DATE TO BE GIVEN: CYCLE: REGIMEN/PROTOCOL: METHOTREXATE + LEUCOVORIN + CYTARABINE (HYPER-CVAD, Even Cycle) PRIMARY DIAGNOSIS: ALLERGIES/REACTIONS: Goal of Chemotherapy: Curative Palliative Neoadjuvant Adjuvant MD to indicate which weight to use: Actual Ideal Adjusted HEIGHT (cm): ACTUAL WEIGHT (kg): IDEAL WEIGHT (kg): ADJUSTED WEIGHT (kg): and BSA (m2): and BSA (m2): and BSA (m2):
Dosing calculations to be completed by Pharmacist: CHEMOTHERAPY DOSE TO BE INFUSE DATE(S) DOSE (mg/m2) BSA (m2) ROUTE MEDICATION ORDERS GIVEN OVER AND FREQUENCY In order of administration: DAY 1= Methotrexate (begin when urine pH 200 mg/m2 X = IV 2 hours Day 1 greater than 7)
THEN 2 Methotrexate 800 mg/m X = IV 24 hours Day 1
Leucovorin 50 mg IV times 1 dose 24 hours after completion of methotrexate infusion, THEN 15 mg IV every 6 hours until methotrexate level less than 0.1 micromol/L Leucovorin dose will be increased to 50 mg IV every 6 hours if methotrexate levels are: . Greater than 20 micromol/L at Hour 0 . Greater than 1 micromol/L at Hour 24 . Greater than 0.1 micromol/L at Hour 48 Every 12 hours Days 2, 3 (4 doses) – begin Cytarabine* 3,000 mg/m2 X = IV 2 hours when methotrexate level less than 1 micromol/L
Methotrexate 12 mg IT
Cytarabine 100 mg IT *Cytarabine may require dose reduction in patients greater than 60 years old if serum creatinine is greater than 2 mg/dL or if the hour 0 methotrexate level is greater than or equal to 20 micromol/L Decrease Cytarabine dose to 1,000 mg/m2 if: (MD to select parameters) Age greater than or equal to 60 years old Serum creatinine greater than 2 mg/dL Hour 0 methotrexate level is greater than/equal to 20 micromol/L CONTINUOUS IV CHEMOTHERAPY: MAY INCREASE RATE BY TO KEEP WITHIN 24 HOUR DOSE. PATIENT MAY BE OFF CONTINUOUS IV CHEMOTHERAPY NO LONGER THAN 30 MINUTES/24 HOURS Physician initial: Page 1 of 3 PATIENT INFORMATION
Revision G PHYSICIAN ORDERS CHEMOTHERAPY: METHOTREXATE + LEUCOVORIN + CYTARABINE (HYPER-CVAD, EVEN CYCLE)
HYDRATION ORDERS HYDRATION SOLUTION ADDITIVES RATE DURATION BEFORE CHEMOTHERAPY DURING CHEMOTHERAPY 5% dextrose in water Sodium bicarbonate Per physician’s 100 ml/hour (D5W) 1,000 ml 100 mEq order AFTER CHEMOTHERAPY HOLD CHEMOTHERAPY FOR THE FOLLOWING REASONS: Absolute Neutrophil Count (ANC) Less Than (typically less than 1,000) Platelets Less Than (typically less than 100,000) Other PHARMACY TO MANAGE ANTIEMETICS ANTIEMETIC ORDERS/DRUG NAME DOSE ROUTE TIMING 16 mg 30 minutes prior to Methotrexate (Day 1) 24 mg Ondansetron PO 16 mg 30 minutes prior to each Cytarabine 24 mg (Days 2-3) 30 minutes prior to Methotrexate (Day 1) 12 mg THEN Daily after starting Methotrexate (Days 2-3) 8 mg THEN Dexamethasone PO 30 minutes pre-first dose 12 mg (Cytarabine Days 2-3, 2 doses only) THEN 8 mg Daily (Days 4-5 of Cytarabine)
150 mg IV 30 minutes pre-first dose Cytarabine (Day 2) Fosaprepitant 30 minutes pre-first dose Cytarabine (Day 2) 12 mg THEN + Dexamethasone (optional) PO 8 mg Daily (Day 3) THEN twice daily (Days 4-5) 30 minutes pre-chemo times 1 dose PRN 0.5-1 mg PO Lorazepam anxiety Do not use additional Dexamethasone or Corticosteriods with this regimen unless ordered by Oncologist PRN ANTIEMETICS (FOR INPATIENT USE) NOTE: Number the antiemetics below in the order to be used. The nurse will select #1 as the first medication to be given and may alternate #2. If orders chosen are not numbered, the nurse will contact the prescriber for clarification.
0.5-1 mg IV Every 4 hours PRN nausea/vomiting/anxiety Lorazepam 12.5-25 mg Promethazine or IV Every 4 hours PRN nausea/vomiting 6.25-12.5 mg** Outpatient Prescription(s): (for outpatients or early discharge)
**For patients greater than 65 years old
Physician initial:
Page 2 of 3 PATIENT INFORMATION
PHYSICIAN ORDERS CHEMOTHERAPY: METHOTREXATE + 742 LEUCOVORIN + CYTARABINE Revision G (HYPER-CVAD, EVEN CYCLE)
TESTS: Muga Scan ECG Other: LABS – NOW: CBC BMP CMP Other LABS – DAILY: CBC BMP CMP Other METHOTREXATE LEVELS – To be drawn STAT at Hour 0 (upon completion of methotrexate), Hour 24, and Hour 48. Notify pharmacy of results for potential cytarabine dose reduction. Urine Output: If urine output is less than give times days Nurse May Initiate CVAD Management Per Nursing Protocol #910.00 Nurse May Utilize Local Anesthetic For CVAD Access Per Nursing Protocol #788 For Infusion Reactions Initiate Drug Related Hypersensitivity Physician Order #774 MEDICATIONS: Dexamethasone 0.1% ophthalmic solution 2 drops in each eye four times daily. Start prior to cytarabine and stop 24 hours after last dose cytarabine. Allopurinol 300 mg PO every day Filgrastim 10 mcg/kg subcutaneously daily starting 24 hours after cytarabine complete Other:
NOTE: These orders should be reviewed by the attending physician, appropriately modified for the individual patient, dated, timed and signed below.
DATE TIME PHARMACIST’S SIGNATURE
DATE TIME PHYSICIAN’S SIGNATURE Another brand of drug, identical in form and content, may be dispensed unless checked.
Page 3 of 3 PATIENT INFORMATION
PHYSICIAN ORDERS CHEMOTHERAPY: METHOTREXATE + 742 LEUCOVORIN + CYTARABINE Revision G (HYPER-CVAD, EVEN CYCLE)