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Rituximab Dose Rounding and Rapid Infusion Rate – Adult – Inpatient/Ambulatory [95]

Rituximab Dose Rounding and Rapid Infusion Rate – Adult – Inpatient/Ambulatory [95] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Ambulatory Delegation Protocols


Delegation Protocol Number: 95

Delegation Protocol Title:
Rituximab Dose Rounding and Rapid Infusion Rate - Adult - Inpatient/Ambulatory

Delegation Protocol Applies To:
UW Carbone Cancer Center, Infusion Center, 1 South Park Street, Transplant Clinic (Patients at Johnson
Creek are excluded.)

Target Patient Population:
Applies to all adult patients receiving rituximab

Delegation Protocol Champions:
Julie Chang, MD - Department of Medicine, Hematology/Oncology
Andrew Waclawik, MD - Department of Neurology
Arjang Djamali, MD - Department of Medicine, Nephrology
David Hei, MD - UW Health Hematology and Oncology Clinics

Delegation Protocol Reviewers:
MaryAnn Steiner, PharmD - Unity Drug Policy, Infusion Center
Mary Mably, RPh, BCOP - Pharmacy Oncology Coordinator
Mike Fallon, PharmD, BCPS - Pharmacy
Jess Branson, RN, DNP, OCN - Inpatient Clinical Nurse Specialist
Carin Endres, PharmD, BCPS - Drug Policy Program
Jodie Ritchie, PharmD - PharmD

Responsible Department:
Department of Pharmacy

Purpose Statement:
This protocol delegates authority from the rituximab-prescribing provider to pharmacists to round
rituximab doses to the nearest 100 mg and order the appropriate infusion rate of rituximab for patients
with documented tolerance to a previous rituximab infusion.

Who May Carry Out This Delegation Protocol:
Pharmacists trained in the use of this delegation protocol.

Guidelines for Implementation:
1. A pharmacist clinically reviews the rituximab order and rounds the dose by no more than 10% to the
nearest 100 mg.
2. The pharmacist reviews the medical record to determine if the patient is a candidate for a rapid
infusion rate. If the patient does not qualify for rapid infusion, the pharmacist will order the
standard infusion rate. Candidates for rapid infusion must:
2.1. Have previously received rituximab. The last dose must have been within the:
2.1.1. Previous 6 months to be eligible for a Rapid-90 Minute Infusion.
2.1.2. Previous 3 month to be eligible for a Rapid-60 Minute Infusion.
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

2.2. Have tolerated the previous administration as indicated by a progress note stating the patient
tolerated the infusion without slowing or stopping the infusion or requiring treatment for an
infusion reaction.
2.3. Meet all of the rate-specific inclusion criteria (Table 1):
Table 1. Inclusion Criteria for Rituximab Rapid Infusion
Rapid-90 Minute Infusion Rapid-60 Minute Infusion
Most recent circulating lymphocyte <5000
cells/mm
3
Most recent circulating lymphocyte <1000
cells/mm
3

Patient does not have New York Classification
(NYHC) III or IV heart failure
Patient does not have New York Classification
(NYHC) III or IV heart failure
Patient is not enrolled in an investigational study
that does not allow rapid infusion of rituximab
Patient is not enrolled in an investigational study
that does not allow rapid infusion of rituximab
Patient is receiving rituximab for a non-oncology
indication or for an oncology indication that does
not meet criteria for Rapid-60 minute infusion
Patient is receiving rituximab for an oncology
indication and does not have a diagnosis of
aggressive lymphoma (e.g. Burkitt’s or
lymphoblastic)
3. The pharmacist will modify the rituximab order with the appropriate rate instructions (see Table 2).
Table 2. Rituximab Infusion Rates
Rituximab Infusion Rate Initial Infusion Rate Titration Maximum Rate
Standard* 50 mg/h for 30 minutes 50 mg/h every 30 minutes 400 mg/h
Rapid- 90 Minute 240 mL/h for 30 minutes To 480 mL/h 480 mL/h
Rapid-60-Minute 240 mL/h for 15 minutes To 720 mL/h 720 mL/h
*Refer to Table 3 for titration of standard infusion rate

Table 3. Titration for Standard Infusion Rate
Total Dose Starting Rate Titration Rate Final Rate
500 mg/600 mL 60 mL/hr 60 mL/hr 480 mL/hr
600 mg/610 mL 51 mL/hr 51 mL/hr 408 mL/hr
700 mg/620 mL 44 mL/hr 44 mL/hr 352 mL/hr
800 mg/630 mL 39 mL/hr 39 mL/hr 312 mL/hr
900 mg/640 mL 36 mL/hr 36 mL/hr 288 mL/hr
1000 mg/650 mL 33 mL/hr 33 mL/hr 264 mL/hr
1100 mg/660 mL 30 mL/hr 30 mL/hr 240 mL/hr
1200 mg/670 mL 28 mL/hr 28 mL/hr 224 mL/hr

4. After completion, the Registered Nurse (RN) documents tolerance of the infusion (i.e., any reactions
during administration, slowing or stopping of the infusion and treatment required for infusion
reactions) in the electronic health record.
5. Prescriber may opt out of this protocol at any time by indicating the patient is not a candidate for
rapid infusion in the order.
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org



Order Mode: Meds: Protocol/Policy, Without Cosign

References:
1. Dotson E, Crawford B, Phillips G, Jones J. Sixty-minute infusion rituximab protocol allows for safe and
efficient workflow. Support Care Cancer. 2016;24(3):1125-1129.
Collateral Documents/Tools:
Rituximab - Adult - Inpatient/Ambulatory Clinical Practice Guideline
IP – Rituximab Non-Oncology Infusion Delegation Protocol – Adult – Supplemental Order Set [1825]
IP – Transplant – Immunosuppression - Rituximab – Adult – Supplemental Order Set [773]

Approved by:
UW Health Ambulatory Protocol Committee: October 2013; *April 2016; May 2017
UWHC Pharmacy and Therapeutics Committee: November 2013; *April 2016; May 2017
UWHC Medical Board: December 2014; *April 2016; May 2017
UW Health Chief Clinical Officer: February 2014; *April 2016; May 2017

Effective Date: May 2017

Scheduled for Review: May 2020
*Expedited Review Process
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org