM
ONCE Starting when released
ALBUMIN
ONCE Starting when released
PROTEIN, TOTAL
ONCE Starting when released
BILIRUBIN, TOTAL
ONCE Starting when released
AST/SGOT
ONCE Starting when released
ALT/SGPT
ONCE Starting when released
ALKALINE PHOSPHATASE
ONCE Starting when released
Pre-Labs (delete all that do not apply)
HCG, QUANTITATIVE
ONCE Starting when released, Routine
Additional Labs
PH, URINE (METHOTREXATE PROTOCOL)
ONCE Starting when released
Obtain pH, Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 2 HOURS Starting when released for 2 occurrences
Obtain pH, Urine (Methotrexate Protocol) at 2 hours and 4 hours after start of Methotrexate infusion.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting when released for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is
undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
EVERY 8 HOURS Starting S+8 at 0000 for 7 days
Obtain pH, Urine (Methotrexate Protocol) every 8 hours after start of methotrexate infusion until methotrexate level is
undetectable.
PH, URINE (METHOTREXATE PROTOCOL)
CONDITIONAL - RN COLLECT Starting when released until S+7 for 7 days
If Urine pH falls below 7, obtain pH, Urine (Methotrexate Protocol) every 2 hours as needed until Urine pH is greater than
or equal to 7 for two consecutive occurrences.
METHOTREXATE
ONCE Starting when released
Obtain methotrexate level 24 hours after the start of methotrexate infusion.
METHOTREXATE
NEXT AM Starting S+2 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate
levels when drug level is undetectable.
METHOTREXATE
NEXT AM Starting S+9 As Scheduled for 7 days
Methotrexate level every AM starting 24 hours after start of methotrexate infusion. May discontinue daily methotrexate
levels when drug level is undetectable.
CREATININE
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3/3/2016 11:55:18 AM Page 48 of 54
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ONCE Starting when released
Obtain creatinine at 24 hours after the start of methotrexate infusion.
CREATININE
NEXT AM Starting S+2 As Scheduled for 7 days
CREATININE
NEXT AM Starting S+9 As Scheduled for 7 days
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total Bilirubin, AST, ALT, Alkaline Phosphatase,
Creatinine, pH Urine (Methotrexate Protocol).
Verify Labs (2)
Verify ongoing treatment labs: Creatinine, pH, Urine (Methotrexate Protocol) and Methotrexate
levels.
Treatment Parameters
Hold treatment and notify authorizing prescriber for: Creatinine greater than 1.5 mg/dL or
Creatinine Clearance less than 60 mL/min or Total bilirubin greater than or equal to 2 mg/dL or AST greater than 2.5 X
ULN or ALT greater than 2.5 X ULN or Alkaline Phosphatase greater than 2.5 X ULN.
Treatment Parameters (2)
Do not administer methotrexate until urine pH is greater than or equal to 7.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Check pH Urine (Methotrexate Protocol) at 3 hours after start of sodium bicarbonate infusion. If
less than 7, give sodium bicarbonate 50 mEq IV. See Conditional Medications.
Monitoring Parameters (2)
Check pH Urine (Methotrexate Protocol) at 2 hours, 4 hours, and 8 hours after start of methotrexate
and then every 8 hours until methotrexate level is undetectable. If less than 7, give sodium bicarbonate 50 mEq IV and
check urine pH every 2 hours until urine pH is greater than or equal to 7. See Conditional Medications and Additional
Labs.
Nursing Communication
CONTINUOUS Starting when released Until Specified
If sodium bicarbonate bolus given, recheck Urine pH in 2 hours. If two boluses of sodium bicarbonate have been given in
8 hours or three boluses in 24 hours, notify pharmacy and provider to review IV fluid orders.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium bicarbonate 100 mEq in dextrose 5 % 1,000 mL infusion
Intravenous, CONTINUOUS Starting when released Until Discontinued
Begin 4 hours prior to start of methotrexate. May discontinue when methotrexate level is undetectable. Sodium
Bicarbonate infusion must NOT be interrupted for any reason without an order from the attending physician or fellow.
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3/3/2016 11:55:18 AM Page 49 of 54
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NOTE:
EVERY 6 HOURS Starting when released
Sodium Bicarbonate infusion must NOT be interrupted for any reason without an order from the attending physician or
fellow.
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
May give IV if unable to tolerate oral dose.
ondansetron (ZOFRAN) 16 mg in sodium chloride 0.9 % 50 mL bag
16 mg, Intravenous, EVERY 24 HOURS PRN, For 48 hours Starting when released,
nausea/vomiting, if unable to tolerate PO
If unable to tolerate the oral dose
dexamethasone (DECADRON) tab 10 mg
10 mg, Oral, ONCE, 1 dose Starting when released
Once prior to methotrexate. If unable to give PO may give IV.
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, EVERY 24 HOURS PRN, For 48 hours Starting when released,
nausea/vomiting
Administer prior to methotrexate. If unable to give PO may give IV.
Treatment Medications
methotrexate PF 16,080 mg in dextrose 5 % 1,000 mL bag
16,080 mg (8,000 mg/m2 × 2.01 m2 Treatment plan actual BSA), Intravenous, ONCE, 1 dose
Starting when released
Day 1. Administer over 4 hours. Do not start until Urine pH is greater than or equal to 7.
leucovorin 20 MG/ML injection 201 mg
201 mg (100 mg/m2 × 2.01 m2 Treatment plan actual BSA), Intravenous, EVERY 6 HOURS
Starting S+1 at 0000, for 3 Minutes
Day 2. Administer over 3 to 5 minutes. Start 24 hours after the START of methotrexate infusion. May discontinue when
methotrexate level is undetectable.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s):
temozolomide (Dispensed on Day 1 of each cycle)
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
Supportive Care Medications (delete all that do not apply)
Note to All Staff (1)
Delete fungal prophylaxis if patient is not on continuous steroids.
clotrimazole (MYCELEX) troche 10 mg
10 mg, Oral, 2 X DAILY Starting when released
For patients on continuous steroids. Dissolve in mouth. Do not chew.
fluconazole (DIFLUCAN) tab 400 mg
400 mg, Oral, 1 X DAILY Starting when released
For patients on continuous steroids
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3/3/2016 11:55:18 AM Page 50 of 54
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Conditional Orders
sodium bicarbonate 8.4 % injection 50 mEq
50 mEq, Intravenous, EVERY 2 HOURS PRN, For 7 days Starting when released until S+7, For
urine pH less than 7, for 1 Minutes
Administer over 1 to 2 minutes. Give if urine pH is less than 7. May discontinue when methotrexate level is undetectable.
prochlorperazine (COMPAZINE) tab 10 mg
10 mg, Oral, EVERY 6 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
If unable to take PO, may give IV.
prochlorperazine (COMPAZINE) injection 10 mg
10 mg, Intravenous, EVERY 6 HOURS PRN Starting when released Until Discontinued,
nausea/vomiting, If unable to tolerate PO.
IV push slowly, max rate 5 mg/minute.
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, EVERY 8 HOURS PRN Starting when released Until Discontinued, nausea/vomiting
Do not exceed total of 24 mg ondansetron per 24 hours (scheduled and PRN)
ondansetron (ZOFRAN) injection 8 mg
8 mg, Intravenous, EVERY 8 HOURS PRN Starting when released Until Discontinued,
nausea/vomiting, If unable to tolerate PO., for 3 Minutes
Do not exceed total of 24 mg of ondansetron per 24 hours (scheduled and PRN). Administer over 3 to 5 minutes
Take Home Medications (delete all that do not apply)
temozolomide (TEMODAR) 250 MG cap
On Days 7 through 11, take *** caps by mouth one time daily at bedtime. Total daily dose is ***
mg., R-0, starting S, Local Printer
Temozolomide dose is 150 mg/m2/day, based on *** m2
temozolomide (TEMODAR) 180 MG cap
On Days 7 through 11, take *** caps by mouth one time daily at bedtime. Total daily dose is ***
mg., R-0, starting S, Local Printer
Temozolomide dose is 150 mg/m2/day, based on *** m2
temozolomide (TEMODAR) 140 MG cap
On Days 7 through 11, take *** caps by mouth one time daily at bedtime. Total daily dose is ***
mg., R-0, starting S, Local Printer
Temozolomide dose is 150 mg/m2/day, based on *** m2
temozolomide (TEMODAR) 100 MG cap
On Days 7 through 11, take *** caps by mouth one time daily at bedtime. Total daily dose is ***
mg., R-0, starting S
Temozolomide dose is 150 mg/m2/day, based on *** m2
temozolomide (TEMODAR) 20 MG cap
On Days 7 through 11, take *** caps by mouth one time daily at bedtime. Total daily dose is ***
mg., R-0, starting S
Temozolomide dose is 150 mg/m2/day, based on *** m2
Take Home Medications
leucovorin 15 MG tab
Take 1 tab by mouth every 6 hours. Take until seen in clinic for follow up appt to confirm
methotrexate level undetectable, 15 mg, Disp-16 tab, R-0, EVERY 6 HOURS starting S
sodium bicarbonate oral powder
Mix 1/2 teaspoon sodium bicarbonate oral powder (baking soda) in 6-8 ounces of a non-acidic fluid
and drink by mouth at 8 AM, 12 PM, 4 PM, 10 PM the day before methotrexate treatment and at 8 AM the morning of
methotrexate treatment., Disp-1 Bottle, R-0, starting S, No Print
Follow-Up
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DAY 10 FOLLOW-UP
LABS: CBC with DIFF, Creatinine.
DAY 17 FOLLOW-UP
LABS: CBC with DIFF, Creatinine.
DAY 24 FOLLOW-UP
LABS: CBC with DIFF, Creatinine.
DAY 29 FOLLOW-UP
Schedule provider visit for follow up.
Day 10 (Lab Day Only), Cycle 5 – Planned for 7/2/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Primary CNS Lymphoma.
THERAPY (INDUCTION): methotrexate 8000 mg/m2 IV over 4 hours Day 1,15 of Cycles 1 through 3 and Day 1 of Cycle
4 for total of 7 doses, leucovorin 100 mg/m2 IV starting 24 hours after the start of the methotrexate infusion and continue
every 6 hours until methotrexate level undetectable, rituximab 375 mg/m2 IV Day 3, 10, 17, 24 of Cycle 1 and Day 3, 10
of Cycle 2 for a total of 6 doses, temozolomide 150 mg/m2 by mouth daily Days 7 through 11.
CYCLE LENGTH: 28 days.
COURSE LENGTH: 4 Cycles, followed by restaging. Patients achieving a complete/unconfirmed complete response may
continue to Cycle 5.
THERAPY (INDUCTION AFTER RESTAGING): methotrexate 8000 mg/m2 IV over 4 hours Day 1 for one
dose, leucovorin 100 mg/m2 IV starting 24 hours after the start of the methotrexate infusion and continue every 6 hours
until methotrexate level undetectable, temozolomide 150 mg/m2 by mouth daily Days 7 through 11.
CYCLE LENGTH: 28 days.
COURSE LENGTH: 1 Cycle.
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.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 17 ( Lab Day Only) , Cycle 5 – Planned for 7/9/2016
Treatment Plan Information
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Zztestonc,Edward E [2435061]
3/3/2016 11:55:18 AM Page 52 of 54
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2016CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Primary CNS Lymphoma.
THERAPY (INDUCTION): methotrexate 8000 mg/m2 IV over 4 hours Day 1,15 of Cycles 1 through 3 and Day 1 of Cycle
4 for total of 7 doses, leucovorin 100 mg/m2 IV starting 24 hours after the start of the methotrexate infusion and continue
every 6 hours until methotrexate level undetectable, rituximab 375 mg/m2 IV Day 3, 10, 17, 24 of Cycle 1 and Day 3, 10
of Cycle 2 for a total of 6 doses, temozolomide 150 mg/m2 by mouth daily Days 7 through 11.
CYCLE LENGTH: 28 days.
COURSE LENGTH: 4 Cycles, followed by restaging. Patients achieving a complete/unconfirmed complete response may
continue to Cycle 5.
THERAPY (INDUCTION AFTER RESTAGING): methotrexate 8000 mg/m2 IV over 4 hours Day 1 for one
dose, leucovorin 100 mg/m2 IV starting 24 hours after the start of the methotrexate infusion and continue every 6 hours
until methotrexate level undetectable, temozolomide 150 mg/m2 by mouth daily Days 7 through 11.
CYCLE LENGTH: 28 days.
COURSE LENGTH: 1 Cycle.
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.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 24 (Lab Day Only), Cycle 5 – Planned for 7/16/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Primary CNS Lymphoma.
THERAPY (INDUCTION): methotrexate 8000 mg/m2 IV over 4 hours Day 1,15 of Cycles 1 through 3 and Day 1 of Cycle
4 for total of 7 doses, leucovorin 100 mg/m2 IV starting 24 hours after the start of the methotrexate infusion and continue
every 6 hours until methotrexate level undetectable, rituximab 375 mg/m2 IV Day 3, 10, 17, 24 of Cycle 1 and Day 3, 10
of Cycle 2 for a total of 6 doses, temozolomide 150 mg/m2 by mouth daily Days 7 through 11.
CYCLE LENGTH: 28 days.
COURSE LENGTH: 4 Cycles, followed by restaging. Patients achieving a complete/unconfirmed complete response may
continue to Cycle 5.
THERAPY (INDUCTION AFTER RESTAGING): methotrexate 8000 mg/m2 IV over 4 hours Day 1 for one
dose, leucovorin 100 mg/m2 IV starting 24 hours after the start of the methotrexate infusion and continue every 6 hours
until methotrexate level undetectable, temozolomide 150 mg/m2 by mouth daily Days 7 through 11.
CYCLE LENGTH: 28 days.
COURSE LENGTH: 1 Cycle.
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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3/3/2016 11:55:18 AM Page 53 of 54
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2016CCKM@uwhealth.org

IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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3/3/2016 11:55:18 AM Page 54 of 54
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