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HEM Rituximab-Bortezomib-Dexamethasone Waldenstrom 3 PDFs for Cycle 1 thru 5 (4339 VER: 03-30-16)

HEM Rituximab-Bortezomib-Dexamethasone Waldenstrom 3 PDFs for Cycle 1 thru 5 (4339 VER: 03-30-16) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


VER: 07-28-16 (4339 VER: 03-30-16) Cycle 1, Page 1
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Rituximab/Bortezomib/Dexamethasone (RVD) – CYCLE 1 ONLY
Disease Group: Hematology
Disease: Waldenstrom Macroglobulinemia, Lymphoplasmacytic Lymphoma

Therapy: Cycle 1: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8, and 11
Cycle 2 AND 5: dexamethasone 40 mg (fixed dose) IV Day 1, 8, 15, and 22
rituximab 375 mg/m2 IV Day 1, 8, 15, and 22
bortezomib 1.6 mg/m2 subcutaneous Day 1, 8, 15, and 22

Cycle 3 AND 4: bortezomib 1.6 mg/m2 subcutaneous Day 1, 8, 15, and 22

Cycle Length (Cycle 1): 21 days, followed by
Cycle Length (Cycle 2, 3, 4, 5): 35 days Course: -5 cycles total

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): Dimopoulos M, et al. Blood 2013;122(19):3276-82.

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


Cycle _____ Starting with:  Day 1 (date) ___________  Day 4 (date) ___________  Day 8 (date) _________
 Day 11 (date) __________

Pre labs:
• Cycle 1, Day 1: Obtain CBC with DIFF, Electrolytes, BUN, Creatinine, Total Bilirubin, AST, LDH,
Immunoglobulins (A, G, M), 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.
• Day 1: Verify the following labs have been obtained: CBC with DIFF, IgM
• Day 1: Hold and notify provider for: ANC ≤ 1000/µL or Platelets ≤ 75K/µL
• Day 1: Notify provider for: IgM > 5000 mg/dL. IgM levels will be monitored for potential rituximab-induced
complications (hyperviscosity or IgM flare)

Nursing Procedure, Assessment and Monitoring: 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) - None



VER: 07-28-16 (4339 VER: 03-30-16) Cycle 1, Page 2
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org

Treatment Medications for Day 1 for Cycle 1: (in order of administration)
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:


• bortezomib (Velcade) __________ mg (1.3 mg/m2) subcutaneous


Treatment Medications for Day 4 for Cycle 1: (in order of administration)
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:


• bortezomib (Velcade) __________ mg (1.3 mg/m2) subcutaneous


Treatment Medications for Day 8 for Cycle 1: (in order of administration)
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:


• bortezomib (Velcade) __________ mg (1.3 mg/m2) subcutaneous


Treatment Medications for Day 11 for Cycle 1: (in order of administration)
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:


• bortezomib (Velcade) __________ mg (1.3 mg/m2) subcutaneous



Other Orders for Day 1, 4, 8, and/or 11:
















VER: 07-28-16 (4339 VER: 03-30-16) Cycle 1, Page 3
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.

• acyclovir (Zovirax) 400 mg tablet, Disp. #60, Refills: 5
Take 1 tablet (400 mg) by mouth two times daily.

 Other:



Follow Up
• Chemotherapy: Cycle 1: Day 1, 4, 8, 11 every 21 days
Cycle 2, 3, 4, 5: Day 1, 8, 15, 22 every 35 days

• Labs:
 Other:


• Procedures/Imaging/Scans:









• Other Orders:






MD Signature_________________________________________ Pager______________
Date __________________Time___________________

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

VER: 07-28-16 (4339 VER: 03-30-16) Cycle 2 and 5, Page 1
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Rituximab/Bortezomib/Dexamethasone (RVD) – CYCLE 2 AND 5 ONLY
Disease Group: Hematology
Disease: Waldenstrom Macroglobulinemia, Lymphoplasmacytic Lymphoma

Therapy: Cycle 1: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8, and 11
Cycle 2 AND 5: dexamethasone 40 mg (fixed dose) IV Day 1, 8, 15, and 22
rituximab 375 mg/m2 IV Day 1, 8, 15, and 22
bortezomib 1.6 mg/m2 subcutaneous Day 1, 8, 15, and 22

Cycle 3 AND 4: bortezomib 1.6 mg/m2 subcutaneous Day 1, 8, 15, and 22

Cycle Length (Cycle 1): 21 days, followed by
Cycle Length (Cycle 2, 3, 4, 5): 35 days Course: -5 cycles total

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): Dimopoulos M, et al. Blood 2013;122(19):3276-82.

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


Cycle _____ Starting with:  Day 1 (date) ___________  Day 8 (date) ___________  Day 15 (date) ________
 Day 22 (date) __________

Pre labs:
• Cycle ≥ 2, Day 1: Obtain CBC with DIFF, Electrolytes, BUN, Creatinine, Total Bilirubin, AST, IgM.
 Other:


Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Day 1: Verify the following labs have been obtained: CBC with DIFF, IgM
• Day 1: Hold and notify provider for: ANC ≤ 1000/µL or Platelets ≤ 75K/µL
• Day 1: Notify provider for: IgM > 5000 mg/dL. IgM levels will be monitored for potential rituximab-induced
complications (hyperviscosity or IgM flare)

Nursing Procedure, Assessment and Monitoring:
• Cycle 2 and 5, Day 1, 8, 15, 22: 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.
• Cycle ≥ 2: Educate patients regarding the potential of occurrence for severe mucocutaneous reactions with
rituximab.
• Flush/Line Care per Institution standards


VER: 07-28-16 (4339 VER: 03-30-16) Cycle 2 and 5, Page 2
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Hydration/Fluids: sodium chloride 0.9% IV to establish line and for flushing
Premedications/Antiemetics: (May substitute formulary equivalent)
Cycles 2 and 5, Day 1, 8, 15, 22: Give prior to rituximab:
• acetaminophen (Tylenol) 650 mg by mouth once.
• diphenhydramine (Benadryl) 25 mg by mouth once

Give prior to chemotherapy (*indicates preferred antiemetic regimen):
 Other:



Treatment Medications for Day 1 for Cycles 2 and 5: (in order of administration)
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:


• dexamethasone (Decadron) 40 mg (fixed dose) IV once over 30 minutes.

• 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.

• bortezomib (Velcade) __________ mg (1.6 mg/m2) subcutaneous


Treatment Medications for Day 8 for Cycles 2 and 5: (in order of administration)
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:


• dexamethasone (Decadron) 40 mg (fixed dose) IV once over 30 minutes.

• 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.

• bortezomib (Velcade) __________ mg (1.6 mg/m2) subcutaneous




VER: 07-28-16 (4339 VER: 03-30-16) Cycle 2 and 5, Page 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Treatment Medications for Day 15 for Cycles 2 and 5: (in order of administration)
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:


• dexamethasone (Decadron) 40 mg (fixed dose) IV once over 30 minutes.

• 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.

• bortezomib (Velcade) __________ mg (1.6 mg/m2) subcutaneous


Treatment Medications for Day 22 for Cycles 2 and 5: (in order of administration)
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:


• dexamethasone (Decadron) 40 mg (fixed dose) IV once over 30 minutes.

• 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.

• bortezomib (Velcade) __________ mg (1.6 mg/m2) subcutaneous

Other Orders for Day 1, 8, 15 and/or 22:













VER: 07-28-16 (4339 VER: 03-30-16) Cycle 2 and 5, Page 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.

• acyclovir (Zovirax) 400 mg tablet, Disp. #60, Refills: 5
Take 1 tablet (400 mg) by mouth two times daily.

 Other:



Follow Up
• Chemotherapy: Cycle 2, 3, 4, 5: Day 1, 8, 15, 22 every 35 days

• Labs:
 Other:


• Procedures/Imaging/Scans:









• Other Orders:







MD Signature_________________________________________ Pager______________
Date __________________Time___________________

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

VER: 07-28-16 (4339 VER: 03-30-16) Cycle 3 and 4, Page 1
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Rituximab/Bortezomib/Dexamethasone (RVD) – CYCLE 3 AND 4 ONLY
Disease Group: Hematology
Disease: Waldenstrom Macroglobulinemia, Lymphoplasmacytic Lymphoma

Therapy: Cycle 1: bortezomib 1.3 mg/m2 subcutaneous Day 1, 4, 8, and 11
Cycle 2 AND 5: dexamethasone 40 mg (fixed dose) IV Day 1, 8, 15, and 22
rituximab 375 mg/m2 IV Day 1, 8, 15, and 22
bortezomib 1.6 mg/m2 subcutaneous Day 1, 8, 15, and 22

Cycle 3 AND 4: bortezomib 1.6 mg/m2 subcutaneous Day 1, 8, 15, and 22

Cycle Length (Cycle 1): 21 days, followed by
Cycle Length (Cycle 2, 3, 4, 5): 35 days Course: -5 cycles total

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): Dimopoulos M, et al. Blood 2013;122(19):3276-82.

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


Cycle _____ Starting with:  Day 1 (date) ___________  Day 8 (date) __________  Day 15 (date) _________
 Day 22 (date) __________

Pre labs:
• Cycle ≥ 2, Day 1: Obtain CBC with DIFF, Electrolytes, BUN, Creatinine, Total Bilirubin, AST, IgM.
 Other:


Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Day 1: Verify the following labs have been obtained: CBC with DIFF, IgM
• Day 1: Hold and notify provider for: ANC ≤ 1000/µL or Platelets ≤ 75K/µL
• Day 1: Notify provider for: IgM > 5000 mg/dL. IgM levels will be monitored for potential rituximab-induced
complications (hyperviscosity or IgM flare)

Nursing Procedure, Assessment and Monitoring:
• Cycle ≥ 2: Educate patients regarding the potential of occurrence for severe mucocutaneous reactions with
rituximab.
• 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) - None


VER: 07-28-16 (4339 VER: 03-30-16) Cycle 3 and 4, Page 2
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Treatment Medications for Day 1 for Cycles 3 and 4: (in order of administration)
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:


• bortezomib (Velcade) __________ mg (1.6 mg/m2) subcutaneous



Treatment Medications for Day 8 for Cycles 3 and 4: (in order of administration)
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:


• bortezomib (Velcade) __________ mg (1.6 mg/m2) subcutaneous



Treatment Medications for Day 15 for Cycles 3 and 4: (in order of administration)
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:


• bortezomib (Velcade) __________ mg (1.6 mg/m2) subcutaneous



Treatment Medications for Day 22 for Cycles 3 and 4: (in order of administration)
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:


• bortezomib (Velcade) __________ mg (1.6 mg/m2) subcutaneous



Other Orders for Day 1, 8, 15 and/or 22:













VER: 07-28-16 (4339 VER: 03-30-16) Cycle 3 and 4, Page 3
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.

• acyclovir (Zovirax) 400 mg tablet, Disp. #60, Refills: 5
Take 1 tablet (400 mg) by mouth two times daily.

 Other:



Follow Up
• Chemotherapy: Cycle 2, 3, 4, 5: Day 1, 8, 15, 22 every 35 days

• Labs:
 Other:


• Procedures/Imaging/Scans:










• Other Orders:









MD Signature_________________________________________ Pager______________
Date __________________Time___________________

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