contents · 2009. 6. 8. · 45 1725 1750 45 100 46 1725 1750 45 125 47 1975 2000 45 125 48-52 1975...

Appendix B

Chemotherapy Regimens

Contents ABVD .....................................................................1 ALL – Dana Farber ...............................................2 ATG & Cyclosporin................................................3 Bortezomib (Velcade®) .........................................4 CBV........................................................................5 Chlorambucil .........................................................6 Chlorambucil + Rituximab ...................................7 CHOMP .................................................................8 CHOP.....................................................................10 CHOP + Rituximab ...............................................11 Cladribine (2-CDA) ...............................................12 CVP (IV) ................................................................13 CVP (IV) + Rituximab ...........................................14 CVP (Oral) .............................................................15 CVP (Oral) + Rituximab........................................16 DHAP.....................................................................17 DPACE...................................................................19 ESHAP...................................................................20 FCM .......................................................................22 FCM + Rituximab..................................................23 Fludarabine ...........................................................24 Fludarabine + Rituximab......................................25 GDP .......................................................................26 HDMVP .................................................................27 HIDAC Consolidation ...........................................29 Hyper-CVAD .........................................................31 Intravenous Immunoglobulin...............................35 IV Iron Replacement (Venofer®) ..........................36 Lenalidomide ........................................................37 Magrath .................................................................38 Melphalan + Prednisone.......................................44 MPT .......................................................................45 MPV .......................................................................46 Mini-BEAM ...........................................................47 MOPP ....................................................................49 NOVE.....................................................................50 NOVE-HIDAC .......................................................51 POMP Maintenance ..............................................52 Rituximab..............................................................53 Thalidomide/Dexamethasone ..............................54 Vidaza ....................................................................55 VP-16/Melphalan ..................................................56 VP-16/Prednisone .................................................59 7+3 Induction........................................................60

Appendix B

B

Appendix B Page 1 of 61

AABBVVDD

Indications First-line therapy for Hodgkin's lymphoma

Drug Regimen Doxorubicin Bleomycin

Vinblastine Dacarbazine

25 mg/m2 by slow IV push days 1 and 15 10 U/m2 by slow IV push days 1 and 15 6 mg/m2 by quick IV push days 1 and 15 375 mg/m2 in 500 mL NS over 75 minutes days 1 and 15

Cycle Frequency Repeat every 28 days (for a total of 4-8 cycles)

Dose Modification

Criteria

Hematologic Toxicity Hold dose for 1 week if absolute neutrophil count < 1.0 x 109/L or platelets < 75 x

109/L Filgrastim support should be considered after first episode of febrile neutropenia

or dose delay ≥ 1 week Renal Failure If creatinine clearance = 0.2 – 1.0 mL/second, reduce bleomycin to 75% dose If creatinine clearance < 0.2 mL/second, reduce bleomycin to 50% dose

Hepatic Dysfunction If bilirubin = 26-51 μmol/L or AST = 60-180 IU/L, reduce doxorubicin to 75%

dose and vinblastine to 50% dose If bilirubin = 52-85 μmol/L or AST > 180 IU/L, reduce doxorubicin to 50% dose

and vinblastine to 25% dose If bilirubin > 85 μmol/L, omit doxorubicin and vinblastine

Cost $355 per 28-day cycle

References Bonadonna, G. and A. Santoro, ABVD chemotherapy in the treatment of

Hodgkin's disease. Cancer Treat Rev, 1982. 9(1): p. 21-35.

Abbreviations: IV = intravenous; NS = normal saline

of 61 Appendix B

AALLLL –– DDaannaa FFaarrbbeerr

Indications First-line therapy for ALL i. Induction (x 1 cycle)

Prednisone Vincristine

Doxorubicin Methotrexate

Leucovorin

L-Asparaginase MTX+ ARA-C

Allopurinol +

Cotrimoxazole (Septra®)

10 mg/m2 q.i.d. p.o. days 1- 28 2 mg IV in 50 mL NS over 15 minutes days 1, 8, 15, 22 30 mg/m2 IV push days 1 and 2 4000 mg/m2 IV in 1 L NS over 4 hours day 3 200 mg/m2 IV 36 hours post MTX and 24 mg/m2 q6h IV or p.o. until MTX level < 0.1 μmol/L 25 000 IU/m2 IM day 5 MTX 12 mg + ARA-C 40 mg IT in preservative-free NS (total 5 mL) days 1, 15, 28 300 mg p.o. daily and 1 DS tablet p.o. b.i.d. q MWF

ii. CNS Therapy (x 1 cycle) Vincristine

6-Mercaptopurine

Doxorubicin MTX + ARA-C

Cranial Irradiation

2 mg IV in 50 mL NS over 15 minutes day 1 50 mg/m2/day p.o. q.h.s. x 14 days (round off dose to nearest 50 mg) 30 mg/m2 IV day 1 push MTX 12 mg + ARA-C 40 mg IT in preservative-free NS (total 5 mL) days 1, 4, 8, 11 1800 cGy over 10 fractions days 1-10

iii. Intensification (3-week cycle x 10 cycles) Vincristine

Dexamethasone

6-Mercaptopurine

Doxorubicin

Methotrexate L-Asparaginase

MTX + ARA-C

2 mg IV in 50 mL NS over 15 minutes day 1 of each cycle 18 mg/m2/day p.o. (in 2 divided doses) days 1-5 of each cycle 50 mg/m2/day p.o. q.h.s. days 1-14 of each cycle (round off dose to nearest 50 mg) 30 mg/m2 IV push day 1 (to maximum of 300 mg/m2 cumulative dose [i.e. 7th cycle]) 30 mg/m2 in 250 mL NS over 1 hour or IM days 1, 8, 15 12 500 IU/m2 weekly x 30 weeks – IM MTX 12 mg + ARA-C 40 mg IT in preservative-free NS (total 5 mL) every 18 weeks

iv. Continuation (3-week cycle until 2 years after CR)

Drug Regimen

Vincristine Dexamethasone

6-Mercaptopurine

Methotrexate MTX + ARA-C

2 mg IV in 50 mL NS over 15 minutes day 1 (each cycle) 6 mg/m2/day p.o./IV (in two divided doses) days 1-5 (each cycle) 50 mg/m2/day p.o. q.h.s. days 1-15 (each cycle) 30 mg/m2 IV in 250 mL NS over 1 hour or IM weekly MTX 12 mg + ARA-C 40 mg IT in preservative-free NS (total 5 mL) every 18 weeks

References Silverman, L.B., et al., Improved outcome for children with acute lymphoblastic leukemia: results of Dana-Farber Consortium Protocol 91-01. Blood, 2001. 97(5): p. 1211-8. Protocol has been modified according to the NCIC AL.4 Protocol 2007

Abbreviations: ALL = acute lymphocytic leukemia; ARA-C = cytarabine; CR = complete response; IT = intrathecally; IV = intravenously; MTX = methotrexate; p.o. = by mouth; q.i.d. = four times daily; q.h.s. = at bedtime


AATTGG && CCyycclloossppoorriinn

Indications First-line immunotherapy for aplastic anemia ATG (first-line)

Test Dose

Treatment Dose

Horse ATG (ATGM® - Upjohn) Horse ATG 25 mg (o.5 mL) in 100 mL normal saline infused intravenously over 1 hour monitoring for allergic reaction 40 mg/kg/day IV days 1-4

ATG (second-line) or if allergic to horse ATG

Test Dose

Treatment Dose

Rabbit ATG (Thymoglobulin® - SangStat) Rabbit ATG (Thymoglobulin® - SangStat) 2.5 mg (0.5 mL) in 100 mL normal saline infused intravenously over 1 hour monitoring for allergic reaction 3.75 mg/kg/day IV days 1-5

Premedication – Daily 1 hour prior to each dose

Prednisone 1 mg/kg p.o. Diphenhydramine (Benadryl®) 50 mg IV Acetaminophen (Tylenol®) 1000 mg p.o.

Cyclosporin 5 mg/kg/day day 14 onwards

Cyclosporin dose should be adjusted to achieve a trough level of 200-400 μg/L Patients > 60 years trough level 150-250 μg/L Children trough level of 100-150 μg/L Note: Monitor renal function, blood pressure, magnesium Cyclosporin can be tapered after 6 months of therapy if counts have normalized and have been stable for 1-2 months

Serum Sickness Prophylaxis

Drug Regimen

Prednisone 1 mg/kg/day to be continued for 9 days after completion of ATG, then tapered over next 5 days

Cycle Frequency One course is given routinely A second course of ATG may be administered if there has been no response by 3

months post treatment, or at later relapse Patients may become sensitized to horse ATG after one administration and thus

are at risk of anaphylaxis. Patients receiving a second course of ATG, or patients that demonstrate an allergic reaction to the test dose of horse ATG should be given the rabbit ATG formulation

Cost 1 course ATG = $13 000 and approximate costs for cyclosporin for 6 months =

$4500

References Marsh, J.C., et al., Guidelines for the diagnosis and management of acquired aplastic anaemia. Br J Haematol, 2003. 123(5): p. 782-801. Rosenfeld, S., et al., Antithymocyte globulin and cyclosporine for severe aplastic

anemia: association between hematologic response and long-term outcome. Jama, 2003. 289(9): p. 1130-5.

Abbreviations: ATG = antithymocyte globulin; IV = intravenously; p.o. = by mouth

PR 10034(2008/12/07)

DISTRIBUTION: White Original - Chart Yellow Copy - Pharmacy Page 1 of 3

PATIENT IDENTIFICATION

PHYSICIAN’S ORDERSAll orders shall be DATED, TIMED, and SIGNEDAll medication orders shall be written in the GENERIC or non-proprietary name.All orders shall be written legibly using ball point pen.

PHYSICIAN’S ORDERS

TIME&

DATE

YYYY/MM/DD

SIGNATuREOF

NuRSE

Yes No

HORSE Antithymocyte Globulin (ATG, Atgam®)Orders for Aplastic Anemia

Doctor must check off appropriate orders.

Doctor’s Signature: PRINT NAME: Pager:

There are two Antithymocyte Globulin Order Forms (horse and rabbit). I have selected the appropriate order form for this patient. Doctor’s Signature:_______________PRINT NAME:___________________Admit to Dr.___________________ on _____________________ (YYYY/MM/DD)Diagnosis____________________________Infuse ATG by central line (see Note #1 on back of this page).Pre-chemotherapy Bloodwork: (if not done within one week prior to admission) CBC, differential, electrolytes, blood glucose, calcium profile, liver profile, renal profile, LDH, uric acidHold ATG until physician writes an order on the Doctor’s Order Form to proceed with ATG test DoseMonday, Wednesday and Friday – CBC, renal profile, calcium profile, liver profile, group and screencyclosporine (CSA) trough levels 1h prior to first dose of day, starting Day 15 (_____/____/____) (YYYY/MM/DD) and every Monday and Friday, thereafter.Target CSA level = 200-300 mcg/LDaily weight (kg) before breakfastRecord intake and output dailyDiet:____________________Monitoring during ATG infusions (See Note #2 on back of this page)Day 1: • Vital signs prior to infusion, then q 15 min x 1 h, q 30 min x 1 h, then q 1 h until infusion is completed• Monitor for allergic reactions continuously during the first 15 minutes and then q 1 h until infusion completed: fever (temperature ≥ 38°C), chills, hives, rash, pruritus, SBP change (increase or decrease of ≥ 20% from pre-infusion reading), shortness of breath, and chest pain. • Stop infusion and notify MD if reaction(s) observed Days 2-4: • Vital signs q 30 min x 1 h, then q 2 h until infusion is completed• Monitor for allergic reactions (see Day 1) every four hours.• Stop infusion and notify MD if reaction(s) observed

NOTES:

1. Ensure that patient has central venous catheter (CVC) access. To avoid delay in therapy infuse ATG through a peripheral line only if central venous access is not feasible/available.2. If patient experienced an allergic reaction or abnormal vital signs (temperature ≥ 38°C, SBP increase or decrease of ≥ 20% from pre-infusion reading) during the previous day’s infusion, consider extending the infusion rate to 12 hours and/or more frequent monitoring (write orders on a Physician’s Order Form).3. Serum sickness manifesting as fever, arthralgia, lymphadenopathy and cutaneous eruptions (morbilliform rash) occurs in the majority of patients with aplastic anemia treated with ATG. Symptoms generally develop within 7 to 14 days after initiating ATG. Prescribe hydrocortisone sodium succinate (Solu-Cortef®) 100 mg q6h.4. Prednisone taper. Consider graduated taper over 5 days, starting on day 14. Write tapering orders on a Physician’s Order Form.

Patient Weight

(kg)

Horse ATG Infusion Dose (40 mg/kg/day)

Prednisone (1 mg/kg/day)

Rounded to 5 mg

Cyclosporine (2.5 mg/kg)

Rounded to 25 mgDay 1 Dose (25 mg Test

Dose has been subtracted) (mg)

Dose for Days 2-4

(Rounded to 250 mg)

45 1725 1750 45 10046 1725 1750 45 12547 1975 2000 45 12548-52 1975 2000 50 12553 1975 2000 55 12554 2225 2250 55 12555-57 2225 2250 55 15058-59 2225 2250 60 15060-63 2475 2500 60 15064-65 2475 2500 65 15066-68 2725 2750 65 17569-71 2725 2750 70 17572 2975 3000 70 17573-74 2975 3000 75 17575-77 2975 3000 75 20078 2975 3000 80 20079-82 3225 3250 80 20083-84 3225 3250 85 20085 3475 3500 85 20086-87 3475 3500 85 22588-90 3475 3500 90 22591-92 3725 3750 90 22593-94 3725 3750 95 22595-96 3725 3750 95 25097 3975 4000 95 25098-100 3975 4000 100 250

PR 10034(2008/12/07)

PR 10034(2008/12/07)




TIME&

DATE

YYYY/MM/DD

SIGNATuREOF

NuRSE

Yes No





Have the following medication readily available in the patient’s medication bin: epinephrine 1:1,000 injmethylprednisolone (Solu-Medrol®), 125mgdiphenhydramine (Benadryl®) Inj, 50mgsalbutamol inhaler + spacer deviceMonitor for signs or symptoms of serum sickness (see Note #3 on back of this page).Notify MD if signs or symptoms of serum sickness develop.Height:__________ cm Weight:__________ kg BSA____________ m2Day 1: TEST DOSE _____/_____/_____(YYYY/MM/DD) Pre-medication NOT to be given PRIOR to test doseHorse ATG (Atgam ®) 0.5mL (25mg) in 100mL of Normal Saline IV to run over 1 hour through 0.2-micron in-line filter. Vital Signs prior to test dose infusion, then q 15 min x 1 hour. Monitor for allergic reactions: fever (temperature ≥ 38°C), chills, hives, rash, pruritus, hyper- or hypotension (SBP increase or decrease of ≥ 20% from pre-infusion reading), shortness of breath, and chest pain continually during the first 15 minutes, then q15 min until infusion completed. If reaction(s) observed stop infusion and notify MD. If no allergic reaction within 1 hour of starting Test Dose proceed with Day 1 infusionDays 1-4: PRE MEDICATION (Begin only if patient tolerates ATG Test Dose)prednisone 1mg/kg/day rounded to nearest 5mg (=_____mg-see back of this page for rounded dose) po, 60 minutes prior to first dose (Day 1) of ATG, then daily x 3 days 60 minutes prior to each subsequent ATG dose (total = 4 doses).acetaminophen 1000 mg po, 60 minutes prior to first dose (Day 1) of ATG, then daily x 3 days 60 minutes prior to each subsequent ATG dose (total = 4 doses).diphenhydramine (Benadryl®) 50 mg IV, 60 minutes prior to first dose (Day 1) of ATG, then daily x 3 days 60 minutes prior to each subsequent ATG dose(total = 4 doses).

NOTES:


Patient Weight

(kg)



Rounded to 5 mg




Dose for Days 2-4

(Rounded to 250 mg)

45 1725 1750 45 10046 1725 1750 45 12547 1975 2000 45 12548-52 1975 2000 50 12553 1975 2000 55 12554 2225 2250 55 12555-57 2225 2250 55 15058-59 2225 2250 60 15060-63 2475 2500 60 15064-65 2475 2500 65 15066-68 2725 2750 65 17569-71 2725 2750 70 17572 2975 3000 70 17573-74 2975 3000 75 17575-77 2975 3000 75 20078 2975 3000 80 20079-82 3225 3250 80 20083-84 3225 3250 85 20085 3475 3500 85 20086-87 3475 3500 85 22588-90 3475 3500 90 22591-92 3725 3750 90 22593-94 3725 3750 95 22595-96 3725 3750 95 25097 3975 4000 95 25098-100 3975 4000 100 250

PR 10034(2008/12/07)




TIME&

DATE

YYYY/MM/DD

SIGNATuREOF

NuRSE

Yes No





PRN Medicationsdiphenhydramine (Benadryl®) 50mg IV q 4h prn for rashacetaminophen 500-1000 mg po q 4 h prn for temperature ≥ 38ºC(total of scheduled and prn doses must not exceed 4,000 mg daily)Day 1: ATG INFUSION _____/_____/_____(YYYY/MM/DD) Horse ATG 40mg/kg (=_________mg-see back of this page: “Day 1 Infusion Dose”) in 1000 mL of Normal Saline to IV run over 12 hours through a 0.2-micron in-line filter.Day 2: ATG INFUSION _____/_____/_____(YYYY/MM/DD)If no allergic reactions observed with Day 1 infusion, administer horse ATG 40mg/kg rounded to nearest 250mg (=___________mg -see back of this page “Infusion for Days 2-4”) in 1000 mL of Normal Saline IV to run over 6 hours through a 0.2-micron in-line filter. If reaction(s) observed with Day 1 infusion, increase infusion rate to 12 hours (see Note #2 on back of this page).Day 3: ATG INFUSION _____/_____/_____(YYYY/MM/DD)If no allergic reactions observed with Day 2 infusion administer horse ATG 40mg/kg rounded to nearest 250mg (=________ mg -see back of this page “Infusion for Days 2-4”) in 1000 mL of Normal Saline IV to run over 6 hours through a 0.2-micron in-line filter. If reaction(s) observed with Day 2 infusion, increase infusion rate to 12 hours (see Note #2 on back of this page).Day 4: ATG INFUSION _____/_____/_____(YYYY/MM/DD)If no allergic reactions observed with Day 3 infusion administer horse ATG 40 mg/kg rounded to nearest 250mg (=_________ mg –see back of this page “Infusion for Days 2-4”) in 1000 mL of Normal Saline IV to run over 6 hours through a 0.2-micron in-line filter. If reaction(s) observed with Day 3 infusion, increase infusion rate to 12 hours (see Note #2 on back of this page).Day 5: _____/_____/_____(YYYY/MM/DD)prednisone 1mg/kg rounded to nearest 5mg (= _____ mg-see back of this page for rounded dose) po daily with breakfast x 9 daysDay 14: _____/_____/_____(YYYY/MM/DD)Contact physician regarding tapering of prednisone dose (see Note #4 on back of this page). cyclosporine 2.5mg/kg rounded to nearest 25mg (= _________mg - see back of this page for rounded dose) po BID for a minimum duration of 6 months

PR 10034(2008/12/07)

NOTES:


Patient Weight

(kg)



Rounded to 5 mg




Dose for Days 2-4

(Rounded to 250 mg)

45 1725 1750 45 10046 1725 1750 45 12547 1975 2000 45 12548-52 1975 2000 50 12553 1975 2000 55 12554 2225 2250 55 12555-57 2225 2250 55 15058-59 2225 2250 60 15060-63 2475 2500 60 15064-65 2475 2500 65 15066-68 2725 2750 65 17569-71 2725 2750 70 17572 2975 3000 70 17573-74 2975 3000 75 17575-77 2975 3000 75 20078 2975 3000 80 20079-82 3225 3250 80 20083-84 3225 3250 85 20085 3475 3500 85 20086-87 3475 3500 85 22588-90 3475 3500 90 22591-92 3725 3750 90 22593-94 3725 3750 95 22595-96 3725 3750 95 25097 3975 4000 95 25098-100 3975 4000 100 250

PR 10034(2008/12/07)





TIME&

DATE

YYYY/MM/DD

SIGNATuREOF

NuRSE

Yes No

RABBIT Antithymocyte Globulin (ATG, Thymoglobulin®)Orders for Aplastic Anemia



PR 10033(2008/12/07)

There are two Antithymocyte Globulin Order Forms (horse and rabbit).I have selected the appropriate order form for this patient. Doctor’s Signature:_______________PRINT NAME:___________________Admit to Dr.______________ on _____________________ (YYYY/MM/DD)Diagnosis_______________________________Infuse ATG by central line (see Note #1 on back of this page) Pre-chemotherapy Bloodwork: (if not done within one week prior to admission) CBC, differential, electrolytes, blood glucose, calcium profile, liver profile, renal profile, LDH, uric acidHold ATG until physician writes an order on the Doctor’s Order Form to proceed with ATG Test DoseMonday, Wednesday and Friday – CBC, renal profile, calcium profile, liver profile, group and screencyclosporine (CSA) trough levels 1h prior to first dose of day, starting Day 15 (_____/____/____) (YYYY/MM/DD) and every Monday and Friday, thereafter.Target CSA level = 200-300 mcg/L.Daily weight (kg) before breakfast.Record intake and output dailyDiet:____________________Monitoring during ATG infusions (See Note #2 on back of this page)Day 1: • Vital signs prior to infusion, then q 15 min x 1 h, q 30 min x 1 h, then q 1 h until infusion is completed• Monitor for allergic reactions continuously during the first 15 minutes and then q 1 h until infusion completed: fever (temperature ≥ 38°C), chills, hives, rash, pruritus, SBP change (increase or decrease of ≥ 20% from pre-infusion reading), shortness of breath, chest pain. • Stop infusion and notify MD if reaction(s) observedDays 2-5: • Vital signs q 30 min x 1 h, then q 2 h until infusion is completed• Monitor for allergic reactions (see Day 1) every four hours• Stop infusion and notify MD if reaction(s) observed

Patient Weight

(kg)

Rabbit ATG Infusion Dose (3.75 mg/kg/day)


Rounded to 5 mg


Rounded to 25 mgDay 1 Dose (2.5 mg Test


Dose for Days 2-5

(Rounded to 25 mg) (mg)

45 172.5 175 45 10046-47 172.5 175 45 12548-49 172.5 175 50 12550-52 197.5 200 50 12553-54 197.5 200 55 12555-56 197.5 200 55 15057 222.5 225 55 15058-62 222.5 225 60 15063 222.5 225 65 15064-65 247.5 250 65 15066-67 247.5 250 65 17568-70 247.5 250 70 17571-72 272.5 275 70 17573-74 272.5 275 75 17575-76 272.5 275 75 20077 297.5 300 75 20078-82 297.5 300 80 20083 297.5 300 85 20084-85 322.5 325 85 20086-87 322.5 325 85 22588-89 322.5 325 90 22590-92 347.5 350 90 22593-94 347.5 350 95 22595-96 347.5 350 95 25097 372.5 375 95 25098-100 372.5 375 100 250

NOTES:

1. Ensure that patient has central venous catheter (CVC) access. To avoid delay in therapy infuse ATG through a peripheral line only if central venous access is not feasible/available.2. If patient experienced an allergic reaction or abnormal vital signs (temperature ≥ 38°C, SBP decrease or increase of ≥ 20% from pre-infusion reading) during the previous day’s infusion, consider extending the infusion rate to 12 hours and/or more frequent monitoring (write orders on a Physician’s Order Form).3. Serum sickness manifesting as fever, arthralgia, lymphadenopathy and cutaneous eruptions (morbilliform rash) occurs in the majority of patients with aplastic anemia treated with ATG. Symptoms generally develop within 7 to 14 days after initiating ATG. Prescribe hydrocortisone sodium succinate (Solu-Cortef®) 100 mg IV q6h. 4. Prednisone taper. Consider graduated taper over 5 days, starting on day 15. Write tapering orders on a Physician’s Order Form.

PR 10033(2008/12/07)

PR 10033(2008/12/07)




TIME&

DATE

YYYY/MM/DD

SIGNATuREOF

NuRSE

Yes No



Doctor’s Signature: PRINT NAME: Pager:DISTRIBUTION: White Original - Chart Yellow Copy - Pharmacy Page 2 of 4

Have the following medication readily available in the patient’s medication bin: epinephrine 1:1,000 injmethylprednisolone (Solu-Medrol®), 125mgdiphenhydramine (Benadryl®) Inj, 50mgsalbutamol inhaler + spacer deviceMonitor for signs or symptoms of serum sickness (see Note #3 on back of this page). Notify MD if signs or symptoms of serum sickness develop. Height:__________cm Weight:__________kg BSA____________m2 Day 1: TEST DOSE _____/_____/_____(YYYY/MM/DD)Pre-medication NOT to be given PRIOR to test doseRabbit ATG (Thymoglobulin®) 0.5mL (2.5mg) in 100mL of Normal Saline IV to run over 1 hour through 0.2-micron in-line filterVital Signs prior to test dose infusion, then q 15 min x 1 hour. Monitor for allergic reactions: fever (temperature ≥ 38°C), chills, hives, rash,pruritus, hyper- or hypotension (increased or decreased SBP of ≥ 20% from pre-infusion reading), shortness of breath, chest pain continually during the first 15 minutes, then q15 minutes until infusion completed. If reaction(s) observed stop infusion and notify MD. If no allergic reaction within 1 hour of starting Test Dose proceed with Day 1 infusionDays 1-5: PRE MEDICATION (Begin only if patient tolerates ATG Test Dose)prednisone 1mg/kg/day rounded to nearest 5mg (=_____mg -see back of this page for rounded dose) po, 60 minutes prior to first dose (Day 1) of ATG, then daily x 4 days 60 minutes prior to each subsequent ATG dose (total = 5 doses).acetaminophen 1000 mg po, 60 minutes prior to first dose (Day 1) of ATG, then daily x 4 days 60 minutes prior to each subsequent ATG dose (total = 5 doses).diphenhydramine (Benadryl®) 50 mg IV, 60 minutes prior to first dose (Day 1) of ATG, then daily x 4 days 60 minutes prior to each subsequent ATG dose (total = 5 doses).

Patient Weight

(kg)



Rounded to 5 mg




Dose for Days 2-5


45 172.5 175 45 10046-47 172.5 175 45 12548-49 172.5 175 50 12550-52 197.5 200 50 12553-54 197.5 200 55 12555-56 197.5 200 55 15057 222.5 225 55 15058-62 222.5 225 60 15063 222.5 225 65 15064-65 247.5 250 65 15066-67 247.5 250 65 17568-70 247.5 250 70 17571-72 272.5 275 70 17573-74 272.5 275 75 17575-76 272.5 275 75 20077 297.5 300 75 20078-82 297.5 300 80 20083 297.5 300 85 20084-85 322.5 325 85 20086-87 322.5 325 85 22588-89 322.5 325 90 22590-92 347.5 350 90 22593-94 347.5 350 95 22595-96 347.5 350 95 25097 372.5 375 95 25098-100 372.5 375 100 250

NOTES:


PR 10033(2008/12/07)

PR 10033(2008/12/07)




TIME&

DATE

YYYY/MM/DD

SIGNATuREOF

NuRSE

Yes No




PRN Medicationdiphenhydramine (Benadryl®) 50 mg IV q 4h prn for rashacetaminophen 500-1000 mg po q4h prn for temperature ≥ 38ºC (total of scheduled and prn doses must not exceed 4,000 mg daily)Day 1: ATG INFUSION _____/_____/_____(YYYY/MM/DD)Rabbit ATG 3.75mg/kg (=___________mg-see back of this page for “Day 1 Infusion Dose”) in 1000 mL of Normal Saline to IV run over 12 hours through a 0.2-micron in-line filter.Day 2: ATG INFUSION _____/_____/_____(YYYY/MM/DD)If no allergic reactions observed with Day 1 infusion, administer rabbit ATG 3.75mg/kg rounded to nearest 25mg (=_________mg – see back of this page “Infusion for Days 2-5”) in 1000 mL of Normal Saline IV to run over 6 hours through a 0.2-micron in-line filter. If reaction(s) observed with Day 1 infusion, increase infusion rate to 12 hours (see Note #2 on back of this page).Day 3: ATG INFUSION _____/_____/_____(YYYY/MM/DD)If no allergic reactions observed with Day 2 infusion administer rabbit ATG 3.75mg/kg rounded to nearest 25mg (=______ mg -see back of this page “Infusion for Days 2-5”) in 1000 mL of Normal Saline IV to run over 6 hours through a 0.2-micron in-line filter. If reaction(s) observed with Day 2 infusion, increase infusion rate to 12 hours (see Note #2 on back of this page).Day 4: ATG INFUSION _____/_____/_____(YYYY/MM/DD)If no allergic reactions observed with Day 3 infusion administer rabbit ATG 3.75 mg/kg rounded to nearest 25mg (=______ mg -see back of this page “Infusion for Days 2-5”) in 1000 mL of Normal Saline IV to run over 6 hours through a 0.2-micron in-line filter. If reaction(s) observed with Day 3 infusion, increase infusion rate to 12 hours (see Note #2 on back of this page).

Patient Weight

(kg)



Rounded to 5 mg




Dose for Days 2-5


45 172.5 175 45 10046-47 172.5 175 45 12548-49 172.5 175 50 12550-52 197.5 200 50 12553-54 197.5 200 55 12555-56 197.5 200 55 15057 222.5 225 55 15058-62 222.5 225 60 15063 222.5 225 65 15064-65 247.5 250 65 15066-67 247.5 250 65 17568-70 247.5 250 70 17571-72 272.5 275 70 17573-74 272.5 275 75 17575-76 272.5 275 75 20077 297.5 300 75 20078-82 297.5 300 80 20083 297.5 300 85 20084-85 322.5 325 85 20086-87 322.5 325 85 22588-89 322.5 325 90 22590-92 347.5 350 90 22593-94 347.5 350 95 22595-96 347.5 350 95 25097 372.5 375 95 25098-100 372.5 375 100 250

NOTES:


PR 10033(2008/12/07)




TIME&

DATE

YYYY/MM/DD

SIGNATuREOF

NuRSE

Yes No




Day 5: ATG INFUSION _____/_____/_____(YYYY/MM/DD)If no allergic reactions observed with Day 4 infusion administer rabbit ATG 3.75mg/kg rounded to nearest 25mg (=_________mg -see back of page this page “Infusion for Days 2-5”) in 1000mL of Normal Saline IV to run over 6 hours through a 0.2-micron in-line filter. If reaction(s) observed with Day 4 infusion, increase infusion rate to 12 hours (see Note #2 on back of this page).Day 6: _____/_____/_____(YYYY/MM/DD)prednisone 1 mg/kg rounded to nearest 5mg (= _____ mg-see back of this page for rounded dose) po daily with breakfast x 9 doses.Day 15: _____/_____/_____(YYYY/MM/DD)Contact the physician regarding tapering of prednisone dose(see Note #4 on back this page).cyclosporine 2.5mg/kg rounded to nearest 25mg (= _________mg -see back of this page for rounded dose) po BID for a minimum duration of 6 months

PR 10033(2008/12/07)

Patient Weight

(kg)



Rounded to 5 mg




Dose for Days 2-5


45 172.5 175 45 10046-47 172.5 175 45 12548-49 172.5 175 50 12550-52 197.5 200 50 12553-54 197.5 200 55 12555-56 197.5 200 55 15057 222.5 225 55 15058-62 222.5 225 60 15063 222.5 225 65 15064-65 247.5 250 65 15066-67 247.5 250 65 17568-70 247.5 250 70 17571-72 272.5 275 70 17573-74 272.5 275 75 17575-76 272.5 275 75 20077 297.5 300 75 20078-82 297.5 300 80 20083 297.5 300 85 20084-85 322.5 325 85 20086-87 322.5 325 85 22588-89 322.5 325 90 22590-92 347.5 350 90 22593-94 347.5 350 95 22595-96 347.5 350 95 25097 372.5 375 95 25098-100 372.5 375 100 250

NOTES:


PR 10033(2008/12/07)

of 61 Appendix B

BBoorrtteezzoommiibb ((VVeellccaaddee®®))

Indications Second-line therapy for patients with multiple myeloma i. Induction

Bortezomib 1.3 mg/m2 IV days 1, 4, 8, 11 Repeat cycle every 21 days for 8 cycles

ii. Maintenance Bortezomib

1.3 mg/m2 IV days 1, 8, 15, 22 Repeat cycle every 35 days for cycle 9-11

Optional

Drug Regimen

Dexamethasone 40 mg p.o. days 1-4, 9-12, 17-20 of cycles 1-4 Repeat cycle every 35 days 40 mg p.o. days 1-4 of cycles 5-9 Repeat every 28 days Maximum 280 days

Cycle Frequency 3 weeks for cycle 1-8 5 weeks for cycle 9-11

Dose

Modification Criteria

Hematologic toxicity grade III/IV thrombocytopenia and neutropenia consider 50% dose reduction

Non-hematologic toxicity grade III/IV ex neuropathy/GI toxicity 50% dose

reduction

Cost Cost $2000 per dose

References Richardson, P.G., et al., Bortezomib or high-dose dexamethasone for relapsed multiple myeloma. N Engl J Med, 2005. 352(24): p. 2487-98.

Abbreviations: IV = intravenously; p.o. = by mouth


CBV

Indications High-dose therapy for lymphoma (Transplant Protocol)

Drug Regimen Day - 7

Day -6

Day - 5

Day -4

Day -3

Day -2

Day -1

Day 0

Etoposide 2400 mg/m2 IV by continuous infusion over 24 hours Hyperhydration D5 NS with 20 mEq KCl and 0.5 g MgSO4/L at 125 mL/m2/hour from day -6 to -1 Cyclophosphamide 1800 mg/m2 IV in 500 mL NS over 2 hours Cyclophosphamide 1800 mg/m2 IV in 500 mL NS over 2 hours Cyclophosphamide 1800 mg/m2 IV in 500 mL NS over 2 hours Cyclophosphamide 1800 mg/m2 IV in 500 mL NS over 2 hours Carmustine 500 mg/m2 IV in 500 mL D5W over 4 hours Hyperhydration until 12 PM (see day -6) Stem Cell Infusion

Cycle Frequency Single course only

Cost $1200 for single course

References Wheeler, C., et al., Cyclophosphamide, carmustine, and etoposide with autologous bone marrow transplantation in refractory Hodgkin's disease and non-Hodgkin's lymphoma: a dose-finding study. J Clin Oncol, 1990. 8(4): p. 648-56.

Abbreviations: D5 NS = 5% dextrose with normal saline; D5W = 5 % dextrose IV = intravenously; KCl = potassium chloride; MgSO4 = magnesium sulphate; NS = normal saline

of 61 Appendix B

CChhlloorraammbbuucciill

Indications First-line therapy for indolent lymphoma/CLL

Drug Regimen Chlorambucil

Prednisone

0.1-0.2 mg/kg/day p.o. x 28 days (round dose off to nearest 2 mg) Or 8 mg/m2/day p.o. x 14 days (round dose off to nearest 2 mg) May also add 50 mg p.o. daily for 5-10 days

Cycle Frequency Repeat every 28 days until progression, toxicity or stable symptomatic improvement

Dose


Hematologic Toxicity If absolute neutrophil count < 1.0 x 109/L hold dose for 1 week

Cost $140 per month (patient’s cost)

Abbreviations: CLL = Chronic lymphocytic leukemia; p.o. = by mouth


CChhlloorraammbbuucciill ++ RRiittuuxxiimmaabb

Indications First-line therapy for indolent lymphoma/CLL

Drug Regimen Premedications

Rituximab

Chlorambucil

Prednisone

Acetaminophen 1000 mg p.o. and diphenhydramine 50 mg IV prior to rituximab 375 mg/m2 IV in 500 mL NS on day 1 of each cycle of chlorambucil (Note: begin infusion at 50 mg/hour, if no infusion related reactions are experienced by the patient escalate by 50 mg/hour every 30 minutes to a maximum of 400 mg/hour) 0.1-0.2 mg/kg/day p.o. x 28 days (round dose off to nearest 2 mg) Or 8 mg/m2/day p.o. x 14 days (round dose off to nearest 2 mg) May also add 50 mg p.o. daily for 5-10 days (Note: If given, prednisone should be started day 1, prior to rituximab as part of premedications)

Cycle Frequency Repeat every 28 days (or as specified by chlorambucil protocol) until progression, toxicity, or stable symptomatic improvement

Dose



Cost Rituximab $2925 per cycle, chlorambucil $140 per cycle (patient’s cost)

Abbreviations: CLL = Chronic lymphocytic leukemia; IV = intravenously; NS = normal saline; p.o. = by mouth

of 61 Appendix B

CCHHOOMMPP

Indications First-line treatment for aggressive histology lymphoma at high risk or confirmed CNS involvement

Therapy of Burkitt's lymphoma

Drug Regimen

Cyclophosphamide Doxorubicin

Vincristine

Prednisone Methotrexate

Methotrexate Methotrexate

Leucovorin

Part A 1200 mg/m2 by IV in 500 mL NS over 30 minutes day 1 40 mg/m2 by IV push day 1 1.4 mg/m2 (maximum 2 mg) by IV in 50 mL NS over 15 minutes - day 1 100 mg p.o. daily for 5 days – days 1-5 12 mg IT in preservative-free NS (total 5 mL) – day 1 Part B 3000 mg/m2 IV (in 1 L NS) over 4 hours day 10 12 mg IT in preservative-free NS (total 5 mL) – day 10 25 mg/m2 IV q6h x 12 doses to begin 24 hours after starting Methotrexate (and continued until MTX level < 0.1 μmol/L)

Cycle Frequency Repeat every 21 days (for a usual total of 6-9 cycles)

Dose Modification

Criteria



or dose delay ≥ 1 week

Renal Failure If serum creatinine > 265 μmol/L omit part B


dose and vincristine to 50% dose If bilirubin = 52-85 μmol/L or AST > 180 IU/L, reduce cyclophosphamide to 75%

dose, doxorubicin to 50% dose and vincristine to 25% dose If bilirubin > 85 μmol/L, omit doxorubicin and vincristine

Cost $275 per cycle (does not include hospitalization cost)

References Bernstein, J.I., et al., Combined modality therapy for adults with small

noncleaved cell lymphoma (Burkitt's and non-Burkitt's types). J Clin Oncol, 1986. 4(6): p. 847-58.

Abbreviations: IT = intrathecally; IV = intravenously; MTX = methotrexate; NS = normal saline; p.o. = by mouth


CCHHOOMMPP ((IInnppaattiieenntt OOrrddeerrss))

Physician’s Orders

Patient Identification

Note: Extracted from the Sunnybrook Health Sciences Centre Inpatient Order Sheet

CHOMP - Part B (High Dose Methotrexate) Chemotherapy for High Grade Lymphoma (Inpatient Portion)

YES NO Doctor must check off Yes/No for all orders

Patient received Part A (CHOMP) of regimen Prechemotherapy blood work (if not done prior to admission): CBC, differential,

electrolytes, blood glucose, calcium profile, liver profile, renal profile, LDH, uric acid Serum methotrexate levels daily starting the day following methotrexate administration,

and continuing until methotrexate level is < 0.1цmol/L Other daily blood work: Renal profile, calcium profile, electrolytes Urine pH b.i.d. Hold chemotherapy until Doctor approves blood work results, and urine pH ≥7.0 Allopurinol 300 mg p.o. daily (starting on day 1) for cycle 1 only Sodium bicarbonate 600 mg p.o. t.i.d. (starting on day 1) Hydration: IV D5W with 150 mmol/L sodium bicarbonate to run @ (80

mL/m2/hr)_________mL/hr starting the morning of IV methotrexate and to continue until methotrexate level is < 0.1цmol/L

Monitor intake and output daily ANTIEMETIC THERAPY Ondansetron 8 mg p.o. q12h x 2 doses, on day 1 starting 30 minutes prior to IV

methotrexate Dexamethasone 12 mg p.o. x 1 dose, 30 minutes prior to IV methotrexate, on day 1 Dexamethasone 4 mg p.o. b.i.d. x 6 doses starting day 2 Prochlorperazine 10 mg p.o./IV q4h p.r.n. for nausea and vomiting CHEMOTHERAPY ADMINISTRATION Date chemotherapy is to be given:_____/_____/_____(YY/MM/DD) Height:__________cm Weight:__________kg BSA:____________m2 Methotrexate (3000 mg/m2)_______mg IV in 1 L normal saline to run over 4 hours Folinic Acid (25 mg/m2)_______mg IV q6h to begin 24 hours after starting the

methotrexate infusion; continue until methotrexate level is < 0.1цmol/L Discontinue folinic acid & hydration only when methotrexate level is < 0.1цmol/L INTRATHECAL CHEMOTHERAPY Date intrathecal chemotherapy is to be given:____/____/___(YY/MM/DD) Preservative-free methotrexate 12 mg in normal saline (total volume of 5 mL) for

intrathecal injection (to be given by doctor) Doctor’s Signature: Date (YY/MM/DD):

of 61 Appendix B

CCHHOOPP

Indications First-line therapy for aggressive histology lymphoma Salvage therapy for indolent lymphoma, CLL

Drug Regimen Cyclophosphamide

Doxorubicin

Vincristine

Prednisone

750 mg/m2 by IV in 50 or 500 mL NS over 30 minutes day 1 50 mg/m2 by IV push day 1 1.4 mg/m2 (maximum 2 mg) by IV in 50 mL NS over 15 minutes day 1 100 mg p.o. daily days 1-5


Dose Modification

Criteria






dose, doxorubicin to 50% dose and vinblastine to 25% dose If bilirubin > 85 μmol/L, omit doxorubicin and vincristine

Cost $60 per cycle

References Gordon, L.I., et al., Comparison of a second-generation combination

chemotherapeutic regimen (m-BACOD) with a standard regimen (CHOP) for advanced diffuse non-Hodgkin's lymphoma. N Engl J Med, 1992. 327(19): p. 1342-9.



CCHHOOPP ++ RRiittuuxxiimmaabb

Indications First-line therapy for diffuse large B-cell lymphoma


Rituximab

Cyclophosphamide

Doxorubicin

Vincristine

Prednisone

Acetaminophen 1000 mg p.o. and diphenhydramine 50 mg IV prior to rituximab 375 mg/m2 IV in 500 mL NS on day 1 of each cycle of CHOP (Note: begin infusion at 50 mg/hour, if no infusion related reactions are experienced by the patient escalate by 50 mg/hour every 30 minutes to a maximum of 400 mg/hour) 750 mg/m2 by IV in 50 or 500 mL NS over 30 minutes day 1 50 mg/m2 by IV push day 1 1.4 mg/m2 (maximum 2 mg) by IV in 50 mL NS over 15 minutes day 1 100 mg p.o. daily days 1 to 5 (Note: Prednisone should be started day 1, prior to rituximab as part of premedications)


Dose Modification

Criteria






dose, doxorubicin to 50% dose and vinblastine to 25% dose If bilirubin > 85 μmol/L, omit doxorubicin and vincristine

Cost $2985 per cycle

References Coiffier, B., et al., CHOP chemotherapy plus rituximab compared with CHOP

alone in elderly patients with diffuse large-B-cell lymphoma. N Engl J Med, 2002. 346(4): p. 235-42.

Hiddemann, W., et al., Frontline therapy with rituximab added to the

combination of cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) significantly improves the outcome for patients with advanced-stage follicular lymphoma compared with therapy with CHOP alone: results of a prospective randomized study of the German Low-Grade Lymphoma Study Group. Blood, 2005. 106(12): p. 3725-32.

Abbreviations: IV = intravenously; NS = normal saline; p.o. = by mouth

of 61 Appendix B

CCllaaddrriibbiinnee ((22--CCDDAA))

Indications First-line therapy for hairy cell lymphoma

Drug Regimen Cladribine

0.1 mg/kg/day CIV x 7 days Or 0.12-0.14 mg/kg/day IV in 500 mL NS over 2 hours daily x 5 days

Cycle Frequency Single course only

Dose Modification

Criteria

Caution with renal insufficiency since 2-CDA is 10-30% excreted in urine

Cost $2500 for single course

References Piro, L.D., et al., Lasting remissions in hairy-cell leukemia induced by a single infusion of 2-chlorodeoxyadenosine. N Engl J Med, 1990. 322(16): p. 1117-21.

Morton, J., et al., High response rates with short infusional 2-

chlorodeoxyadenosine in de novo and relapsed low-grade lymphoma. Australian and New Zealand Lymphoma Study Group. Br J Haematol, 1996. 95(1): p. 110-5.

Abbreviations: CIV = continuous intravenous infusion; IV = intravenously; NS = normal saline


CCVVPP ((IIVV))

Indications First-line/salvage therapy for indolent lymphoma/CLL


Vincristine

Prednisone

800 mg/m2 IV in 50mL or 500mL NS over 30 minutes day 1 1.4 mg/m2 (maximum 2 mg) IV in 50 mL NS over 15 minutes day 1 100 mg/day p.o. days 1 to 5

Cycle Frequency Repeat every 21 days (usually for a total of 6 to 8 cycles)

Dose Modification

Criteria


Hepatic Dysfunction If bilirubin = 25 – 50 μmol/L or AST = 60 – 180 IU/L, reduce vincristine to 50%

dose If bilirubin = 51 – 85 μmol/L or AST > 180 IU/L, reduce vincristine to 25% dose

and cyclophosphamide to 75% dose If bilirubin > 85 μmol/L, omit cyclophosphamide and vincristine

Cost $20 per cycle

References Marcus, R., et al., CVP chemotherapy plus rituximab compared with CVP as first-

line treatment for advanced follicular lymphoma. Blood, 2005. 105(4): p. 1417-23.


of 61 Appendix B

CCVVPP ((IIVV)) ++ RRiittuuxxiimmaabb



Rituximab

Cyclophosphamide

Vincristine

Prednisone

Acetaminophen 1000 mg p.o. and diphenhydramine 50 mg IV prior to rituximab 375 mg/m2 IV in 500 mL NS on day 1 of each cycle of CVP (Note: begin infusion at 50 mg/hour, if no infusion related reactions are experienced by the patient escalate by 50 mg/hour every 30 minutes to a maximum of 400 mg/hour) 800 mg/m2 IV in 50 mL or 500 mL NS over 30 minutes day 1 1.4 mg/m2 IV (maximum 2 mg) in 50 mL NS over 15 minutes day 1 100 mg/day p.o. days 1 to 5 (Note: Prednisone should be started day 1, prior to rituximab as part of premedications)


Dose Modification

Criteria






References Marcus, R., et al., CVP chemotherapy plus rituximab compared with CVP as first-

line treatment for advanced follicular lymphoma. Blood, 2005. 105(4): p. 1417-23.



CCVVPP ((OOrraall))



Vincristine

Prednisone

400 mg/m2/day p.o. days 1-5 (round off to closest 25 mg) 1.4 mg/m2 (maximum 2 mg) IV in 50 mL NS over 15 minutes day 1 100 mg/day p.o. days 1-5 (round off to closest 50 mg)


Dose Modification

Criteria





Cost $30 per cycle

References Bagley, C.M., Jr., et al., Advanced lymphosarcoma: intensive cyclical

combination chemotherapy with cyclophosphamide, vincristine, and prednisone. Ann Intern Med, 1972. 76(2): p. 227-34.

Abbreviations: CLL = chronic lymphocytic leukemia; IV = intravenously; NS = normal saline; p.o. = by mouth

of 61 Appendix B

CCVVPP ((OOrraall)) ++ RRiittuuxxiimmaabb



Rituximab

Cyclophosphamide

Vincristine

Prednisone

Acetaminophen 1000 mg p.o. and diphenhydramine 50 mg IV prior to rituximab 375 mg/m2 IV in 500 mL NS on day 1 of each cycle of CVP (Note: begin infusion at 50 mg/hour, if no infusion related reactions are experienced by the patient escalate by 50 mg/hour every 30 minutes to a maximum of 400 mg/hour) 400 mg/m2/day p.o. days 1-5 (round off to closest 25 mg) 1.4 mg/m2 (maximum 2 mg) IV in 50 mL NS over 15 minutes day 1 100 mg/day p.o. days 1-5 (round off to closest 50 mg)


Dose Modification

Criteria








DHAP

Indications Salvage therapy for aggressive histology lymphoma

Drug Regimen Cisplatin

Cytarabine

Dexamethasone

100 mg/m2 CIV over 24 hours day 1 2000 mg/m2 IV in 250 mL NS over 3 hours repeat 12 hours later day 2 40 mg p.o. or IV daily days 1-4

Cycle Frequency Repeat every 21-28 days

Dose Modification

Criteria


Renal Failure If creatinine clearance = 0.5 – 1.0 mL/second or serum creatinine = 136-185 μmol/L reduce cisplatin to 50% dose If creatinine clearance < 0.5 mL/second or serum creatinine > 185 μmol/L omit

cisplatin

Cost $295 per cycle (does not include hospitalization costs)

References Velasquez, W.S., et al., Effective salvage therapy for lymphoma with cisplatin in combination with high-dose Ara-C and dexamethasone (DHAP). Blood, 1988. 71(1): p. 117-22.

Abbreviations: CIV = continuous intravenous infusion; IV = intravenously; NS = normal saline; p.o. = by mouth

of 61 Appendix B

DHAP ((IInnppaattiieenntt OOrrddeerrss))




DHAP Chemotherapy for Lymphoma YES NO Doctor must check off Yes/No for all orders

Prechemotherapy blood work (if not done prior to admission): CBC, differential, electrolytes, blood glucose, calcium profile, liver profile, renal profile, LDH, uric acid

Hold chemotherapy until blood work satisfactory, urine pH > 7, third space fluid (if present) is drained

Allopurinol 300 mg p.o. daily HYDRATION IV normal saline with 4 mmol/L magnesium sulphate + 20 mmol/L KCl + 20 g/L mannitol

at: 250 mL/hour x 6 hours pre-cisplatin 125 mL/hour during cisplatin 200 mL/hour x 6 hours following completion of cisplatin Then change to IV normal saline at 75 mL/hour ANTIEMETIC THERAPY Ondansetron 8 mg p.o. 30 minutes prior to chemotherapy on day 1, then q12h x 3

doses Prochlorperazine 10 mg p.o./IV q4h prn (for nausea) CHEMOTHERAPY ADMINISTRATION Height:__________cm Weight:__________kg BSA:____________m2 DAY 1 (YY/MM/DD): | | | Dexamethasone 40 mg p.o. or IV in 50 mL normal saline over 15 minutes (with

breakfast) Cisplatin (33 mg/m2) ________mg in 1 L normal saline + 20 g/L mannitol to run at 125

mL/hour x 3 bags (i.e. 100 mg/m2 over 24 hours) DAY 2 (YY/MM/DD): | | | To begin immediately following completion of cisplatin: cytarabine (2000 mg/m

2) _______ mg in 250 mL normal saline over 3 hours q12h x 2 doses

Dexamethasone 40 mg p.o. or IV in 50 mL normal saline over 15 minutes (with breakfast)

DAY 3 (YY/MM/DD): | | | Dexamethasone 40 mg p.o. or IV in 50 mL normal saline over 15 minutes (with

breakfast) DAY 4 (YY/MM/DD): | | | Dexamethasone 40 mg p.o. or IV in 50 mL normal saline over 15 minutes (with

breakfast) Doctor’s Signature: Date (YY/MM/DD):


DPACE

Indications Salvage therapy for multiple myeloma

Drug Regimen Dexamethasone Cisplatin

Adriamycin Cyclophosphamide

Etoposide

40 mg p.o./day days 1-4 10 mg/m2 IV daily by continuous infusion days 1-4 10 mg/m2 IV daily by continuous infusion days 1-4 400 mg/m2 IV daily by continuous infusion days 1-4 40 mg/m2 IV daily by continuous infusion days 1-4

Cycle Frequency Repeat every 4-6 weeks

Dose Modification

Criteria


109/L Consider filgrastim support

Renal Failure If creatinine > 265 μmol/L omit cisplatin

Cost $210 per cycle

References Barlogie B, Desikan R, Munshi N, et al. Single course D.T. pace anti-

angiochemotherapy effects CR in plasma cell leukemia and fulminant multiple myeloma (MM). Blood. Nov 1998, Vol 92, No 10, Suppl 1, Part 2: 273b (Abstract #4180).

Munshi N, Desikan R, Zangari M, et al. Chemoangiotherapy with DT-Pace for

previously treated multiple myeloma (MM). Blood. Nov. 1999, Vol 94, No 10, Suppl 1, Part 1: 123a (Abstract#540)

Abbreviations: IV = intravenously; p.o. = by mouth

of 61 Appendix B

ESHAP

*Indications Salvage therapy for aggressive histology lymphoma

Drug Regimen Etoposide

Methylprednisolone

Cisplatin

Cytarabine

40-60 mg/m2/day in 250 mL of NS over 30 minutes days 1-4 500 mg IV in 100 mL NS over 15 minutes days 1-5 25 mg/m2/day CIV in 500 mL NS over 24 hour days 1-4 2000 mg/m2 IV in 250 mL NS over 2 hours day 5

Cycle Frequency Repeat every 21 – 28 days

Dose Modification

Criteria

Hematologic Toxicity If absolute neutrophil count < 1.0 x 109/L or platelets < 75 x 109/L, hold for 1

week

Hepatic Dysfunction If bilirubin = 26-51 μmol/L or AST = 60-180 IU/L, reduce etoposide to 50% dose If bilirubin = 52-85 μmol/L, reduce etoposide to 25% dose If bilirubin > 85 μmol/L or AST > 180 IU/L, omit etoposide dose

Renal Failure If creatinine clearance = 0.5-1.0 mL/second or serum creatinine = 136-185 μmol/L reduce cisplatin to 50% dose If creatinine clearance = 0.2-0.8 mL/second or serum creatinine > 130 μmol/L,

reduce etoposide to 75% dose If creatinine clearance < 0.5 mL/second or serum creatinine > 185 μmol/L, omit

cisplatin dose If creatinine clearance < 0.2 mL/second, reduce etoposide to 50%

Cost $300 per cycle

References Cabanillas, F., Non-Hodgkin's lymphomas: a review of the M.D. Anderson

experience. Semin Oncol, 1992. 19(1 Suppl 1): p. 11-3. Velasquez, W.S., et al., ESHAP--an effective chemotherapy regimen in refractory

and relapsing lymphoma: a 4-year follow-up study. J Clin Oncol, 1994. 12(6): p. 1169-76.

Abbreviations: CIV = continuous intravenous infusion; IV = intravenously; NS = normal saline; p.o. = by mouth


ESHAP ((IInnppaattiieenntt OOrrddeerrss))




ESHAP Protocol - Chemotherapy for Lymphoma YES NO Doctor must check off Yes/No for all orders


Hold chemotherapy until a Doctor approves blood work results Repeat CBC on Day 4 Oral intake of fluids (2 L/day) during cisplatin infusion and for 2 days post cisplatin infusion ANTIEMETIC THERAPY Ondansetron 8 mg p.o. 30 minutes prior to chemotherapy, starting on day 1, then q12h x 9 doses Dexamethasone 8 mg p.o. od x 3 doses, with breakfast, starting on day 6 __/__/__ (YY/MM/DD) Prochlorperazine 10 mg p.o./IV q4h prn for nausea and vomiting CHEMOTHERAPY ADMINISTRATION Height:__________cm Weight:__________kg BSA:____________m2 DAY 1 (YY/MM/DD): | | | Methylprednisolone 500 mg IV in 100 mL normal saline over 15 minutes, give 60 minutes prior to

start of chemotherapy Cisplatin (25 mg/m2)_______mg IV in 500mL normal saline as continuous infusion over 24 hours

Etoposide (40 mg/m2)________mg IV in 250 mL normal saline over 30 minutes with in-line filter (Y-site with cisplatin)

DAY 2 (YY/MM/DD): | | | Methylprednisolone 500 mg IV in 100 mL normal saline over 15 minutes, interrupt cisplatin infusion

and flush line with 50 mL normal saline before and after methylprednisolone Cisplatin (25 mg/m2)_______mg IV in 500 mL normal saline as continuous infusion over 24 hours

Etoposide (40 mg/m2)________mg IV in 250 mL normal saline over 30 minute with in-line filter (Y-site with cisplatin)

DAY 3 (YY/MM/DD): | | | Methylprednisolone 500 mg IV in 100 mL normal saline over 15 minutes; interrupt cisplatin infusion



DAY 4 (YY/MM/DD): | | | Methylprednisolone 500 mg IV in 100 mL normal saline over 15 minutes; interrupt cisplatin infusion



DAY 5 (YY/MM/DD): | | | Methylprednisolone 500 mg IV in 100 mL normal saline over 15 minutes

After completion of cisplatin infusion: Cytarabine (2000 mg/m2)________mg IV in 250 mL normal saline over 2 hours

Doctor’s Signature: Date (YY/MM/DD):

of 61 Appendix B

FCM

Indications First-line or relapsed therapy for indolent lymphoma/mantle cell lymphoma

Drug Regimen Fludarabine

Cyclophosphamide

Mitoxantrone

25 mg/m2/day IV in 50-100 mL NS over 15-30 minutes days 1, 2, 3 200 mg/m2/day IV in 50 mL NS over 30 minutes days 1, 2, 3 8 mg/m2 IV over 30 minutes day 1

Cycle Frequency Repeat every 28 days for a total of 4 cycles

Dose Modification

Criteria




Hepatic Dysfunction If bilirubin = 26-51 μmol/L or AST = 60-180 IU/L, reduce mitoxantrone to 75%

dose If bilirubin= 52-85 μmol/L or AST > 180 IU/L, reduce cyclophosphamide to 75%

dose, mitoxantrone to 50% dose If bilirubin > 85 μmol/L, omit mitoxantrone

Cost $840 per cycle

References Forstpointner, R., et al., The addition of rituximab to a combination of

fludarabine, cyclophosphamide, mitoxantrone (FCM) significantly increases the response rate and prolongs survival as compared with FCM alone in patients with relapsed and refractory follicular and mantle cell lymphomas: results of a prospective randomized study of the German Low-Grade Lymphoma Study Group. Blood, 2004. 104(10): p. 3064-71.

Abbreviations: IV = intravenously; NS = normal saline


FCM + Rituximab

Indications First-line or relapsed therapy for indolent lymphoma/mantle cell lymphoma


Rituximab

Fludarabine

Cyclophosphamide

Mitoxantrone

Acetaminophen 1000 mg p.o. and diphenhydramine 50 mg IV prior to rituximab 375 mg/m2 IV in 500 mL NS on day 1 of each cycle of FCM (Note: begin infusion at 50 mg/hour, if no infusion related reactions are experienced by the patient escalate by 50 mg/hour every 30 minutes to a maximum of 400 mg/hour) 25 mg/m2/day IV in 50-100 mL NS over 15-30 minutes days 1, 2 and 3 200 mg/m2/day IV in 50 mL NS over 30 minutes days 1, 2 and 3 8 mg/m2 IV over 30 minutes day 1

Cycle Frequency Repeat every 28 days for a total of 4 cycles

Dose Modification

Criteria




Hepatic Dysfunction If bilirubin = 26-51 μmol/L or AST = 60-180 IU/L, reduce mitoxantrone to 75%

dose If bilirubin= 52-85 μmol/L or AST > 180 IU/L, reduce cyclophosphamide to 75%

dose, mitoxantrone to 50% dose If bilirubin > 85 μmol/L, omit mitoxantrone

Cost $840 per cycle

References Forstpointner, R., et al., The addition of rituximab to a combination of

fludarabine, cyclophosphamide, mitoxantrone (FCM) significantly increases the response rate and prolongs survival as compared with FCM alone in patients with relapsed and refractory follicular and mantle cell lymphomas: results of a prospective randomized study of the German Low-Grade Lymphoma Study Group. Blood, 2004. 104(10): p. 3064-71.

Abbreviations: IV = intravenously; NS = normal saline; p.o. = by mouth

of 61 Appendix B

Fludarabine

Indications First-line or salvage therapy for indolent lymphoma/CLL

Drug Regimen Fludarabine

25 mg/m2/day IV in 50-100 mL NS over 15- 30 minutes days 1-5 Or 40 mg/m2/day p.o. days 1-5 (round off to nearest 10 mg)

Cycle Frequency Repeat every 28 days until desired response, progression or toxicity

Dose


Hematologic Toxicity If absolute neutrophil count < 1.0 x 109/L or platelets < 75 x 109/L, hold for 1 week

Cost $1125 per cycle for oral regimen; $1300 per cycle for intravenous regimen

References Ross, S.R., D. McTavish, and D. Faulds, Fludarabine. A review of its

pharmacological properties and therapeutic potential in malignancy. Drugs, 1993. 45(5): p. 737-59.

Redman, J.R., et al., Phase II trial of fludarabine phosphate in lymphoma: an

effective new agent in low-grade lymphoma. J Clin Oncol, 1992. 10(5): p. 790-4.



Fludarabine + Rituximab

Indications First-line or salvage therapy for indolent lymphoma/CLL


Rituximab

Fludarabine

Acetaminophen 1000 mg p.o. and diphenhydramine 50 mg IV prior to rituximab 375 mg/m2 IV in 500 mL NS on day 1 of each cycle of fludarabine (Note: begin infusion at 50 mg/hour, if no infusion related reactions are experienced by the patient escalate by 50 mg/hour every 30 minutes to a maximum of 400 mg/hour) 25 mg/m2/day IV in 50-100 mL NS over 15-30 minutes days 1-5 or 40 mg/m2/day p.o. days 1-5 (round off to nearest 10 mg)

Cycle Frequency Repeat every 28 days until desired response, progression or toxicity

Dose Modification

Criteria

Hematologic Toxicity If absolute neutrophil count < 1.0 x 109/L or platelets < 75 x 109/L, hold for 1 week

Cost $4050 per cycle for intravenous regimen; $3875 per cycle for oral regimen

References Byrd, J.C., et al., Randomized phase 2 study of fludarabine with concurrent

versus sequential treatment with rituximab in symptomatic, untreated patients with B-cell chronic lymphocytic leukemia: results from Cancer and Leukemia Group B 9712 (CALGB 9712). Blood, 2003. 101(1): p. 6-14.


of 61 Appendix B

GDP

Indications Salvage therapy for relapsed Hodgkin’s or non-Hodgkin’s lymphoma

Drug Regimen 0.9% Sodium Chloride

Gemcitabine

20% Mannitol

Cisplatin

0.9% Sodium Chloride

1000 mL IV over 1 hour prechemotherapy day 1 1000 mg/m2 IV in 100 mL NS over 30 minutes days 1 and 8 250 mL IV over 2 hours (run concurrently with cisplatin) day 1 40 mg p.o. daily days 1-4 1000 mL IV over 1 hour post chemotherapy day 1

Cycle Frequency Repeat every 21 days for up to 6 courses

Dose Modification

Criteria

Hematologic Toxicity (Day 1 only) If absolute neutrophil count < 1.0 x 109/L or platelets < 50 x 109/L,

delay 1 week Renal Dysfunction

CrCl (mL/min) Cisplatin dose > 60 75 mg/m2 on day 1 45-59 37.5 mg/m2 on days 1 and 8 < 45 Delay

Cost $950 per course

References Crump, M., et al., Gemcitabine, dexamethasone, and cisplatin in patients with

recurrent or refractory aggressive histology B-cell non-Hodgkin lymphoma: a Phase II study by the National Cancer Institute of Canada Clinical Trials Group (NCIC-CTG). Cancer, 2004. 101(8): p. 1835-42.

BCCA Protocol Summary for Treatment of Lymphoma with Gemcitabine, Dexamethasone and Cisplatin (GDP). www.bccancer.bc.ca/HPI/ChemotherapyProtocols/Lymphoma/LYGDP.htm.

Abbreviations: CrCl = creatinine clearance; IV = intravenously; NS = normal saline; p.o. = by mouth

http://www.bccancer.bc.ca/HPI/ChemotherapyProtocols/Lymphoma/LYGDP.htm


HDMVP

Indications First-line therapy for primary CNS lymphoma

Drug Regimen Methotrexate

Vincristine

Procarbazine

Methotrexate

Folinic Acid

3500 mg/m2 IV in 1 L NS over 4 hours day 1 1.4 mg/m2 (maximum 2 mg) IV in 50 mL NS over 15 minutes day 1 100 mg/m2 (round off to the nearest 50 mg) p.o. daily days 1-7 inclusive 12 mg IT day 1 and day 3 25 mg/m2 IV q6h to begin 24 hours after the start of the methotrexate infusion and to be continued until MTX level < 0.1 µmol/L

Cycle Frequency 2-4 cycles given at 4-week intervals

Dose Modification

Criteria


109/L

Renal Failure Do not give if serum creatinine > 265 µmol/L

Cost $370 per cycle

References Mangel J, Buckstein R, Berinstein NL, Spaner D, Davey P, Perry J and Imrie K.

Upfront HDMVP chemotherapy without radiation for the treatment of newly diagnosed primary CNS lymphoma. Blood. Nov. 16, 2001, Vol 98, No 11, page 130a (Abstract #546).

Abbreviations: IT = intrathecally; IV = intravenously; MTX = methotrexate; NS = normal saline; p.o. = by mouth

of 61 Appendix B

HDMVP (Inpatient Orders)




HDMVP Chemotherapy for Primary CNS Lymphoma YES NO Doctor must check off Yes/No for all orders


Urine pH BID Hold chemotherapy until blood work satisfactory, urine pH > 7.0, third space fluid

(if present) is drained Sodium bicarbonate 600 mg p.o. t.i.d. (starting the day before IV methotrexate)

Hydration: IV D5W with 150 mmol/L sodium bicarbonate to run @ (80 mL/m2/hr) ___________ mL/hr to start the day before IV methotrexate and to continue until methotrexate level is < 0.1 μmol

Serum methotrexate levels daily until methotrexate level is < 0.1 μmol Other daily blood work: Renal profile, calcium profile, electrolytes Monitor input and output daily ANTIEMETIC THERAPY Dexamethasone 10 mg IV 30 minutes prior to chemotherapy on day 1 Dexamethasone 8 mg p.o. on day 2 (with breakfast) Ondansetron 8 mg p.o. 30 minutes prior to chemotherapy on day 1, then q12h x 1 dose Prochlorperazine 10 mg p.o./IV 30 minutes prior to chemotherapy on days 2-7 Prochlorperazine 10 mg p.o./IV q4h prn for nausea CHEMOTHERAPY ADMINISTRATION Height:__________cm Weight:__________kg BSA:____________m2 DAY 1 (YY/MM/DD): | | | Methotrexate (3500 mg/m2) _______ mg IV in 1 L normal saline to run over 4 hours Vincristine (1.4 mg/m2) _______ mg IV push (maximum 2 mg) Procarbazine (100 mg/m2; round off to nearest 50 mg) _______ mg p.o. daily to be

given on days 1-7 inclusive ___/___/___ - __/___/____ (YY/MM/DD) Methotrexate 12 mg in preservative-free normal saline (total volume of 5 mL) for

intrathecal injection on days 1, 3, 5, 8, 10, 12 (to be given by doctor) DAY 2 (YY/MM/DD): | | | Folinic Acid (25 mg/m2) _______ mg IV q6h to begin 24 hours after starting the

methotrexate infusion: continue until methotrexate level is < 0.1 μmol Doctor’s Signature: Date (YY/MM/DD):


HIDAC Consolidation

Indications Consolidation for AML (under age 60)

Drug Regimen Daunorubicin Cytarabine

45 mg/m2 IV push days 1 and 2 3000 mg/m2 IV in 250 mL NS over 3 hour q12h days 1, 3 and 5

Cycle Frequency 2-3 cycles 4-6 weeks apart

Dose Modification

Criteria

Hematologic Toxicity If absolute neutrophil count < 1.0 x 109/L or platelets < 50 x 109/L, delay HIDAC

consolidation cycle

Hepatic Failure If bilirubin = 26-51 µmol/L or AST = 60-180 IU/L, reduce daunorubicin to 75% of

initial dose

If bilirubin = 52-85 µmol/L or AST > 180 IU/L, reduce daunorubicin to 50% of initial dose

If bilirubin > 85, omit daunorubicin


Abbreviations: AML = acute myelogenous leukemia, IV = intravenously; NS = normal saline

of 61 Appendix B

HIDAC (Inpatient Orders)




HIDAC Consolidation - Chemotherapy for Acute Myelogenous Leukemia YES NO Doctor must check off Yes/No for all orders


Hold chemotherapy until a Doctor approves blood work results Prednisolone 1% ophthalmic solution 1 drop both eyes qid x7 days, starting on day 1 Monitor intake and output daily ANTIEMETIC THERAPY Dexamethasone 12 mg p.o. 30 minutes prior to chemotherapy on days 1, 2, 3 and 5 Ondansetron 8mg p.o. 30 minutes prior to chemotherapy and qhs on days 1, 2, 3 and 5 Dexamethasone 8 mg p.o. od x 3 doses, with breakfast starting on day 6

__/__/__(YY/MM/DD) Prochlorperazine 10mg p.o./IV q4h prn for nausea and vomiting CHEMOTHERAPY ADMINISTRATION Height:__________cm Weight:__________kg BSA:____________m2 DAY 1 (YY/MM/DD): | | | Daunorubicin (45 mg/m2)________mg IV push Cytarabine (3000 mg/m2)________mg IV in 250 mL of normal saline to run over 3 hours

q12h x 2 doses DAY 2 (YY/MM/DD): | | | Daunorubicin (45 mg/m2)________mg IV push DAY 3 (YY/MM/DD): | | | Cytarabine (3000 mg/m2)________mg IV in 250 mL of normal saline to run over 3 hours

q12h x 2 doses DAY 5 (YY/MM/DD): | | | Cytarabine (3000 mg/m2)________mg IV in 250 mL of normal saline to run over 3 hours

q12h x 2 doses Doctor’s Signature: Date (YY/MM/DD):


Hyper-CVAD Indications First-line therapy for ALL and lymphoblastic leukemia

Course A Cyclophosphamide

Doxorubicin

Vincristine

Dexamethasone

300 mg/m2 IV in 100 mL NS over 3 hours q12h x 6 doses on days 1, 2 and 3 50 mg/m2 IV push on day 4 (12 hours after last dose of Cyclophosphamide) 2 mg IV in 50 mL NS over 15 minutes on days 4 and 11 40 mg IV or p.o. daily days 1-4 and days 11-14

Course B Methotrexate

Folinic Acid

Sodium Bicarbonate

Cytarabine

1000 mg/m2 in 1 L NS over 24 hours day 1 With methotrexate give IV D5W + 150 mEq NaHCO3 at 80 mL/m2/h starting the morning of MTX infusion; continue until MTX level 85 µmol/L, omit doxorubicin

Cost $835 per cycle (Parts A & B together)

References Kantarjian HM, O’Brien S, Smith TL, et al. Results of treatment with hyper-CVAD, a dose-

intensive regimen, in adult acute lymphocytic leukemia. J Clin Oncol. 2000 Feb;18(3):547-61.

Abbreviations: ALL = acute lymphoblastic leukemia; IT = intrathecally; IV = intravenously; MTX = Methotrexate; NS = normal saline; p.o. = by mouth; ULN = upper limit of normal

of 61 Appendix B

Hyper-CVAD (Inpatient Orders)




Hyper-CVAD Course A Chemotherapy for High Risk ALL/Burkitt's Lymphoma YES NO Doctor must check off Yes/No for all orders

Pre-chemotherapy blood work (if not done prior to admission): CBC, differential, electrolytes, blood glucose, calcium profile, liver profile, renal profile, LDH, uric acid

Hold chemotherapy until a Doctor approves blood work results Daily blood work: CBC, differential, electrolytes, renal profile

Allopurinol 300 mg p.o. daily (starting on day 1) for Cycle 1 only ANTIEMETIC THERAPY Ondansetron 8 mg p.o. 30 minutes prior to first dose of chemotherapy, then q12h x 7 doses

Prochlorperazine 10 mg p.o./IV q4h prn for nausea or vomiting

Dexamethasone 8 mg p.o. od x 3 doses, with breakfast starting on Day 5 __/__/__ (YY/MM/DD)

CHEMOTHERAPY ADMINISTRATION Height:__________cm Weight:__________kg BSA:____________m2 DAY 1 (YY/MM/DD): | | | Dexamethasone 40 mg p.o./IV with breakfast

Cyclophosphamide (300 mg/m2)_______mg IV in 100 mL normal saline over 3 hours q12h x 2 doses

DAY 2 (YY/MM/DD): | | | Dexamethasone 40 mg p.o./IV with breakfast


Preservative-free methotrexate 12 mg in normal saline (total volume of 5 mL) for intrathecal injection (to be given by Doctor)




Doxorubicin (50 mg/m2)_______mg IV push (12 hours after last dose of cyclophosphamide)

Vincristine 2 mg IV in 50 mL of normal saline over 15 minutes

DAY 11 (YY/MM/DD): | | | To be given in OCC as an outpatient (If yes, ensure follow up appointment in the chemotherapy

suite is booked prior to discharge)

Dexamethasone 40 mg p.o./IV daily x 4 days with breakfast on days 11 to 14

Vincristine 2 mg IV in 50 mL of normal saline over 15 minutes

Cytarabine 70 mg in normal saline (total volume of 5 mL) for intrathecal injection (to be given by the Doctor)

Doctor’s Signature: Date (YY/MM/DD):


Hyper-CVAD ((IInnppaattiieenntt OOrrddeerrss))




Hyper-CVAD Course B Chemotherapy for High Risk ALL/Burkitt's Lymphoma YES NO Doctor must check off Yes/No for all orders

Patient received Hyper-CVAD Part A


Serum methotrexate levels daily (starting day 2) until methotrexate level is < 0.1µmol/L Other daily blood work: Calcium profile, electrolytes, renal profile

Urine pH b.i.d.

Hold chemotherapy until a Doctor approves blood work Allopurinol 300 mg p.o. daily (starting on day 1) for Cycle 1 only Sodium bicarbonate 600 mg p.o. t.i.d. (starting on day 1)

Prednisolone 1% ophthalmic solution 1 drop both eyes qid x 5 days, starting on day 1

Hydration: IV D5W with 150 mmol/L sodium bicarbonate to run @ (80 mL/m2/hr) _________mL/hr starting the morning of IV methotrexate and to continue until the methotrexate level is < 0.1μmol/L

Monitor intake and output daily

ANTIEMETIC THERAPY Dexamethasone 12 mg p.o. 30 minutes prior to chemotherapy on days 1-3

Ondansetron 8 mg p.o. 30 minutes prior to first dose of chemotherapy, then q12h x 5 doses

Dexamethasone 8 mg p.o. od x 3 doses, with breakfast, starting on Day 4 __/__/__ (YY/MM/DD)

Prochlorperazine 10 mg p.o./IV q4h prn with nausea and vomiting

CHEMOTHERAPY ADMINISTRATION Height:__________cm Weight:__________kg BSA:____________m2 DAY 1 (YY/MM/DD): | | | Methotrexate (1000 mg/m2)_______mg IV in 1 L normal saline to run over 24 hours

DAY 2 (YY/MM/DD): | | | Folinic acid (25 mg/m2)_______mg IV q6h to begin 24 hours after starting the methotrexate

infusion; co

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