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HEM CLL Cyclophosphamide(28D:1,2,3)/Fludarabine(28D:1,2,3)/Rituximab(28D:1) (3483 VER: 02-02-16)

HEM CLL Cyclophosphamide(28D:1,2,3)/Fludarabine(28D:1,2,3)/Rituximab(28D:1) (3483 VER: 02-02-16) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


Final Approved VER: 03-17-16 (3483 VER: 02-02-16) Page 1 of 5
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Cyclophosphamide, Fludarabine, Rituximab
Disease Group: Hematology
Disease: Chronic Lymphocytic Leukemia, Small Lymphocytic Lymphoma

Therapy:
Cycle 1: rituximab 375 mg/m2 IV Day 1,
fludarabine 25 mg/m2 IV Day 1, 2 and 3,
cyclophosphamide 250 mg/m2 IV Day 1, 2, and 3

Cycle ≥ 2: rituximab 500 mg/m2 IV Day 1,
fludarabine 25 mg/m2 IV Day 1, 2 and 3,
cyclophosphamide 250 mg/m2 IV Day 1, 2, and 3

Cycle Length: 28 days Course: 6 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): Robak T, et al. J Clin Oncol 2010;28(10):1756-65, Hallek M, et al. Blood (ASH Annual Meeting
Abstracts) 2009; 114: Abstract 535.

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


Cycle _______ Starting with:  Day 1 (date) __________  Day 2 (date) __________  Day 3 (date) _________

Pre labs:
• Cycle 1, Day 1: Obtain CBC with DIFF, Creatinine, 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 with DIFF, Creatinine
 Other:


Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Day 1: Verify the following labs have been obtained: CBC with DIFF, Creatinine
• Day 1: Hold and notify provider for: ANC < 1000/µL or Platelets < 75K/µL or Creatinine ≥ 1.4 mg/dL or
Creatinine Clearance < 50 mL/min



Final Approved VER: 03-17-16 (3483 VER: 02-02-16) Page 2 of 5
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
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.
• Instruct patient to drink 8 to 10 glasses of water (8 ounces each) for 3 days, starting the day of treatment.
• 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)
Day 1: Give prior to rituximab
• Acetaminophen (Tylenol) 650 mg by mouth once.
• diphenhydramine (Benadryl) 25 mg by mouth once

Day 1: 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 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) 80 mg by mouth once.
 palonosetron (Aloxi) 0.25 mg IV once.
 Other:



Day 3: 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) 80 mg by mouth once.
 palonosetron (Aloxi) 0.25 mg IV once.
 Other:



Final Approved VER: 03-17-16 (3483 VER: 02-02-16) Page 3 of 5
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
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:


• Cycle 1: rituximab (Rituxan) ___________ mg (375 mg/m2) IV once.

• Cycles ≥ 2: rituximab (Rituxan) __________ mg (500 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.


• fludarabine (Fludara) ______________ mg (25 mg/m2) IV once over 30 minutes.

• cyclophosphamide (Cytoxan) _____________ (250 mg/m2) IV once over 30 minutes.


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:


• fludarabine (Fludara) ______________ mg (25 mg/m2) IV once over 30 minutes.

• cyclophosphamide (Cytoxan) _____________ (250 mg/m2) IV once over 30 minutes.


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


• fludarabine (Fludara) ______________ mg (25 mg/m2) IV once over 30 minutes.

• cyclophosphamide (Cytoxan) _____________ (250 mg/m2) IV once over 30 minutes.


Other Orders for Day 1, 2, and/or 3:






Final Approved VER: 03-17-16 (3483 VER: 02-02-16) Page 4 of 5
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: 11
Take 1 tablet (400 mg) by mouth two times daily.

• sulfamethoxazole-trimethoprim (Bactrim DS) 800-160 mg per tablet, Disp. #16, Refills: 11
Take 1 tablet (800-160 mg) by mouth two times daily on Saturday and Sunday.

 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)

Select One: (May substitute formulary equivalent)
 filgrastim (Neupogen) 300 mcg/0.5 mL syringe. Disp. 10 syringes, Refills: 5
Inject one syringe (300 mcg) under skin one time daily in evening at least 24 hours after last chemotherapy
dose. Continue until ANC is greater than ___________ after nadir

 filgrastim (Neupogen) 480 mcg/0.8 mL syringe. Disp. 10 syringes, Refills: 5
Inject one syringe (480 mcg) under skin one time daily in evening at least 24 hours after last chemotherapy
dose. Continue until ANC is greater than ___________ after nadir

 Other:





Final Approved VER: 03-17-16 (3483 VER: 02-02-16) Page 5 of 5
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Follow Up
• Chemotherapy: Day 1, 2, and 3 every 28 days

• Labs:
 Day 15 – 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 #: ________