CANTERBURY DHB (HAEMATOLOGY DEPARTMENT)

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METHOTREXATE – GVHD prophylaxis post ALLO SCT Days1, 3, 6, and 11 / DELIVER TO: HDW / BMTU
Patient Category:
Y J A P O 1 3 Z / OSP Group:
1 2 3 4 5 6 7 / Doctors Name:
NZMC Reg. No.: / Special Authority Number:
(Affix Patient Label Here) / Antiemetics / Weight / Height
BSA
Dose Modified / YES / NO
Ensure the first MTX dose is given 24 hours after stem cell infusion / ADMINISTRATION USE
DAY / DATE / TIME / CHEMOTHERAPY AGENT / DOSE / ROUTE / INSTRUCTIONS / DR SIGN / GIVEN BY /

CHECK

/ TIME
+1 / 1300 / Methotrexate 15mg/m2 / IV / Bolus
+2 / 1700 / Folinic acid 7.5mg / 7.5mg / PO/IV / Bolus/Oral
+3 / 0100 / Folinic acid 7.5mg / 7.5mg / PO/IV / Bolus/Oral
1300 / Methotrexate 10mg/m2 / IV / Bolus
+4 / 1700 / Folinic acid 7.5mg / 7.5mg / PO/IV / Bolus/Oral
+5 / 0100 / Folinic acid 7.5mg / 7.5mg / PO/IV / Bolus/Oral
0900 / Folinic acid 7.5mg / 7.5mg / PO/IV / Bolus/Oral
1700 / Folinic acid 7.5mg / 7.5mg / PO/IV / Bolus/Oral
+6 / 0100 / Folinic acid 7.5mg / 7.5mg / PO/IV / Bolus/Oral
1300 / Methotrexate 10mg/m2 / IV / Bolus
+7 / 1700 / Folinic acid 7.5mg / 7.5mg / PO/IV / Bolus/Oral
+8 / 0100 / Folinic acid 7.5mg / 7.5mg / PO/IV / Bolus/Oral

Note:Folinic acid is given 28hrs after the methotrexate. Give folinic acid PO if oral drugs are tolerated.

METHOTREXATE – GVHD prophylaxis post ALLO SCT Days1, 3, 6, and 11 / DELIVER TO: HDW / BMTU
Patient Category:
Y J A P O 1 3 Z / OSP Group:
1 2 3 4 5 6 7 / Doctors Name:
NZMC Reg. No.: / Special Authority Number:
(Affix Patient Label Here) / Antiemetics / Weight / Height
BSA
Dose Modified / YES / NO
ADMINISTRATION USE
DAY / DATE / TIME / CHEMOTHERAPY AGENT / DOSE / ROUTE / INSTRUCTIONS / DR SIGN / GIVEN BY / CHECK / TIME
+8 / 0900 / Folinic acid 7.5mg / 7.5mg / PO/IV / Bolus/Oral
1700 / Folinic acid 7.5mg / 7.5mg / PO/IV / Bolus/Oral
+9 / 0100 / Folinic acid 7.5mg / 7.5mg / PO/IV / Bolus/Oral
0900 / Folinic acid 7.5mg / 7.5mg / PO/IV / Bolus/Oral
1700 / Folinic acid 7.5mg / 7.5mg / PO/IV / Bolus/Oral
0100 / Folinic acid 7.5mg / 7.5mg / PO/IV / Bolus/Oral
+10 / 0900 / Folinic acid 7.5mg / 7.5mg / PO/IV / Bolus/Oral
1700 / Folinic acid 7.5mg / 7.5mg / PO/IV / Bolus/Oral
+11 / 0100 / Folinic acid 7.5mg / 7.5mg / PO/IV / Bolus/Oral
1300 / Methotrexate 10mg/m2 / IV / Bolus
+12 / 1700 / Folinic acid 7.5mg / 7.5mg / PO/IV / Bolus/Oral
+13 / 0100 / Folinic acid 7.5mg / 7.5mg / PO/IV / Bolus/Oral

Note:Folinic acid is given 28hrs after the methotrexate. Give folinic acid PO if oral drugs are tolerated.

METHOTREXATE – GVHD prophylaxis post ALLO SCT Days1, 3, 6, and 11 / DELIVER TO: HDW / BMTU
Patient Category:
Y J A P O 1 3 Z / OSP Group:
1 2 3 4 5 6 7 / Doctors Name:
NZMC Reg. No.: / Special Authority Number:
(Affix Patient Label Here) / Antiemetics / Weight / Height
BSA
Dose Modified / YES / NO
ADMINISTRATION USE
DAY / DATE / TIME /

CHEMOTHERAPY AGENT

/ DOSE / ROUTE / INSTRUCTIONS / DR SIGN / GIVEN BY / CHECK / TIME
+13 / 0900 / Folinic acid 7.5mg / 7.5mg / PO/IV / Bolus/Oral
1700 / Folinic acid 7.5mg / 7.5mg / PO/IV / Bolus/Oral
+14 / 0100 / Folinic acid 7.5mg / 7.5mg / PO/IV / Bolus/Oral
0900 / Folinic acid 7.5mg / 7.5mg / PO/IV / Bolus/Oral
1700 / Folinic acid 7.5mg / 7.5mg / PO/IV / Bolus/Oral
+15 / 0100 / Folinic acid 7.5mg / 7.5mg / PO/IV / Bolus/Oral
0900 / Folinic acid 7.5mg / 7.5mg / PO/IV / Bolus/Oral
1700 / Folinic acid 7.5mg / 7.5mg / PO/IV / Bolus/Oral
+16 / 0100 / Folinic acid 7.5mg / 7.5mg / PO/IV / Bolus/Oral
Aurthorised by: Clinical Director Steve GibbonsPharmacist Bevan Harden / 3 August 2007
E:\Chemo Charts\GVHD MTX.doc / Ref:
CHEMOTHERAPY
MEDICATION
CHART
C26oo73