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HEM Gemcitabine-Oxaliplatin (28D:2,16) Rituximab (28D:1,15 )(1059 VER: 02-02-16)

HEM Gemcitabine-Oxaliplatin (28D:2,16) Rituximab (28D:1,15 )(1059 VER: 02-02-16) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


VER: 08-11-16 (1059 VER: 02-02-16) Page 1 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Gemcitabine/Oxaliplatin/Rituximab
Disease Group: Hematology
Disease: Non-Hodgkin Lymphoma

Therapy: rituximab 375 mg/m2 IV Day 1 and 15,
oxaliplatin 100 mg/m2 IV Day 2 and 16,
gemcitabine 1000 mg/m2 IV Day 2 and 16,

Cycle Length: 28 days Course: 4 cycles

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): El Gnaoui T, et al. J Clin Oncol 2006;24(18S):abstract 7562; Savage DG, et al. Ann Oncol
2000;11(5):595-7

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


Cycle _______ Starting with:  Day 1 (date) ___________  Day 2 (date) ___________
 Day 15 (date) ___________  Day 16 (date) ___________
Pre labs:
• Cycle 1, Day 1: Obtain CBC without DIFF, ANC, Electrolytes, BUN, Creatinine, Glucose, Total Bilirubin, AST,
Alkaline Phosphatase, 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:

• Cycle ≥2, Day 1: Obtain CBC without DIFF, ANC, Electrolytes, BUN, Creatinine, Glucose, Total Bilirubin, AST,
Alkaline Phosphatase
 Other:

• Day 2: Obtain CBC with DIFF, Creatinine
 Other:

• Day 15: Obtain CBC without DIFF, ANC
 Other:

• Day 16: Obtain CBC with DIFF
 Other:

Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Verify the following labs have been obtained:
 Day 2: CBC with DIFF, Creatinine
 Day 16: CBC with DIFF
• Hold and notify provider for:
 Day 2: ANC ≤ 1000/µL or Platelets ≤ 75K/µL or Creatinine Clearance < 30 mL/min
 Day 16: ANC ≤ 1000/µL or Platelets ≤ 75K/µL

VER: 08-11-16 (1059 VER: 02-02-16) Page 2 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org

Nursing Procedure, Assessment and Monitoring:
• Monitor vital signs during rituximab infusion 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.
• Educate patients regarding the potential of occurrence for severe mucocutaneous reactions with rituximab.
• Educate/reinforce with patient regarding “cold neuropathy” that occurs with oxaliplatin.
• Flush/Line Care per Institution standards

Hydration/Fluids:
• Day 1 and 15: sodium chloride 0.9% IV to establish line and for flushing
• Day 2 and 16: dextrose 5% IV to establish line and for flushing

Premedications/Antiemetics: (May substitute formulary equivalent)
Day 1 and 15: Give prior to rituximab:
• acetaminophen (Tylenol) 650 mg by mouth once.
• diphenhydramine (Benadryl) 25 mg by mouth once.
 Other:

Day 2: Give prior to chemotherapy (*indicates preferred antiemetic regimen):
 *ondansetron (Zofran) 16 mg by mouth once. PO preferred – may give 8 mg IV if unable to tolerate PO.
 *dexamethasone (Decadron) 10 mg by mouth once. PO preferred – may give 10 mg IV if unable to tolerate
PO.
 fosaprepitant (Emend) 150 mg IV once.
 aprepitant (Emend) 125 mg by mouth once.
 palonosetron (Aloxi) 0.25 mg IV once.
 Other:

Day 16: Give prior to chemotherapy (*indicates preferred antiemetic regimen):
 *ondansetron (Zofran) 16 mg by mouth once. PO preferred – may give 8 mg IV if unable to tolerate PO.
 *dexamethasone (Decadron) 10 mg by mouth once. PO preferred – may give 10 mg IV if unable to tolerate
PO.
 fosaprepitant (Emend) 150 mg IV once.
 aprepitant (Emend) 125 mg by mouth once.
 palonosetron (Aloxi) 0.25 mg IV once.
 Other:

Treatment Medications for Day 1: (in order of administration)
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 patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.

Treatment Medications (continued on next page)

VER: 08-11-16 (1059 VER: 02-02-16) Page 3 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Treatment Medications for Day 2: (in order of administration)
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:


• gemcitabine (Gemzar) __________mg (1000 mg/m2) IV once over 30 minutes.
Additional sodium chloride 0.9% may be y-set into IV site to decrease irritation.

• oxaliplatin (Eloxatin) ____________ mg (100 mg/m2) IV once over 120 minutes
Incompatible with sodium chloride. Allow adequate flushing with dextrose 5% in water when necessary
between chemotherapy treatment medications. Hypersensitivity Risk. For first and second dose, patient
should be treated in a location to optimize emergency care.


Treatment Medications for Day 15: (in order of administration)
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 patient returns to baseline, infusion may be restarted at half the rate during which the reaction occurred.


Treatment Medications for Day 16: (in order of administration)
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:


• gemcitabine (Gemzar) __________mg (1000 mg/m2) IV once over 30 minutes.
Additional sodium chloride 0.9% may be y-set into IV site to decrease irritation.

• oxaliplatin (Eloxatin) ____________ mg (100 mg/m2) IV once over 120 minutes
Incompatible with sodium chloride. Allow adequate flushing with dextrose 5% in water when necessary
between chemotherapy treatment medications. Hypersensitivity Risk. For first and second dose, patient
should be treated in a location to optimize emergency care.


Other Orders for Day 1, 2, 15 and/or 16:








VER: 08-11-16 (1059 VER: 02-02-16) Page 4 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Take Home Medications - (Prescribe Cycle 1, Day 1: Review for adequate supply during treatment)
• ondansetron (Zofran) 8 mg tablet, Disp. #30, Refills: 5
Take 1 tablet (8 mg) by mouth every 8 hours as needed for nausea/vomiting.

• prochlorperazine (Compazine) 10 mg tablet, Disp. #30, Refills: 5
Take 1 tablet (10 mg) by mouth every 6 hours as needed for nausea/vomiting.

 aprepitant (Emend) 80 mg capsule, Disp. #2, Refills: 5
Take 1 capsule by mouth once daily for two days following chemotherapy.
(Prescribe only if patient received aprepitant as a premedication)


 Other:



Follow Up
• Chemotherapy: Day 1, 2, 15 and 16 every 28 days

• Labs:
 Day 21 and 24 – Obtain CBC with DIFF
 Other:


• Procedures/Imaging/Scans:







• Other Orders:





MD Signature_________________________________________ Pager______________
Date __________________Time___________________


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