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HEM NHL Rituximab Maintenance(56D1) (4248 VER: 10-3-16)

HEM NHL Rituximab Maintenance(56D1) (4248 VER: 10-3-16) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


VER: 12-28-16 (4248 VER: 10-3-16) Page 1 of 3
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Rituximab (Maintenance)
Disease Group: Hematology
Disease: Non-Hodgkin Lymphoma

Therapy: rituximab 375 mg/m2 IV Day 1

Cycle Length: 56 days Course: 12 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.

References: Hochster H, et al. J Clin Oncol 2009;27:1607-14; Salles G, et al. Lancet 2011;377:42-51;
Forstpointer R, et al. Blood 2006;108:4003-8; van Oers MH, et al. J Clin Oncol 2010;28:2853-8.

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


Cycle _______ Starting with:  Day 1 (date) ___________

Pre labs:
• Cycle 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:


• Cycle ≥ 2: Obtain CBC with DIFF
 Other:



Treatment Conditions: None
• 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


VER: 12-28-16 (4248 VER: 10-3-16) Page 2 of 3
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Premedications/Antiemetics: (May substitute formulary equivalent)
Give 30 minutes prior to rituximab:
• acetaminophen (Tylenol) 650 mg by mouth once
• diphenhydramine (Benadryl) 25 mg by mouth 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 the patient returns to baseline, infusion may be restarted at half the rate during which
the reaction occurred.



Other Orders for Day 1:








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



VER: 12-28-16 (4248 VER: 10-3-16) Page 3 of 3
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Follow Up
• Chemotherapy: Day 1 every 56 days

• Labs:
 Other:




• Procedures/Imaging/Scans:
















• Other Order















MD Signature_________________________________________ Pager______________
Date __________________Time___________________

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