* See Recording Chart Page 9

Haematology / Page 1 of 9
NHL – Burkitt-type Lymphoma
CODOX-M / Height / cm
Weight / kg
BSA / m2
Cycle length: / 21 days / CBC / Day 1 / Limits / Allergies/hypersensitivities
Antiemetics
Domperidone 10mg PO QID
± Cyclizine 25 mg – 50 mg PO/IV TDS / Agent
Cyclophosphamide
Vincristine
Doxorubicin
Methotrexate
Folinic acid (PO)
DOSE MODIFIED:NO YESNoYes / Round
50mg
0.1mg
2mg
100mg
15mg
Cycle no: / Date
Destination: / BMTU / Neuts / > 1 x 109/L
Plts / 75 x 109/L
Reference:based on Mead et al Blood 2008; 12(6) 2248-2260
Day / Date / Time / Agent / Dose / Route / Instructions / Doctor / Nurse / Check / Start / Stop
1 / Cytarabine 70mg IT / IT / See separate intrathecal chemotherapy medication chart (C160016)
1 / T= -60 mins / # Methylprednisolone / 100 / mg / IV / In 100 mL sodium chloride 0.9 % over 15 minutes
T= -60 mins / Paracetamol / 1000 / mg / PO / 30-60 minutes prior to rituximab
T= -60 mins / Loratadine / 20 / mg / PO / 30-60 minutes prior to rituximab
*Rituximab 375mg/m2 / mg / IV / Standard infusion: added to 500 mL sodium chloride 0.9 %
Rapid infusion: added to 500 mL sodium chloride 0.9 %
Dexamethasone / 8 / mg / PO / Give 1 hour prior to chemotherapy
Ondansetron / 8 / mg / PO/IV / Give 1 hour prior to chemotherapy
Cyclophosphamide 800 mg/m2 / mg / IV / In 100 mL sodium chloride 0.9 % over 30 minutes
Vincristine 1.5 mg/m2(max 2mg) / mg / IV / In 50 mL sodium chloride 0.9 % free run over 10 minutes

#If no reaction to the first dose of rituximab, methylprednisolone may be omitted at the prescribers discretion

* See recording chart page 9

Tumour lysis syndrome may occur in Burkitt’s lymphoma. Consider high dose allopurinol or rasburicase.

Consultant:Special authority:

NZMC Reg. No: Rituximab:

NHL – Burkitt-type Lymphoma
CODOX-M / Height / cm
Weight / kg
BSA / m2
Date / Time / Agent / Dose / Route / Instructions / Rate / Doctor / Nurse / Check / Start / Stop
1 / Sodium chloride 0.9 % / 100 - 500 / mL / IV / Flush and fast running sodium chloride 0.9 %
Doxorubicin 40 mg/m2 / mg / IV / Bolus into fast running sodium chloride 0.9 %
Ondansetron / 8 / mg / PO/IV
2 / 0800 / Dexamethasone / 8 / mg / PO / Give 1 hour prior to chemotherapy
0800 / Ondansetron / 8 / mg / PO/IV / Give 1 hour prior to chemotherapy
Cyclophosphamide 200 mg/m2 / mg / IV / In 100 mL sodium chloride 0.9% over 30 minutes
2000 / Ondansetron / 8 / mg / PO/IV
3 / 0800 / Dexamethasone / 8 / mg / PO / Give 1 hour prior to chemotherapy
0800 / Ondansetron / 8 / mg / PO/IV / Give 1 hour prior to chemotherapy
Cyclophosphamide 200 mg/m2 / mg / IV / In 100 mL sodium chloride 0.9% over 30 minutes
2000 / Ondansetron / 8 / mg / PO/IV
3 / Cytarabine 70mg IT / IT / See separate intrathecal chemotherapy medication chart (C160016)
4 / 0800 / Dexamethasone / 8 / mg / PO / Give 1 hour prior to chemotherapy
0800 / Ondansetron / 8 / mg / PO/IV / Give 1 hour prior to chemotherapy
Cyclophosphamide 200 mg/m2 / mg / IV / In 100 mL sodium chloride 0.9% over 30 minutes
2000 / Ondansetron / 8 / mg / PO/IV
NHL – Burkitt-type Lymphoma
CODOX-M / Height / cm
Weight / kg
BSA / m2
Day / Date / Time / Agent / Dose / Route / Instructions / Rate / Doctor / Nurse / Check / Start / Stop
5 / 0800 / Dexamethasone / 8 / mg / PO / Give 1 hour prior to chemotherapy
0800 / Ondansetron / 8 / mg / PO/IV / Give 1 hour prior to chemotherapy
Cyclophosphamide 200 mg/m2 / mg / IV / In 100 mL sodium chloride 0.9% over 30 minutes
2000 / Ondansetron / 8 / mg / PO/IV
6 / 0800 / Dexamethasone / 8 / mg / PO
0800 / Ondansetron / 8 / mg / PO/IV
2000 / Ondansetron / 8 / mg / PO/IV
7 / 0800 / Dexamethasone / 8 / mg / PO
0800 / Ondansetron / 8 / mg / PO/IV
2000 / Ondansetron / 8 / mg / PO/IV
8 / 0800 / Ondansetron / 8 / mg / PO/IV / Give 1 hour prior to chemotherapy
Vincristine 1.5mg/m2(max 2mg) / mg / IV / In 50 mL sodium chloride 0.9% free run over 10 minutes
NHL – Burkitt-type Lymphoma
CODOX-M / Height / cm
Weight / kg
BSA / m2
Infusion rate
125 X BSA / = mL/hr
Day / Date / Time / Agent / Dose / Route / Instructions / Rate / Doctor / Nurse / Check / Start / Stop
9 / 2200 / Ural Sachet® / 1 / PO / Dissolved in 20mL water
2200 / 1000 mL glucose 4 % & sodium chloride 0.18 %
+ 30 mmol potassium chloride
+ 50 mmol sodium bicarbonate / IV / Infuse at 125 mL/m2/hr as above
10 / 1000 mL glucose 4 % & sodium chloride 0.18 %
+ 30 mmol potassium chloride
+ 50 mmol sodium bicarbonate / IV / Infuse at 125 mL/m2/hr as above
1000 mL glucose 4 % & sodium chloride 0.18 %
+ 30 mmol potassium chloride
+ 50 mmol sodium bicarbonate / IV / Infuse at 125 mL/m2/hr as above
T = -1 hr / Dexamethasone / 8 / mg / PO / Give 1 hour prior to chemotherapy
T = -1 hr / Ondansetron / 8 / mg / PO/IV / Give 1 hour prior to chemotherapy
T = 0 hrs / Methotrexate
300 mg/m2(≤ 65 years)
100 mg/m2(> 65 years) / mg / IV / In 250 mL sodium chloride 0.9 % over 1 hour / 250ml/hr
T = +1 hr / Methotrexate
2700 mg/m2(≤ 65 years)
900 mg/m2(> 65 years) / mg / IV / In 1000 mL sodium chloride 0.9% over 23 hrs / 46ml/hr (rate incl 50mL flush)

Measure serum creatinine and calculate CrCl one week prior to methotrexate infusion. If CrCl is < 80 mL/min, adjust methotrexate as per appendix 15 of the UKALL14 protocol
IV fluids run concurrently with chemotherapy. Check fluid balance at least 4 hourly, consider frusemide if urine output falls below 400mL/m2 in any 4 hour period, or 1 kg weight increase
Urine pH must be > 7.5 before starting methotrexate - adjust sodium bicarbonate to keep pH between 7 and 8 during infusion and subsequent folinic acid rescue
Stop proton pump inhibitors (omeprazole/lansoprazole/pantoprazole) the day prior to methotrexate infusion, restart once methotrexate has cleared
It is recommended prophylactic trimethoprim/sulphamethoxazole (co-trimoxazole) be stopped 1 week before methotrexate therapy

NHL – Burkitt-type Lymphoma
CODOX-M / Height / cm
Weight / kg
BSA / m2
Infusion rate
125 X BSA / = mL/hr
Day / Date / Time / Agent / Dose / Route / Instructions / Doctor / Nurse / Check / Start / Stop
10 / 1000 mL glucose 4 % & sodium chloride 0.18 %
+ 30 mmol potassium chloride
+ 50 mmol sodium bicarbonate / IV / Infuse at 125 mL/m2/hr as above
1000 mL glucose 4 % & sodium chloride 0.18 %
+ 30 mmol potassium chloride
+ 50 mmol sodium bicarbonate / IV / Infuse at 125 mL/m2/hr as above
2000 / Ondansetron / 8 / mg / PO/IV
1000 mL glucose 4 % & sodium chloride 0.18 %
+ 30 mmol potassium chloride
+ 50 mmol sodium bicarbonate / IV / Infuse at 125 mL/m2/hr as above
1000 mL glucose 4 % & sodium chloride 0.18 %
+ 30 mmol potassium chloride
+ 50 mmol sodium bicarbonate / IV / Infuse at 125 mL/m2/hr as above
11 / 1000 mL glucose 4 % & sodium chloride 0.18 %
+ 30 mmol potassium chloride
+ 50 mmol sodium bicarbonate / IV / Infuse at 125 mL/m2/hr as above
1000 mL glucose 4 % & sodium chloride 0.18 %
+ 30 mmol potassium chloride
+ 50 mmol sodium bicarbonate / IV / Infuse at 125 mL/m2/hr as above
0800 / Dexamethasone / 8 / mg / PO
0800 / Ondansetron / 8 / mg / PO/IV
T =+24 hrs / Stop Methotrexate infusion
1000 mL glucose 4 % & sodium chloride 0.18 %
+ 30 mmol potassium chloride
+ 50 mmol sodium bicarbonate / IV / Infuse at 125 mL/m2/hr as above
1000 mL glucose 4 % & sodium chloride 0.18 %
+ 30 mmol potassium chloride
+ 50 mmol sodium bicarbonate / IV / Infuse at 125 mL/m2/hr as above
NHL – Burkitt-type Lymphoma
CODOX-M / Height / cm
Weight / kg
BSA / m2
Infusion rate
125 X BSA / = mL/hr
Day / Date / Time / Agent / Dose / Route / Instructions / Doctor / Nurse / Check / Start / Stop
11 / 1000 mL glucose 4 % & sodium chloride 0.18 %
+ 30 mmol potassium chloride
+ 50 mmol sodium bicarbonate / IV / Infuse at 125 mL/m2/hr as above
1000 mL glucose 4 % & sodium chloride 0.18 %
+ 30 mmol potassium chloride
+ 50 mmol sodium bicarbonate / IV / Infuse at 125 mL/m2/hr as above
T =+36hr / Folinic acid / 30 / mg / PO / Give IV bolus if PO not tolerated
T =+39hr / Folinic acid / 30 / mg / PO / Give IV bolus if PO not tolerated
12 / 1000 mL glucose 4 % & sodium chloride 0.18 %
+ 30 mmol potassium chloride
+ 50 mmol sodium bicarbonate / IV / Infuse at 125 mL/m2/hr as above
T =+42hr / Folinic acid / 30 / mg / PO / Give IV bolus if PO not tolerated
1000 mL glucose 4 % & sodium chloride 0.18 %
+ 30 mmol potassium chloride
+ 50 mmol sodium bicarbonate / IV / Infuse at 125 mL/m2/hr as above
T =+45hr / Folinic acid / 30 / mg / PO / Give IV bolus if PO not tolerated
0800 / Dexamethasone / 8 / mg / PO
1000 mL glucose 4 % & sodium chloride 0.18 %
+ 30 mmol potassium chloride
+ 50 mmol sodium bicarbonate / IV / Infuse at 125 mL/m2/hr as above
T =+48hr / Folinic acid / 30 / mg / PO / Give IV bolus if PO not tolerated
T =+48hr / Methotrexate level(time ______, level______) / Continue folinic aciduntil methotrexate level < 0.1 micromol/L. Notify lab if MTX levels will be required over a weekend.

Continue folinic acid and high dose fluids for at least 48 hours, and continue as per UKALL 14 protocol (appendix 15) depending on methotrexate levels

Continue folinic acid and high dose fluids as per UKALL 14 protocol (appendix 15) depending on methotrexate levels. If further folinic acid required, prescribe on Medchart

* IT MTX will only be given on day 15 if the MTX level is below 0.1micromol/L

Give IT MTX regardless of blood count, although platelets should be more than 50x 109/L when the lumbar puncture is performed. Platelet transfusion may be required.

Authorised by : Dr P Ganly Pharmacists: Bevan Harden / Caroline Innes Updated: Feb 2015, June 2016, July 2017
Review: 2018

Haematology / Page 1 of 9
Rituximab (Mabthera®) 375 mg/m2giving instructions
Patient label
Date

Standard infusion:

/ Commence infusion at 50 mg/hr for the first hour, if no side effects; increase the infusion rate in 50 mg increments every 30 minutes to a maximum rate of 400 mg/hr. Remember that the IV line will have been primed with saline therefore rituximab will not be infused immediately.
To calculate 50mg in _____mL
Rapid infusion: / If no previous toxicities, give 20% of the dose over 30 minutes and the remaining 80% over the following 60 minutes.
If any adverse effects noted: / Discontinue infusion, evaluate severity of symptoms, and treat accordingly. If reactions settle, recommence at ½ the previous rate. Consider hydrocortisone 100 mg IV if required, plus chlorphenamine and paracetamol depending on time interval.
Recordings: / Document T, P, R, B/P and EWS on adult observation chart (C280010) at baseline, 30 minutes, 60 minutes, and hourly thereafter (more frequently if patient is reacting).
Following infusion: Observe for delayed side effects, for 1 hour following 1st infusion. If patient has reacted, observe following subsequent infusion also.
Time / Rate / Comments
Baseline

Note:•Monitor patients with high tumour burden for infusion related reactions and tumour lysis syndrome.

•Ensure adequate hydration and consider addition of allopurinol for 1 – 3 courses.

DO NOT SHAKE during preparation, rotate gently. Aggregation & precipitation of antibody can occur.

PRN medications for Hypersensitivity reactions

Date / Time / Medication / Dose / Route / Doctor / Nurse / Check
Hydrocortisone / 100 mg / Slow IV bolus
Paracetamol / 1000 mg / PO
Chlorphenamine / 10 mg / Slow IV bolus
PRN antiemetics / DR / NURSE SIGN
Domperidone / 10 mg / PO QID
Cyclizine / 50 mg / PO/IV Q8H
Lorazepam / 0.5-1 mg / PO BD
Authorised by: Dr P Ganly Pharmacists: B Harden / C Innes / Updated: Feb 2015, May 2016
Review: 2017