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HEM Rituximab with Mini-CHOP (4323 VER: 10-3-16)

HEM Rituximab with Mini-CHOP (4323 VER: 10-3-16) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 8-23-17 (4323 VER: 10-3-16) Page 1 of 3
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Rituximab with Mini-CHOP
Disease Group: Hematology
Disease: Non-Hodgkin Lymphoma

Therapy: rituximab 375 mg/m2 IV Day 1,
doxorubicin 25 mg/m2 IV Day 1,
vinCRIStine 1 mg IV Day 1,
cyclophosphamide 400 mg/m2 IV Day 1,
prednisone 100 mg by mouth Day 1, 2, 3, 4 and 5

Cycle Length: 21 days Course: 6 to 8 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): Peyrade F, et al. Lancet Oncol 2011;12:460-8; Plosker GL, et al. Drugs 2003;63(8):803-43.

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


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

Pre labs:
• Cycle 1, Day 1: Obtain CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT,
Alkaline Phosphatase, Calcium, Uric Acid, LDH, 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, Creatinine, Total Bilirubin
 Other:


Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Cycle 1, Day 1: Verify the following labs have been obtained: CBC with DIFF, Electrolytes, Glucose, BUN,
Creatinine, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Calcium, Uric Acid, LDH.
• Cycle ≥ 2, Day 1: Verify the following labs have been obtained: WBC, ANC, Platelets, Creatinine, Total
Bilirubin
• Hold and notify provider for: ANC ≤ 1000/µL or Platelets ≤ 75K/µL



Final Approved VER: 8-23-17 (4323 VER: 10-3-16) Page 2 of 3
Copyright © 2017 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.
• Instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
• Flush/Line Care per Institution standards

Hydration/Fluids: sodium chloride 0.9% IV infuse 1000 mL throughout treatment

Premedications/Antiemetics
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):
 *ondansetron (Zofran) 16 mg by mouth once. PO preferred – may give 8 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 the patient returns to baseline, infusion may be restarted at half the rate during which
the reaction occurred.

• prednisone (Deltasone) 100 mg by mouth once.

• doxorubicin (Adriamycin) __________ mg (25 mg/m2) IV once. Administer IV side arm push 3 to 5 mL/minute
into running IV.

• vinCRIStine (Oncovin) 1 mg IV once over 3 to 5 minutes. Must be administered via gravity through a
peripheral IV (not an infusion pump)

• cyclophosphamide (Cytoxan) ____________ mg (400 mg/m2) IV once. Administer over 30 minutes.

Other Orders for Day 1:



Final Approved VER: 8-23-17 (4323 VER: 10-3-16) Page 3 of 3
Copyright © 2017 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)
• prednisone (Deltasone) 50 mg tablet, Disp. #8, Refills: ____
Take 2 tablets (100 mg) by mouth once daily on Day 2 through 5.
(Day 1 dose given as premedication in clinic.)

• ranitidine (Zantac) 150 mg tablet, Disp. #60, Refills: 5
Take 1 tablet (150 mg) by mouth 2 times daily.

• 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: 11
Take 1 tablet (400 mg) by mouth two times daily.

 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 every 21 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 #: ________