Protocol Index	

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IP CAGT ALLOGENEIC SCT FLU-MEL-PTCY	

Types:      ONCOLOGY TREATMENT
Synonyms:  FLU, FLUDARA, MELPHALAN, ALKERAN, SARCOLYSIN, CYCLOPHOSPHAMIDE, CYTOXAN, BMT, CAGT, ALLOGENEIC, SCT, FLUMELCAM, PTCY

Transplant	Repeat 1 time	Cycle length: 90 days	Day -5 through -1	Perform every 1 day x1		Provider Communication
  	ONC PROVIDER COMMUNICATION 64	Interval: Once	Occurrences: --	Comments:	Verify Hep B panel status prior to cycle. Date *** of panel. Result positive/negative/pending/unknown:22867

The required components for the hepatitis B panel includes: Hepatitis B surface antigen (HBsAg), total hepatitis B core antibody (anti-HBc), and hepatitis B antibody (anti-HBs).
			Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Pre-Medications
  	ondansetron (ZOFRAN) tablet 8 mg	Dose: 8 mg	Route: oral	every 24 hours for 4 doses	Start: S			Instructions:	Day -5 through Day -2		  	OLANZapine (ZYPREXA) tablet 10 mg	Dose: 10 mg	Route: oral	daily for 4 doses	Start: S+4  8:00 AM			Instructions:	Day -1 through Day +2		  	ondansetron (ZOFRAN) 16 mg, dexAMETHasone (DECADRON) 12 mg in sodium chloride 0.9% 50 mL IVPB	Dose: 16 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S+4  8:00 AM			Instructions:	Instructions: Day -1 prior to Melphalan.
Admin instructions:  Administer 30 minutes prior to treatment on Day -1.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION	Medications	16 mg	Main Ingredient	No	DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION	Medications	12 mg	Yes	No	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	50 mL	No	Yes			  	fosaprepitant (EMEND) IVPB 150 mg	Dose: 150 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S+4  8:00 AM			Instructions:	Instructions: Day -1 prior to Melphalan
Administer 30 minutes prior to treatment on Day -1.			Supportive Care
  	acyclovir (ZOVIRAX) 5 mg/kg (Ideal)	Dose: 5 mg/kg	Route: intravenous	every 8 hours	Start: S				  	micafungin (MYCAMINE) 100 mg in sodium chloride 0.9% 100 mL IVPB	Dose: 100 mg	Route: intravenous	every 24 hours over 1 Hours for 10 doses	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	MICAFUNGIN 100 MG INTRAVENOUS SOLUTION (RESTRICTED)	Medications	100 mg	Main Ingredient	No	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	100 mL	Yes	Yes			  	levoFLOXacin (LEVAQUIN) tablet 500 mg	Dose: 500 mg	Route: oral	daily at 0600	Start: S+8			Instructions:	Start on Day +3			Antiemetics
  	promethazine (PHENERGAN) injection 12.5 mg	Dose: 12.5 mg	Route: intravenous	every 4 hours PRN	Start: S					Chemotherapy
  	fludarabine (FLUDARA) 30 mg/m2 in sodium chloride 0.9% 100 mL chemo IVPB	Dose: 30 mg/m2	Route: intravenous	every 24 hours over 30 Minutes for 4 doses	Start: S			Instructions:	Day -5, -4, -3, -2	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	FLUDARABINE 50 MG/2 ML INTRAVENOUS SOLUTION	Medications	30 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	100 mL	No	Yes				Chemotherapy
  	TRANSFUSION REACTION EVALUATION	Interval: Until discontinued	Occurrences: --	Comments:	Ice chips and / or popsicles to patient 30 minutes prior, during and for 30 minutes following Melphalan infusion.
		  	ONC NURSING COMMUNICATION 30	Interval: Once	Occurrences: --	Comments:	Administer Melphalan NO later than 10:00 am.
		  	melphalan HCL (ALKERAN) 140 mg/m2 in sodium chloride 0.9% 250 mL chemo IVPB	Dose: 140 mg/m2	Route: intravenous	once over 15 Minutes for 1 dose	Start: S+4  9:00 AM			Instructions:	Day -1.

Infuse within 60 minutes from vial reconstitution.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	MELPHALAN HCL 50 MG INTRAVENOUS POWDER FOR SOLUTION	Medications	140 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes				Line Flush
  	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN							Day 0	Perform every 1 day x1		Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Pre-Medications
  	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S				  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Premed for TRANSPLANT		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Premed for TRANSPLANT		  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	once for 1 dose				Instructions:	Premed for TRANSPLANT			Transplant Orders
  	ONC NURSING COMMUNICATION 55	Interval: Once	Occurrences: --	Comments:	-Oxygen at bedside during transplantation
-Anaphylaxis precautions at bedside during transplant:
		  	meperidine (DEMEROL) injection (RESTRICTED) 12.5 mg	Dose: 12.5 mg	Route: intravenous	every 15 min PRN for 3 doses				Instructions:	Administer every 15 minutes x 3 doses PRN for each episode of rigors (if rigors persist, call MD).		  	epINEPHrine (ADRENALIN) injection 1 mg/mL 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	once PRN	Start: S	End: S+2			  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once PRN	Start: S	End: S+2			  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	once PRN							Day 1 through 8	Perform every 1 day x1		Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Pre-Medications
  	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	every 24 hours for 5 doses	Start: S  8:00 AM			Instructions:	Instructions: Administer on Days +1 through +5		  	ondansetron (ZOFRAN) IV 8 mg	Dose: 8 mg	Route: intravenous	every 8 hours PRN	Start: S+5			Instructions:	Instructions: Start Day +6		  	fosaprepitant (EMEND) IVPB 150 mg	Dose: 150 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S+2  8:00 AM			Instructions:	Instructions: Administer 30 minutes prior to treatment on Day +3			Labs
  	ECG 12-LEAD	Interval: Daily	Occurrences: --	Comments:	Starting Day +3. Must be reviewed by MD daily prior to each Cyclophosphamide dose.
		  	URINALYSIS, AUTOMATED WITH MICROSCOPY	Interval: Daily	Occurrences: --	Comments:	Start Day +3.
			Nursing Orders
  	ONC NURSING COMMUNICATION 7	Interval: Until discontinued	Occurrences: --	Comments:	During CYCLOPHOSPHAMIDE:
-12 lead EKG must be ordered and reviewed by physician prior to each dose.
-Starting 4 hours PRIOR to cyclophosphamide, change IVF to Normal Saline at 125 mL/hr and continue for 24 hours after last dose of cyclophosphamide completes.  (MAX total volume infusion rate during chemotherapy = 350 mL/hr).
-Instruct patient to void every 1-2 hours DAILY x 3 days.
			Hydration
  	sodium chloride 0.9 % infusion	Dose: 125 mL/hr	Route: intravenous	continuous	Start: S+2					Chemotherapy
  	mesna (MESNEX) 20 mg/kg in sodium chloride 0.9% 100 mL chemo IVPB	Dose: 20 mg/kg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S+2  8:30 AM			Instructions:	Instructions: Give immediately prior to first cyclophosphamide infusion.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	MESNA 100 MG/ML INTRAVENOUS SOLUTION	Medications	20 mg/kg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			  	cycloPHOSphamide (CYTOXAN) 50 mg/kg in dextrose 5% 500 mL chemo IVPB	Dose: 50 mg/kg	Route: intravenous	every 24 hours over 2 Hours for 2 doses	Start: S+2  9:00 AM			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION	Medications	50 mg/kg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	500 mL	No	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	500 mL	Yes	Yes			  	mesna (MESNEX) 10 mg/kg in sodium chloride 0.9% 100 mL chemo IVPB	Dose: 10 mg/kg	Route: intravenous	every 4 hours over 30 Minutes for 12 doses	Start: S+2  1:00 PM			Instructions:	Start 4 hours after loading dose of Mesna.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	MESNA 100 MG/ML INTRAVENOUS SOLUTION	Medications	10 mg/kg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes				Additional Orders
  	furosemide (LASIX) injection 20 mg	Dose: 20 mg	Route: intravenous	every 24 hours for 2 doses	Start: S+2 11:00 AM			Instructions:	-Give at completion of each dose of cyclophosphamide infusion on Day +3 and Day +4		  	furosemide (LASIX) injection 20 mg	Dose: 20 mg	Route: intravenous	every 24 hours for 2 doses	Start: S+2  5:00 PM			Instructions:	Give 6 hours AFTER completion of each dose of Cyclophosphamide infusion on Day +3 and Day +4			Supportive Care
  	posaconazole (NOXAFIL) tablet (RESTRICTED) 300 mg	Dose: 300 mg	Route: oral	every 24 hours	Start: S+4  9:00 AM			Instructions:	Do NOT crush, split, or chew.  The delayed release tablet is NOT to interchange / substitute with oral posaconazole suspension.
Instructions: Stat Day +5		  	filgrastim-sndz (ZARXIO) injection solution	Dose: --	Route: subcutaneous	daily at 1600	Start: S+6			Instructions:	Do not administer filgrastim-sndz within 24 hours before chemotherapy. 
START Day +7.			Acute Graft Versus Host Prophylaxis
  	tacrolimus (PROGRAF) IVPB 0.02 mg/kg (Ideal)	Dose: 0.02 mg/kg	Route: intravenous	every 24 hours over 24 Hours	Start: S			Instructions:	May cause QTc prolongation.  Use the lesser of IBW or actual body weight (ABW).		  	mycophenolate (CELLCEPT) 1,000 mg in dextrose 5% IVPB	Dose: 1,000 mg	Route: intravenous	Every 8 Hours (TIME CRITICAL)  over 2 Hours	Start: S+4			Instructions:	Start Day +5	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION	Medications	1,000 mg	Main Ingredient	No	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	167 mL	Always	Yes