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HEM NHL Rituximab (180D1,8,15,22) (1022 VER: 04-21-16)

HEM NHL Rituximab (180D1,8,15,22) (1022 VER: 04-21-16) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 05-24-16 (1022 VER: 04-21-16) Page 1 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Rituximab
Disease Group: Hematology
Disease: Lymphoma (CD20 positive), Mantle Cell Lymphoma

Therapy: rituximab 375 mg/m2 IV Day 1, 8, 15 and 22

Cycle Length: 28 days Course: May give 1 cycle every 6 months for up to 2 years as maintenance therapy

Note to all Staff: 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.

Reference(s): Hainsworth JD, et al. J Clin Oncol 2003;21(19):1746-51, Kahl BS, et al. J Clin Oncol
2014;32(28):3096-102, Ardeshna KM, et al. Lancet Oncol 2014;15(4):424-35.

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


Cycle 1: Starting with:  Day 1 (date) _____________  Day 8 (date) _____________
 Day 15 (date) ____________  Day 22 (date) ____________

Pre labs:
• Day 1: Obtain CBC with DIFF, Hepatitis B Core Antibody (Total), Hepatitis B Surface Antigen, Hepatitis B
Surface Antibody, Hepatitis B DNA Ultra Quantitative PCR (obtain only if Hepatitis B Core Antibody is
positive).
 Other:


Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.

Nursing Procedure, Assessment and Monitoring:
• Educate patients regarding the potential of occurrence for severe mucocutaneous reactions with rituximab.
• 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/Line Care per Institution standards

Hydration/Fluids: sodium chloride 0.9% IV to establish line and for flushing

Premedications/Antiemetics: (May substitute formulary equivalent)
Give prior to rituximab:
• Acetaminophen 650 mg by mouth once.
• Diphenhydramine 25 mg by mouth once
 Other:



Final Approved VER: 05-24-16 (1022 VER: 04-21-16) Page 2 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Treatment Medications for Day 1:
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:



• rituximab (Rituxan) __________mg (375 mg/m2) IV once.
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. Begin infusion at 50 mg/hr. If hypersensitivity or infusion-related events do not
occur, increase infusion rate in 50 mg/hr increments every 30 minutes to a maximum rate of 400 mg/hr. 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.

Treatment Medications for Day 8:
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:



• rituximab (Rituxan) __________mg (375 mg/m2) IV once.
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. Begin infusion at 50 mg/hr. If hypersensitivity or infusion-related events do not
occur, increase infusion rate in 50 mg/hr increments every 30 minutes to a maximum rate of 400 mg/hr. 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.

Treatment Medications for Day 15:
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:



• rituximab (Rituxan) __________mg (375 mg/m2) IV once.
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. Begin infusion at 50 mg/hr. If hypersensitivity or infusion-related events do not
occur, increase infusion rate in 50 mg/hr increments every 30 minutes to a maximum rate of 400 mg/hr. 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.




Treatment Medications (continued on next page)

Final Approved VER: 05-24-16 (1022 VER: 04-21-16) Page 3 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Treatment Medications for Day 22:
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:

• rituximab (Rituxan) __________mg (375 mg/m2) IV once.
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. Begin infusion at 50 mg/hr. If hypersensitivity or infusion-related events do not
occur, increase infusion rate in 50 mg/hr increments every 30 minutes to a maximum rate of 400 mg/hr. 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.

Other Orders for Day 1, 8, 15, 22:




Take Home Medications: (Prescribe Cycle 1, Day 1: Review for adequate supply during treatment)
 Other:




Follow Up
• Chemotherapy: Day 8, 15 and 22 only

• Labs:
 Other:


• Procedures/Imaging/Scans:





• Other Orders:




MD Signature_________________________________________ Pager______________
Date __________________Time___________________

Order Verification:
RN Signature: __________________________ Date: ___________ Time: __________ Pager #: ________
RPh Signature: _________________________ Date: ___________ Time: __________ Pager #: ________