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IP/OP RESEARCH PRO00035735 ANHL1931 PINGALI ARM B	

Types:      Research Oncology Treatment
Synonyms:  DA-EPOCH-R, DA EPOCH R, NIVO, NIVOLUMAB

Cycle 1	Repeat 1 time	Cycle length: 21 days	Day 1	Perform every 1 day x1		Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Line Care
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Treatment Conditions
  	TREATMENT CONDITIONS	Interval: Until discontinued	Occurrences: --	Comments:	Please refer to Study Protocol for any questions or discrepancies. See Schedule of Events Calendar for sequence of diagnostic tests, examinations, and treatment administration: See Safety Parameters-for Toxicity Management and Dose Modification Guidelines: Protocol Access hyperlink:  ANHL1931_Protocol.pdf
		  	TREATMENT CONDITIONS 3	Interval: Until discontinued	Occurrences: --	Comments:	Dose Modifications and Management for Nivolumab Treatment : Refer to Section 5.0 / 5.1 Management of AEs Associated with Nivolumab
Protocol Access Hyperlink: ANHL1931_Protocol.pdf
		  	TREATMENT CONDITIONS 11	Interval: Until discontinued	Occurrences: --	Comments:	Dose Modifications and Management for  Treatment DA-EPOCH : Refer to Section 5.0 / 5.3 Management of AEs Associated with Etoposide, Doxorrubicin, Cyclophosphamide, Vincristine, Prednisone 
Protocol Access Hyperlink: ANHL1931_Protocol.pdf
		  	TREATMENT CONDITIONS 10	Interval: Until discontinued	Occurrences: --	Comments:	Dose Modifications and Management for Rituximab Treatment : Refer to Section 5.0 / 5.2 Management of AEs Associated with Rituximab
Protocol Access Hyperlink: ANHL1931_Protocol.pdf
			Nursing Orders
  	ONC NURSING COMMUNICATION 14	Interval: Once	Occurrences: --	Comments:	All baseline studies must be performed prior to starting protocol therapy unless otherwise indicated.
		  	ONC NURSING COMMUNICATION 2	Interval: Once	Occurrences: --	Comments:	Physical exam
		  	VITAL SIGNS - T/P/R/BP	Interval: Once	Occurrences: --		  	HEIGHT AND WEIGHT	Interval: Until discontinued	Occurrences: --	Comments:	If there is a GREATER than 5% change in weight, BSA will be recalculated prior to each cycle.
		  	ONC NURSING COMMUNICATION 6	Interval: Once	Occurrences: --	Comments:	Adverse Events: Continuously every day, every cycle. 
To ensure compliance with these regulations/this guidance, as IND/IDE sponsor, NCI requires that AEs be submitted according to the timeframes in the AE reporting tables assigned to the protocol, using the CTEP Adverse Event Reporting System (CTEP-AERS).
		  	ONC NURSING COMMUNICATION 8	Interval: Once	Occurrences: --	Comments:	Concomitant Medications: continuously every day, every cycle. 
Please refer to section 4.0 page 24-25 for restrictions.
		  	ONC NURSING COMMUNICATION 11	Interval: Once	Occurrences: --	Comments:	If unable to take PO, may substitute IV methylprednisolone at 80% of oral dose for predniSONE or prednisoLONE (prednisone 100 mg= methylprednisolone 80 mg).
			Nursing Orders
  	ONC NURSING COMMUNICATION 12	Interval: Once	Occurrences: --	Comments:	Start Nivolumab PRIOR to prednisone and rituximab.
			Provider Communication
  	ONC PROVIDER COMMUNICATION	Interval: Once	Occurrences: --	Comments:	Verify Ejection Fraction prior to Cycle 1.  Ejection Fraction: ***% on *** (date).

If patient has not had a recent MUGA or ECHO, order one via order entry. A baseline cardiac evaluation with a MUGA scan or an ECHO is recommended, especially in patients with risk factors for increased cardiac toxicity. Repeated MUGA or ECHO determinations of LVEF should be performed, particularly with higher, cumulative anthracycline doses.

			Nursing Orders
  	TRANSTHORACIC ECHOCARDIOGRAM COMPLETE W CONT STRAIN 3D IF NEEDED	Interval: 1 time imaging	Occurrences: --	Comments:	As clinically indicated per institutional guidelines
		  	ECG 12-LEAD	Interval: Once	Occurrences: --	Comments:	As clinically indicated per institutional guidelines
			Labs
  	RESEARCH STUDY SPECIMEN	Interval: Once	Occurrences: --		  	RESEARCH STUDY SPECIMEN	Interval: Once	Occurrences: --		  	RESEARCH STUDY SPECIMEN	Interval: Once	Occurrences: --			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: Once	Occurrences: --			Labs
  	THYROID STIMULATING HORMONE	Interval: Once	Occurrences: --	Comments:	If TSH is abnormal T3 and FT4 should be evaluated.
			Labs
  	AST (SGOT)	Interval: --	Occurrences: --		  	ALT (SGPT)	Interval: --	Occurrences: --		  	TOTAL BILIRUBIN	Interval: Once	Occurrences: --		  	BILIRUBIN DIRECT	Interval: Once	Occurrences: --			Labs
  	SODIUM LEVEL	Interval: Once	Occurrences: --		  	POTASSIUM LEVEL	Interval: Once	Occurrences: --		  	CHLORIDE LEVEL	Interval: Once	Occurrences: --		  	CALCIUM LEVEL	Interval: Once	Occurrences: --		  	MAGNESIUM LEVEL	Interval: Once	Occurrences: --		  	PHOSPHORUS LEVEL	Interval: Once	Occurrences: --			Labs
  	HCG QUALITATIVE, SERUM SCREEN	Interval: Once	Occurrences: --	Comments:	ONLY for females of child bearing potential
			Chemotherapy
  	INV-Nivolumab (ANHL1931/Pro00035735/Pingali) in sodium chloride 0.9% 100 mL IVPB	Dose: --	Route: intravenous	once over 30 Minutes for 1 dose	Start: S			Instructions:	Prepared dose contains active nivolumab in NS. Infuse intravenously over 30 minutes via 0.2 to 1.2 micron low protein binding in line filter. Flush line with NS at the end of infusion. 
HAZARDOUS - Handle with care
Caution: New Drug-Limited by Federal (USA) Law to Investigational use.
	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-NIVOLUMAB 100 MG INTRAVENOUS SOLN (ANHL1931/PRO00035735/PINGALI)	Medications	 	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes				Pre-Medications
  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer 30 minutes before rituximab.		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 30 minutes before rituximab.		  	predniSONE (DELTASONE) tablet 100 mg	Dose: 100 mg	Route: oral	once for 1 dose	Start: S			Instructions:	o Administer 30 minutes prior to the rituximb. 
o Prednisone is part of anti-lymphoma regimen. Do NOT omit dose. Do NOT give other steroid and hold prednisone.			Chemotherapy
◉	riTUXimab-abbs (TRUXIMA) 375 mg/m2 in sodium chloride 0.9% INITIAL INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 30 Minutes	Instructions:	Initiate infusion at rate of 50 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), then increase infusion rate by 50 mg/hour every 30 minutes, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	RiTUXimab (PF) (RITUXAN) 375 mg/m2 in sodium chloride 0.9% INITIAL INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 30 Minutes	Instructions:	Initiate infusion at rate of 50 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), then increase infusion rate by 50 mg/hour every 30 minutes, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	rituximab-pvvr (PF) (RUXIENCE) 375 mg/m2 in sodium chloride 0.9% INITIAL INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 30 Minutes	Instructions:	Initiate infusion at rate of 50 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), then increase infusion rate by 50 mg/hour every 30 minutes, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	rituximab-arrx (RIABNI) 375 mg/m2 in sodium chloride 0.9% INITIAL INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 30 Minutes	Instructions:	Initiate infusion at rate of 50 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), then increase infusion rate by 50 mg/hour every 30 minutes, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ARRX 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	riTUXimab-abbs (TRUXIMA) in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: --	Route: intravenous	once for 1 dose			Offset: 30 Minutes	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION	Medications	 	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	RiTUXimab (PF) (RITUXAN) in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: --	Route: intravenous	once for 1 dose			Offset: 30 Minutes	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS	Medications	 	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	rituximab-pvvr (PF) (RUXIENCE) in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: --	Route: intravenous	once for 1 dose			Offset: 30 Minutes	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION	Medications	 	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	rituximab-arrx (RIABNI) in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: --	Route: intravenous	once for 1 dose			Offset: 30 Minutes	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ARRX 10 MG/ML INTRAVENOUS SOLUTION	Medications	 	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	riTUXimab-abbs (TRUXIMA) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	RiTUXimab (PF) (RITUXAN) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	RAPID INFUSION RATE:  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.

Reaction grades:

Grade 3 Reaction: Prolonged (e.g., not rapidly responsive to symptomatic medication and/or brief interruption of infusion); recurrence of symptoms following initial improvement; hospitalization indicated for clinical sequelae (e.g., renal impairment, pulmonary infiltrates).

Grade 4 Reaction: Life-threatening consequences; urgent intervention indicated (e.g., vasopressors or ventilator support).	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	rituximab-pvvr (PF) (RUXIENCE) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	rituximab-arrx (RIABNI) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ARRX 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes				Rituximab Instructions
  	VITAL SIGNS - T/P/R/BP PER UNIT PROTOCOL	Interval: Once	Occurrences: --	Comments:	1) During Rituximab infusion:
-Vitals every 15 minutes during 1st hour of infusion, THEN
-Every 30 minutes for 1 hour, THEN
-Every hour until end of infusion
-Call MD if SBP less than 90, pulse less than 60 or greater than 120, temperature greater than 38.5 degrees C
		  	ONC NURSING COMMUNICATION 26	Interval: Once	Occurrences: --	Comments:	2) Infuse antibody via pump
3) If any of the following occurs: FEVER (T greater than 38.5 degrees C), RIGORS, HYPOTENSION (30mm Hg decrease from baseline), and / or MUCOSAL CONGESTION / EDEMA, HOLD infusion until improvement of symptoms (When symptoms improve, resume infusion at HALF the previous rate)
			Rituximab Infusion Reaction Orders
  	meperidine (DEMEROL) injection (RESTRICTED) 25 mg	Dose: 25 mg	Route: intravenous	once PRN					  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	once PRN					  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	once PRN	Start: S					Rituximab Additional Orders
  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: intramuscular	once PRN	Start: S					Pre-Medications
  	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose			Offset: 2 Hours	Instructions:	Administer 30 minutes before doxorubicin/vincristine/etoposide.		  	fosaprepitant (EMEND) IVPB 150 mg	Dose: 150 mg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 2 Hours	Instructions:	Administer 30 minutes before doxorubicin/vincristine/etoposide.			Chemotherapy
  	DOXOrubicin (ADRIAmycin) 10 mg/m2, vinCRIStine (ONCOVIN) 0.4 mg/m2 in sodium chloride 0.9% 250 mL chemo IVPB	Dose: --	Route: intravenous	once over 22 Hours for 1 dose			Offset: 2.5 Hours	Instructions:	VESICANT; Protect from light	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DOXORUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION	Medications	10 mg/m2	Always	Yes	VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION	Medications	0.4 mg/m2	Always	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes			  	etoposide (TOPOSAR) 50 mg/m2 in sodium chloride (NON-PVC) 0.9 % 500 mL chemo IVPB	Dose: 50 mg/m2	Route: intravenous	once over 22 Hours for 1 dose			Offset: 2.5 Hours	Instructions:	Administer through a 0.22 micron filter and non-PVC tubing set	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION	Medications	50 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % IV SOLP (EXCEL;NON-PVC)	QS Base	500 mL	Yes	Yes				Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: Until discontinued	Occurrences: --	Comments:	Grade 1 - MILD Symptoms (cutaneous and subcutaneous symptoms only - itching, flushing, periorbital edema, rash, or runny nose)
1. Stop the infusion.
2. Place the patient on continuous monitoring.
3. Obtain vital signs.
4. Administer Normal Saline at 50 mL per hour using a new bag and new intravenous tubing.
5. If greater than or equal to 30 minutes since the last dose of Diphenhydramine, administer Diphenhydramine 25 mg intravenous once.
6. If less than 30 minutes since the last dose of Diphenhydramine, administer Cetirizine 10 mg orally and Famotidine 20 mg intravenous once.
7. Notify the treating physician.
8. If no improvement after 15 minutes, advance level of care to Grade 2 (Moderate) or Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 83	Interval: Until discontinued	Occurrences: --	Comments:	Grade 2 - MODERATE Symptoms (cardiovascular, respiratory, or gastrointestinal symptoms - shortness of breath, wheezing, nausea, vomiting, dizziness, diaphoresis, throat or chest tightness, abdominal or back pain)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
6. Administer Normal Saline at 150 mL per hour using a new bag and new intravenous tubing.
7. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous), Cetirizine 10 mg orally and Famotidine 20 mg intravenous once.
8. If no improvement after 15 minutes, advance level of care to Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 4	Interval: Until discontinued	Occurrences: --	Comments:	Grade 3 – SEVERE Symptoms (hypoxia, hypotension, or neurologic compromise – cyanosis or O2 saturation less than 92%, hypotension with systolic blood pressure less than 90 mmHg, confusion, collapse, loss of consciousness, or incontinence)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. If heart rate is less than 50 or greater than 120, or blood pressure is less than 90/50 mmHg, place patient in reclined or flattened position.
6. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
7. Administer Normal Saline at 1000 mL intravenous bolus using a new bag and new intravenous tubing.
8. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous) and Famotidine 20 mg intravenous once.
9. Administer Epinephrine (1:1000) 0.3 mg subcutaneous.
10. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	PRN	Start: S				  	cetirizine (ZyrTEC) tablet 10 mg	Dose: 10 mg	Route: oral	once PRN	Start: S				  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	PRN					  	dexAMETHasone (DECADRON) IV 4 mg	Dose: 4 mg	Route: intravenous	PRN	Start: S				  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					Discharge Nursing Orders
☑	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN					☑	HEParin, porcine (PF) injection 500 Units	Dose: 500 Units	Route: intra-catheter	once PRN	Start: S			Instructions:	Concentration: 100 units/mL. Heparin flush for Implanted Vascular Access Device maintenance.				Days 2,3,4	Perform every 1 day x3		Line Care
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Nursing Orders
  	ONC NURSING COMMUNICATION 6	Interval: Once	Occurrences: --	Comments:	Adverse Events: Continuously every day, every cycle. 
To ensure compliance with these regulations/this guidance, as IND/IDE sponsor, NCI requires that AEs be submitted according to the timeframes in the AE reporting tables assigned to the protocol, using the CTEP Adverse Event Reporting System (CTEP-AERS).
		  	ONC NURSING COMMUNICATION 8	Interval: Once	Occurrences: --	Comments:	Concomitant Medications: continuously every day, every cycle. 
Please refer to section 4.0 page 24-25 for restrictions/
		  	ONC NURSING COMMUNICATION 11	Interval: Once	Occurrences: --	Comments:	May substitute IV methylprednisolone at 80% of oral dose for predniSONE or prednisoLONE if unable to take PO.
			Pre-Medications
  	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 30 minutes before chemo.			Pre-Medications
  	predniSONE (DELTASONE) tablet 100 mg	Dose: 100 mg	Route: oral	once for 1 dose	Start: S			Instructions:	o Administer 30 minutes before chemo. 
o Prednisone is part of anti-lymphoma regimen. Do NOT omit dose. Do NOT give other steroid and hold prednisone.			Chemotherapy
  	DOXOrubicin (ADRIAmycin) 10 mg/m2, vinCRIStine (ONCOVIN) 0.4 mg/m2 in sodium chloride 0.9% 250 mL chemo IVPB	Dose: --	Route: intravenous	once over 22 Hours for 1 dose			Offset: 30 Minutes	Instructions:	VESICANT; Protect from light	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DOXORUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION	Medications	10 mg/m2	Always	Yes	VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION	Medications	0.4 mg/m2	Always	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes			  	etoposide (TOPOSAR) 50 mg/m2 in sodium chloride (NON-PVC) 0.9 % 500 mL chemo IVPB	Dose: 50 mg/m2	Route: intravenous	once over 22 Hours for 1 dose			Offset: 30 Minutes	Instructions:	Administer through a 0.22 micron filter and non-PVC tubing set	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION	Medications	50 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % IV SOLP (EXCEL;NON-PVC)	QS Base	500 mL	Yes	Yes					Day 5	Perform every 1 day x1		Line Care
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Nursing Orders
  	ONC NURSING COMMUNICATION 6	Interval: Once	Occurrences: --	Comments:	Adverse Events: Continuously every day, every cycle. 
To ensure compliance with these regulations/this guidance, as IND/IDE sponsor, NCI requires that AEs be submitted according to the timeframes in the AE reporting tables assigned to the protocol, using the CTEP Adverse Event Reporting System (CTEP-AERS).
		  	ONC NURSING COMMUNICATION 8	Interval: Once	Occurrences: --	Comments:	Concomitant Medications: continuously every day, every cycle. 
Please refer to section 4.0 page 24-25 for restrictions/
		  	ONC NURSING COMMUNICATION 11	Interval: Once	Occurrences: --	Comments:	May substitute IV methylprednisolone at 80% of oral dose for predniSONE or prednisoLONE if unable to take PO.
			Nursing Orders
  	ONC NURSING COMMUNICATION 16	Interval: Once	Occurrences: --	Comments:	Patient should receive myeloid growth factor support 24-72 hours after completion of the cyclophosphamide infusion.  Please coordinate with OP clinic to schedule patient within the appropriate time window or notify clinical pharmacist if inpatient administration is needed
			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: Once	Occurrences: --			Pre-Medications
  	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 30 minutes before chemo.			Pre-Medications
  	predniSONE (DELTASONE) tablet 100 mg	Dose: 100 mg	Route: oral	once for 1 dose	Start: S			Instructions:	o Administer 30 minutes before chemo. 
o Prednisone is part of anti-lymphoma regimen. Do NOT omit dose. Do NOT give other steroid and hold prednisone.			Chemotherapy
  	cyclophosphamide (CYTOXAN) 750 mg/m2 in sodium chloride 0.9% 250 mL chemo IVPB	Dose: 750 mg/m2	Route: intravenous	once over 60 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	Administer over 30 to 60 minutes immediately AFTER infusions for Etoposide/Doxorubicin/Vincristine are completed.  Usually in 250mL 0.9% NaCl. 
Refer to dose level guidelines Section 4.2.3.1	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION	Medications	750 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	250 mL	No	Yes					Day 6	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Supportive Care
  	pegfilgrastim (NEULASTA) on-body injection kit 6 mg	Dose: 6 mg	Route: subcutaneous	once for 1 dose				Instructions:	Start myeloid growth factor support 24 to 72 hours AFTER completion of the infusion of cyclophosphamide. See 4.2.3 for details.				Days 9,13,17,21	Perform every 4 days x4		Nursing Orders
  	ONC NURSING COMMUNICATION 6	Interval: --	Occurrences: --	Comments:	Adverse Events: Continuously every day, every cycle. 
To ensure compliance with these regulations/this guidance, as IND/IDE sponsor, NCI requires that AEs be submitted according to the timeframes in the AE reporting tables assigned to the protocol, using the CTEP Adverse Event Reporting System (CTEP-AERS).
		  	ONC NURSING COMMUNICATION 8	Interval: --	Occurrences: --	Comments:	Concomitant Medications: continuously every day, every cycle. 
Please refer to section 4.0 page 24-25 for restrictions
			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --					
Cycle 2	Repeat 1 time	Cycle length: 21 days	Day 1	Perform every 1 day x1		Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Line Care
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Treatment Conditions
  	TREATMENT CONDITIONS	Interval: Until discontinued	Occurrences: --	Comments:	Please refer to Study Protocol for any questions or discrepancies. See Schedule of Events Calendar for sequence of diagnostic tests, examinations, and treatment administration: See Safety Parameters-for Toxicity Management and Dose Modification Guidelines: Protocol Access hyperlink:  ANHL1931_Protocol.pdf
		  	TREATMENT CONDITIONS 3	Interval: Until discontinued	Occurrences: --	Comments:	Dose Modifications and Management for Nivolumab Treatment : Refer to Section 5.0 / 5.1 Management of AEs Associated with Nivolumab
Protocol Access Hyperlink: ANHL1931_Protocol.pdf
		  	TREATMENT CONDITIONS 11	Interval: Until discontinued	Occurrences: --	Comments:	Dose Modifications and Management for  Treatment DA-EPOCH : Refer to Section 5.0 / 5.3 Management of AEs Associated with Etoposide, Doxorrubicin, Cyclophosphamide, Vincristine, Prednisone 
Protocol Access Hyperlink: ANHL1931_Protocol.pdf
		  	TREATMENT CONDITIONS 10	Interval: Until discontinued	Occurrences: --	Comments:	Dose Modifications and Management for Rituximab Treatment : Refer to Section 5.0 / 5.2 Management of AEs Associated with Rituximab
Protocol Access Hyperlink: ANHL1931_Protocol.pdf
			Nursing Orders
  	ONC NURSING COMMUNICATION 2	Interval: Once	Occurrences: --	Comments:	Physical exam
		  	VITAL SIGNS - T/P/R/BP	Interval: Once	Occurrences: --		  	MEASURE WEIGHT	Interval: Until discontinued	Occurrences: --	Comments:	If there is a GREATER than 5% change in weight, BSA will be recalculated prior to each cycle.
		  	ONC NURSING COMMUNICATION 6	Interval: Once	Occurrences: --	Comments:	Adverse Events: Continuously every day, every cycle. 
To ensure compliance with these regulations/this guidance, as IND/IDE sponsor, NCI requires that AEs be submitted according to the timeframes in the AE reporting tables assigned to the protocol, using the CTEP Adverse Event Reporting System (CTEP-AERS).
		  	ONC NURSING COMMUNICATION 8	Interval: Once	Occurrences: --	Comments:	Concomitant Medications: continuously every day, every cycle. 
Please refer to section 4.0 page 24-25 for restrictions/
		  	ONC NURSING COMMUNICATION 11	Interval: Once	Occurrences: --	Comments:	If unable to take PO, may substitute IV methylprednisolone at 80% of oral dose for predniSONE or prednisoLONE (prednisone 100 mg= methylprednisolone 80 mg).
			Nursing Orders
  	ONC NURSING COMMUNICATION 12	Interval: Once	Occurrences: --	Comments:	Start Nivolumab PRIOR to prednisone and rituximab.
			Provider Communication
  	ONC PROVIDER COMMUNICATION	Interval: Once	Occurrences: --	Comments:	Verify Ejection Fraction prior to Cycle 1.  Ejection Fraction: ***% on *** (date).

If patient has not had a recent MUGA or ECHO, order one via order entry. A baseline cardiac evaluation with a MUGA scan or an ECHO is recommended, especially in patients with risk factors for increased cardiac toxicity. Repeated MUGA or ECHO determinations of LVEF should be performed, particularly with higher, cumulative anthracycline doses.

			Nursing Orders
  	TRANSTHORACIC ECHOCARDIOGRAM COMPLETE W CONT STRAIN 3D IF NEEDED	Interval: 1 time imaging	Occurrences: --	Comments:	As clinically indicated per institutional guidelines
		  	ECG 12-LEAD	Interval: Once	Occurrences: --	Comments:	As clinically indicated per institutional guidelines
			Labs
  	RESEARCH STUDY SPECIMEN	Interval: Once	Occurrences: --		  	RESEARCH STUDY SPECIMEN	Interval: Once	Occurrences: --		  	RESEARCH STUDY SPECIMEN	Interval: Once	Occurrences: --			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: Once	Occurrences: --			Labs
  	THYROID STIMULATING HORMONE	Interval: Once	Occurrences: --	Comments:	If TSH is abnormal T3 and FT4 should be evaluated.
			Labs
  	AST (SGOT)	Interval: --	Occurrences: --		  	ALT (SGPT)	Interval: --	Occurrences: --		  	TOTAL BILIRUBIN	Interval: Once	Occurrences: --		  	BILIRUBIN DIRECT	Interval: Once	Occurrences: --			Labs
  	SODIUM LEVEL	Interval: Once	Occurrences: --		  	POTASSIUM LEVEL	Interval: Once	Occurrences: --		  	CHLORIDE LEVEL	Interval: Once	Occurrences: --		  	CALCIUM LEVEL	Interval: Once	Occurrences: --		  	MAGNESIUM LEVEL	Interval: Once	Occurrences: --		  	PHOSPHORUS LEVEL	Interval: Once	Occurrences: --			Labs
  	HCG QUALITATIVE, SERUM SCREEN	Interval: Once	Occurrences: --	Comments:	ONLY for females of child bearing potential
			Treatment Conditions
  	TREATMENT CONDITIONS 13	Interval: Until discontinued	Occurrences: --	Comments:	No count requirement for Cycle 1. Subsequent cycles require ANC GREATER than or EQUAL to 1000/µL and PLTS GREATER than or EQUAL to 100,000/µL. Dosing for doxorubicin, etoposide and cyclophosphamide starts at level #1 as described in Section 4.2.3.1. 
See dose modification instructions as described in Section 5.0. Please note: patients will begin at Cycle 2 if already received one cycle of chemo-immunotherapy (See Section 3.2.5)
			Chemotherapy
  	INV-Nivolumab (ANHL1931/Pro00035735/Pingali) in sodium chloride 0.9% 100 mL IVPB	Dose: --	Route: intravenous	once over 30 Minutes for 1 dose	Start: S			Instructions:	Prepared dose contains active nivolumab in NS. Infuse intravenously over 30 minutes via 0.2 to 1.2 micron low protein binding in line filter. Flush line with NS at the end of infusion. 
HAZARDOUS - Handle with care
Caution: New Drug-Limited by Federal (USA) Law to Investigational use.
	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-NIVOLUMAB 100 MG INTRAVENOUS SOLN (ANHL1931/PRO00035735/PINGALI)	Medications	 	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes				Pre-Medications
  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer 30 minutes before rituximab.		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 30 minutes before rituximab.		  	predniSONE (DELTASONE) tablet 100 mg	Dose: 100 mg	Route: oral	once for 1 dose	Start: S			Instructions:	o Administer 30 minutes prior to the rituximb. 
o Prednisone is part of anti-lymphoma regimen. Do NOT omit dose. Do NOT give other steroid and hold prednisone.			Chemotherapy
◉	riTUXimab-abbs (TRUXIMA) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 30 Minutes	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	RiTUXimab (PF) (RITUXAN) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 30 Minutes	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	rituximab-pvvr (PF) (RUXIENCE) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 30 Minutes	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	rituximab-arrx (RIABNI) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 30 Minutes	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ARRX 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	riTUXimab-abbs (TRUXIMA) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	RiTUXimab (PF) (RITUXAN) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	RAPID INFUSION RATE:  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.

Reaction grades:

Grade 3 Reaction: Prolonged (e.g., not rapidly responsive to symptomatic medication and/or brief interruption of infusion); recurrence of symptoms following initial improvement; hospitalization indicated for clinical sequelae (e.g., renal impairment, pulmonary infiltrates).

Grade 4 Reaction: Life-threatening consequences; urgent intervention indicated (e.g., vasopressors or ventilator support).	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	rituximab-pvvr (PF) (RUXIENCE) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	rituximab-arrx (RIABNI) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ARRX 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes				Rituximab Instructions
  	VITAL SIGNS - T/P/R/BP PER UNIT PROTOCOL	Interval: Once	Occurrences: --	Comments:	1) During Rituximab infusion:
-Vitals every 15 minutes during 1st hour of infusion, THEN
-Every 30 minutes for 1 hour, THEN
-Every hour until end of infusion
-Call MD if SBP less than 90, pulse less than 60 or greater than 120, temperature greater than 38.5 degrees C
		  	ONC NURSING COMMUNICATION 26	Interval: Once	Occurrences: --	Comments:	2) Infuse antibody via pump
3) If any of the following occurs: FEVER (T greater than 38.5 degrees C), RIGORS, HYPOTENSION (30mm Hg decrease from baseline), and / or MUCOSAL CONGESTION / EDEMA, HOLD infusion until improvement of symptoms (When symptoms improve, resume infusion at HALF the previous rate)
			Rituximab Infusion Reaction Orders
  	meperidine (DEMEROL) injection (RESTRICTED) 25 mg	Dose: 25 mg	Route: intravenous	once PRN					  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	once PRN					  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	once PRN	Start: S					Rituximab Additional Orders
  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: intramuscular	once PRN	Start: S					Pre-Medications
  	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose			Offset: 2 Hours	Instructions:	Administer 30 minutes before doxorubicin/vincristine/etoposide.		  	fosaprepitant (EMEND) IVPB 150 mg	Dose: 150 mg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 2 Hours	Instructions:	Administer 30 minutes before doxorubicin/vincristine/etoposide.			Chemotherapy
  	DOXOrubicin (ADRIAmycin) 10 mg/m2, vinCRIStine (ONCOVIN) 0.4 mg/m2 in sodium chloride 0.9% 250 mL chemo IVPB	Dose: --	Route: intravenous	once over 22 Hours for 1 dose			Offset: 2.5 Hours	Instructions:	VESICANT; Protect from light	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DOXORUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION	Medications	10 mg/m2	Always	Yes	VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION	Medications	0.4 mg/m2	Always	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes			  	etoposide (TOPOSAR) 50 mg/m2 in sodium chloride (NON-PVC) 0.9 % 500 mL chemo IVPB	Dose: 50 mg/m2	Route: intravenous	once over 22 Hours for 1 dose			Offset: 2.5 Hours	Instructions:	Administer through a 0.22 micron filter and non-PVC tubing set	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION	Medications	50 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % IV SOLP (EXCEL;NON-PVC)	QS Base	500 mL	Yes	Yes				Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: Until discontinued	Occurrences: --	Comments:	Grade 1 - MILD Symptoms (cutaneous and subcutaneous symptoms only - itching, flushing, periorbital edema, rash, or runny nose)
1. Stop the infusion.
2. Place the patient on continuous monitoring.
3. Obtain vital signs.
4. Administer Normal Saline at 50 mL per hour using a new bag and new intravenous tubing.
5. If greater than or equal to 30 minutes since the last dose of Diphenhydramine, administer Diphenhydramine 25 mg intravenous once.
6. If less than 30 minutes since the last dose of Diphenhydramine, administer Cetirizine 10 mg orally and Famotidine 20 mg intravenous once.
7. Notify the treating physician.
8. If no improvement after 15 minutes, advance level of care to Grade 2 (Moderate) or Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 83	Interval: Until discontinued	Occurrences: --	Comments:	Grade 2 - MODERATE Symptoms (cardiovascular, respiratory, or gastrointestinal symptoms - shortness of breath, wheezing, nausea, vomiting, dizziness, diaphoresis, throat or chest tightness, abdominal or back pain)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
6. Administer Normal Saline at 150 mL per hour using a new bag and new intravenous tubing.
7. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous), Cetirizine 10 mg orally and Famotidine 20 mg intravenous once.
8. If no improvement after 15 minutes, advance level of care to Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 4	Interval: Until discontinued	Occurrences: --	Comments:	Grade 3 – SEVERE Symptoms (hypoxia, hypotension, or neurologic compromise – cyanosis or O2 saturation less than 92%, hypotension with systolic blood pressure less than 90 mmHg, confusion, collapse, loss of consciousness, or incontinence)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. If heart rate is less than 50 or greater than 120, or blood pressure is less than 90/50 mmHg, place patient in reclined or flattened position.
6. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
7. Administer Normal Saline at 1000 mL intravenous bolus using a new bag and new intravenous tubing.
8. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous) and Famotidine 20 mg intravenous once.
9. Administer Epinephrine (1:1000) 0.3 mg subcutaneous.
10. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	PRN	Start: S				  	cetirizine (ZyrTEC) tablet 10 mg	Dose: 10 mg	Route: oral	once PRN	Start: S				  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	PRN					  	dexAMETHasone (DECADRON) IV 4 mg	Dose: 4 mg	Route: intravenous	PRN	Start: S				  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					Discharge Nursing Orders
☑	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN					☑	HEParin, porcine (PF) injection 500 Units	Dose: 500 Units	Route: intra-catheter	once PRN	Start: S			Instructions:	Concentration: 100 units/mL. Heparin flush for Implanted Vascular Access Device maintenance.				Days 2,3,4	Perform every 1 day x3		Line Care
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Nursing Orders
  	ONC NURSING COMMUNICATION 6	Interval: Once	Occurrences: --	Comments:	Adverse Events: Continuously every day, every cycle. 
To ensure compliance with these regulations/this guidance, as IND/IDE sponsor, NCI requires that AEs be submitted according to the timeframes in the AE reporting tables assigned to the protocol, using the CTEP Adverse Event Reporting System (CTEP-AERS).
		  	ONC NURSING COMMUNICATION 8	Interval: Once	Occurrences: --	Comments:	Concomitant Medications: continuously every day, every cycle. 
Please refer to section 4.0 page 24-25 for restrictions/
		  	ONC NURSING COMMUNICATION 11	Interval: Once	Occurrences: --	Comments:	May substitute IV methylprednisolone at 80% of oral dose for predniSONE or prednisoLONE if unable to take PO.
			Pre-Medications
  	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 30 minutes before chemo.			Pre-Medications
  	predniSONE (DELTASONE) tablet 100 mg	Dose: 100 mg	Route: oral	once for 1 dose	Start: S			Instructions:	o Administer 30 minutes before chemo. 
o Prednisone is part of anti-lymphoma regimen. Do NOT omit dose. Do NOT give other steroid and hold prednisone.			Chemotherapy
  	DOXOrubicin (ADRIAmycin) 10 mg/m2, vinCRIStine (ONCOVIN) 0.4 mg/m2 in sodium chloride 0.9% 250 mL chemo IVPB	Dose: --	Route: intravenous	once over 22 Hours for 1 dose			Offset: 30 Minutes	Instructions:	VESICANT; Protect from light	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DOXORUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION	Medications	10 mg/m2	Always	Yes	VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION	Medications	0.4 mg/m2	Always	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes			  	etoposide (TOPOSAR) 50 mg/m2 in sodium chloride (NON-PVC) 0.9 % 500 mL chemo IVPB	Dose: 50 mg/m2	Route: intravenous	once over 22 Hours for 1 dose			Offset: 30 Minutes	Instructions:	Administer through a 0.22 micron filter and non-PVC tubing set	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION	Medications	50 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % IV SOLP (EXCEL;NON-PVC)	QS Base	500 mL	Yes	Yes					Day 5	Perform every 1 day x1		Line Care
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Nursing Orders
  	ONC NURSING COMMUNICATION 6	Interval: Once	Occurrences: --	Comments:	Adverse Events: Continuously every day, every cycle. 
To ensure compliance with these regulations/this guidance, as IND/IDE sponsor, NCI requires that AEs be submitted according to the timeframes in the AE reporting tables assigned to the protocol, using the CTEP Adverse Event Reporting System (CTEP-AERS).
		  	ONC NURSING COMMUNICATION 8	Interval: Once	Occurrences: --	Comments:	Concomitant Medications: continuously every day, every cycle. 
Please refer to section 4.0 page 24-25 for restrictions/
		  	ONC NURSING COMMUNICATION 11	Interval: Once	Occurrences: --	Comments:	May substitute IV methylprednisolone at 80% of oral dose for predniSONE or prednisoLONE if unable to take PO.
			Nursing Orders
  	ONC NURSING COMMUNICATION 16	Interval: Once	Occurrences: --	Comments:	Patient should receive myeloid growth factor support 24-72 hours after completion of the cyclophosphamide infusion.  Please coordinate with OP clinic to schedule patient within the appropriate time window or notify clinical pharmacist if inpatient administration is needed
			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: Once	Occurrences: --			Pre-Medications
  	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 30 minutes before chemo.			Pre-Medications
  	predniSONE (DELTASONE) tablet 100 mg	Dose: 100 mg	Route: oral	once for 1 dose	Start: S			Instructions:	o Administer 30 minutes before chemo. 
o Prednisone is part of anti-lymphoma regimen. Do NOT omit dose. Do NOT give other steroid and hold prednisone.			Chemotherapy
  	cyclophosphamide (CYTOXAN) 750 mg/m2 in sodium chloride 0.9% 250 mL chemo IVPB	Dose: 750 mg/m2	Route: intravenous	once over 60 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	Administer over 30 to 60 minutes immediately AFTER infusions for Etoposide/Doxorubicin/Vincristine are completed.  Usually in 250mL 0.9% NaCl. 
Refer to dose level guidelines Section 4.2.3.1	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION	Medications	750 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	250 mL	No	Yes					Day 6	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Supportive Care
  	pegfilgrastim (NEULASTA) on-body injection kit 6 mg	Dose: 6 mg	Route: subcutaneous	once for 1 dose				Instructions:	Start myeloid growth factor support 24 to 72 hours AFTER completion of the infusion of cyclophosphamide. See 4.2.3 for details.				Days 9,13,17	Perform every 4 days x3		Nursing Orders
  	ONC NURSING COMMUNICATION 6	Interval: --	Occurrences: --	Comments:	Adverse Events: Continuously every day, every cycle. 
To ensure compliance with these regulations/this guidance, as IND/IDE sponsor, NCI requires that AEs be submitted according to the timeframes in the AE reporting tables assigned to the protocol, using the CTEP Adverse Event Reporting System (CTEP-AERS).
		  	ONC NURSING COMMUNICATION 8	Interval: --	Occurrences: --	Comments:	Concomitant Medications: continuously every day, every cycle. 
Please refer to section 4.0 page 24-25 for restrictions
			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --				Day 21	Perform every 4 days x1		Nursing Orders
  	ONC NURSING COMMUNICATION 6	Interval: --	Occurrences: --	Comments:	Adverse Events: Continuously every day, every cycle. 
To ensure compliance with these regulations/this guidance, as IND/IDE sponsor, NCI requires that AEs be submitted according to the timeframes in the AE reporting tables assigned to the protocol, using the CTEP Adverse Event Reporting System (CTEP-AERS).
		  	ONC NURSING COMMUNICATION 8	Interval: --	Occurrences: --	Comments:	Concomitant Medications: continuously every day, every cycle. 
Please refer to section 4.0 page 24-25 for restrictions
			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --			Imaging
  	PET CT WHOLE BODY	Interval: --	Occurrences: --	Comments:	Optional PET/CT after cycle 2. Optional PET/CT after cycle 4 in patients for whom imaging after cycle 2 demonstrates increase in SUV from baseline without increase in tumor size by CT measurements'
			Imaging
  	CT CHEST W CONTRAST ABDOMEN W CONTRAST PELVIS W CONTRAST	Interval: --	Occurrences: --	Comments:	After cycle 2 if PET/CT not performed. Every 6 months until 2 years off therapy (6 mo, 12mo, 18mo, 2 yrs). After 2 years, only if clinically indicated
			Procedures
  	BIOPSY BONE MARROW	Interval: --	Occurrences: --	Comments:	o Unilateral bone marrow biopsy and aspirate.   
o If involved at diagnosis. Optional, not required.
					
Cycle 3	Repeat 1 time	Cycle length: 21 days	Day 1	Perform every 1 day x1		Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Line Care
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Treatment Conditions
  	TREATMENT CONDITIONS	Interval: Until discontinued	Occurrences: --	Comments:	Please refer to Study Protocol for any questions or discrepancies. See Schedule of Events Calendar for sequence of diagnostic tests, examinations, and treatment administration: See Safety Parameters-for Toxicity Management and Dose Modification Guidelines: Protocol Access hyperlink:  ANHL1931_Protocol.pdf
		  	TREATMENT CONDITIONS 3	Interval: Until discontinued	Occurrences: --	Comments:	Dose Modifications and Management for Nivolumab Treatment : Refer to Section 5.0 / 5.1 Management of AEs Associated with Nivolumab
Protocol Access Hyperlink: ANHL1931_Protocol.pdf
		  	TREATMENT CONDITIONS 11	Interval: Until discontinued	Occurrences: --	Comments:	Dose Modifications and Management for  Treatment DA-EPOCH : Refer to Section 5.0 / 5.3 Management of AEs Associated with Etoposide, Doxorrubicin, Cyclophosphamide, Vincristine, Prednisone 
Protocol Access Hyperlink: ANHL1931_Protocol.pdf
		  	TREATMENT CONDITIONS 10	Interval: Until discontinued	Occurrences: --	Comments:	Dose Modifications and Management for Rituximab Treatment : Refer to Section 5.0 / 5.2 Management of AEs Associated with Rituximab
Protocol Access Hyperlink: ANHL1931_Protocol.pdf
			Nursing Orders
  	ONC NURSING COMMUNICATION 2	Interval: Once	Occurrences: --	Comments:	Physical exam
		  	VITAL SIGNS - T/P/R/BP	Interval: Once	Occurrences: --		  	MEASURE WEIGHT	Interval: Until discontinued	Occurrences: --	Comments:	If there is a GREATER than 5% change in weight, BSA will be recalculated prior to each cycle.
		  	ONC NURSING COMMUNICATION 6	Interval: Once	Occurrences: --	Comments:	Adverse Events: Continuously every day, every cycle. 
To ensure compliance with these regulations/this guidance, as IND/IDE sponsor, NCI requires that AEs be submitted according to the timeframes in the AE reporting tables assigned to the protocol, using the CTEP Adverse Event Reporting System (CTEP-AERS).
		  	ONC NURSING COMMUNICATION 8	Interval: Once	Occurrences: --	Comments:	Concomitant Medications: continuously every day, every cycle. 
Please refer to section 4.0 page 24-25 for restrictions/
		  	ONC NURSING COMMUNICATION 11	Interval: Once	Occurrences: --	Comments:	If unable to take PO, may substitute IV methylprednisolone at 80% of oral dose for predniSONE or prednisoLONE (prednisone 100 mg= methylprednisolone 80 mg).
			Nursing Orders
  	ONC NURSING COMMUNICATION 12	Interval: Once	Occurrences: --	Comments:	Start Nivolumab PRIOR to prednisone and rituximab.
			Provider Communication
  	ONC PROVIDER COMMUNICATION	Interval: Once	Occurrences: --	Comments:	Verify Ejection Fraction prior to Cycle 1.  Ejection Fraction: ***% on *** (date).

If patient has not had a recent MUGA or ECHO, order one via order entry. A baseline cardiac evaluation with a MUGA scan or an ECHO is recommended, especially in patients with risk factors for increased cardiac toxicity. Repeated MUGA or ECHO determinations of LVEF should be performed, particularly with higher, cumulative anthracycline doses.

			Nursing Orders
  	TRANSTHORACIC ECHOCARDIOGRAM COMPLETE W CONT STRAIN 3D IF NEEDED	Interval: 1 time imaging	Occurrences: --	Comments:	As clinically indicated per institutional guidelines
		  	ECG 12-LEAD	Interval: Once	Occurrences: --	Comments:	As clinically indicated per institutional guidelines
			Labs
  	RESEARCH STUDY SPECIMEN	Interval: Once	Occurrences: --			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: Once	Occurrences: --			Labs
  	THYROID STIMULATING HORMONE	Interval: Once	Occurrences: --	Comments:	If TSH is abnormal T3 and FT4 should be evaluated.
			Labs
  	AST (SGOT)	Interval: --	Occurrences: --		  	ALT (SGPT)	Interval: --	Occurrences: --		  	TOTAL BILIRUBIN	Interval: Once	Occurrences: --		  	BILIRUBIN DIRECT	Interval: Once	Occurrences: --			Labs
  	SODIUM LEVEL	Interval: Once	Occurrences: --		  	POTASSIUM LEVEL	Interval: Once	Occurrences: --		  	CHLORIDE LEVEL	Interval: Once	Occurrences: --		  	CALCIUM LEVEL	Interval: Once	Occurrences: --		  	MAGNESIUM LEVEL	Interval: Once	Occurrences: --		  	PHOSPHORUS LEVEL	Interval: Once	Occurrences: --			Labs
  	HCG QUALITATIVE, SERUM SCREEN	Interval: Once	Occurrences: --	Comments:	ONLY for females of child bearing potential
			Treatment Conditions
  	TREATMENT CONDITIONS 13	Interval: Until discontinued	Occurrences: --	Comments:	No count requirement for Cycle 1. Subsequent cycles require ANC GREATER than or EQUAL to 1000/µL and PLTS GREATER than or EQUAL to 100,000/µL. Dosing for doxorubicin, etoposide and cyclophosphamide starts at level #1 as described in Section 4.2.3.1. 
See dose modification instructions as described in Section 5.0. Please note: patients will begin at Cycle 2 if already received one cycle of chemo-immunotherapy (See Section 3.2.5)
			Chemotherapy
  	INV-Nivolumab (ANHL1931/Pro00035735/Pingali) in sodium chloride 0.9% 100 mL IVPB	Dose: --	Route: intravenous	once over 30 Minutes for 1 dose	Start: S			Instructions:	Prepared dose contains active nivolumab in NS. Infuse intravenously over 30 minutes via 0.2 to 1.2 micron low protein binding in line filter. Flush line with NS at the end of infusion. 
HAZARDOUS - Handle with care
Caution: New Drug-Limited by Federal (USA) Law to Investigational use.
	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-NIVOLUMAB 100 MG INTRAVENOUS SOLN (ANHL1931/PRO00035735/PINGALI)	Medications	 	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes				Pre-Medications
  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer 30 minutes before rituximab.		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 30 minutes before rituximab.		  	predniSONE (DELTASONE) tablet 100 mg	Dose: 100 mg	Route: oral	once for 1 dose	Start: S			Instructions:	o Administer 30 minutes prior to the rituximb. 
o Prednisone is part of anti-lymphoma regimen. Do NOT omit dose. Do NOT give other steroid and hold prednisone.			Chemotherapy
◉	riTUXimab-abbs (TRUXIMA) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 30 Minutes	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	RiTUXimab (PF) (RITUXAN) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 30 Minutes	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	rituximab-pvvr (PF) (RUXIENCE) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 30 Minutes	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	rituximab-arrx (RIABNI) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 30 Minutes	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ARRX 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	riTUXimab-abbs (TRUXIMA) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	RiTUXimab (PF) (RITUXAN) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	RAPID INFUSION RATE:  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.

Reaction grades:

Grade 3 Reaction: Prolonged (e.g., not rapidly responsive to symptomatic medication and/or brief interruption of infusion); recurrence of symptoms following initial improvement; hospitalization indicated for clinical sequelae (e.g., renal impairment, pulmonary infiltrates).

Grade 4 Reaction: Life-threatening consequences; urgent intervention indicated (e.g., vasopressors or ventilator support).	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	rituximab-pvvr (PF) (RUXIENCE) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	rituximab-arrx (RIABNI) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ARRX 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes				Rituximab Instructions
  	VITAL SIGNS - T/P/R/BP PER UNIT PROTOCOL	Interval: Once	Occurrences: --	Comments:	1) During Rituximab infusion:
-Vitals every 15 minutes during 1st hour of infusion, THEN
-Every 30 minutes for 1 hour, THEN
-Every hour until end of infusion
-Call MD if SBP less than 90, pulse less than 60 or greater than 120, temperature greater than 38.5 degrees C
		  	ONC NURSING COMMUNICATION 26	Interval: Once	Occurrences: --	Comments:	2) Infuse antibody via pump
3) If any of the following occurs: FEVER (T greater than 38.5 degrees C), RIGORS, HYPOTENSION (30mm Hg decrease from baseline), and / or MUCOSAL CONGESTION / EDEMA, HOLD infusion until improvement of symptoms (When symptoms improve, resume infusion at HALF the previous rate)
			Rituximab Infusion Reaction Orders
  	meperidine (DEMEROL) injection (RESTRICTED) 25 mg	Dose: 25 mg	Route: intravenous	once PRN					  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	once PRN					  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	once PRN	Start: S					Rituximab Additional Orders
  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: intramuscular	once PRN	Start: S					Pre-Medications
  	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose			Offset: 2 Hours	Instructions:	Administer 30 minutes before doxorubicin/vincristine/etoposide.		  	fosaprepitant (EMEND) IVPB 150 mg	Dose: 150 mg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 2 Hours	Instructions:	Administer 30 minutes before doxorubicin/vincristine/etoposide.			Chemotherapy
  	DOXOrubicin (ADRIAmycin) 10 mg/m2, vinCRIStine (ONCOVIN) 0.4 mg/m2 in sodium chloride 0.9% 250 mL chemo IVPB	Dose: --	Route: intravenous	once over 22 Hours for 1 dose			Offset: 2.5 Hours	Instructions:	VESICANT; Protect from light	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DOXORUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION	Medications	10 mg/m2	Always	Yes	VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION	Medications	0.4 mg/m2	Always	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes			  	etoposide (TOPOSAR) 50 mg/m2 in sodium chloride (NON-PVC) 0.9 % 500 mL chemo IVPB	Dose: 50 mg/m2	Route: intravenous	once over 22 Hours for 1 dose			Offset: 2.5 Hours	Instructions:	Administer through a 0.22 micron filter and non-PVC tubing set	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION	Medications	50 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % IV SOLP (EXCEL;NON-PVC)	QS Base	500 mL	Yes	Yes				Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: Until discontinued	Occurrences: --	Comments:	Grade 1 - MILD Symptoms (cutaneous and subcutaneous symptoms only - itching, flushing, periorbital edema, rash, or runny nose)
1. Stop the infusion.
2. Place the patient on continuous monitoring.
3. Obtain vital signs.
4. Administer Normal Saline at 50 mL per hour using a new bag and new intravenous tubing.
5. If greater than or equal to 30 minutes since the last dose of Diphenhydramine, administer Diphenhydramine 25 mg intravenous once.
6. If less than 30 minutes since the last dose of Diphenhydramine, administer Cetirizine 10 mg orally and Famotidine 20 mg intravenous once.
7. Notify the treating physician.
8. If no improvement after 15 minutes, advance level of care to Grade 2 (Moderate) or Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 83	Interval: Until discontinued	Occurrences: --	Comments:	Grade 2 - MODERATE Symptoms (cardiovascular, respiratory, or gastrointestinal symptoms - shortness of breath, wheezing, nausea, vomiting, dizziness, diaphoresis, throat or chest tightness, abdominal or back pain)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
6. Administer Normal Saline at 150 mL per hour using a new bag and new intravenous tubing.
7. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous), Cetirizine 10 mg orally and Famotidine 20 mg intravenous once.
8. If no improvement after 15 minutes, advance level of care to Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 4	Interval: Until discontinued	Occurrences: --	Comments:	Grade 3 – SEVERE Symptoms (hypoxia, hypotension, or neurologic compromise – cyanosis or O2 saturation less than 92%, hypotension with systolic blood pressure less than 90 mmHg, confusion, collapse, loss of consciousness, or incontinence)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. If heart rate is less than 50 or greater than 120, or blood pressure is less than 90/50 mmHg, place patient in reclined or flattened position.
6. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
7. Administer Normal Saline at 1000 mL intravenous bolus using a new bag and new intravenous tubing.
8. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous) and Famotidine 20 mg intravenous once.
9. Administer Epinephrine (1:1000) 0.3 mg subcutaneous.
10. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	PRN	Start: S				  	cetirizine (ZyrTEC) tablet 10 mg	Dose: 10 mg	Route: oral	once PRN	Start: S				  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	PRN					  	dexAMETHasone (DECADRON) IV 4 mg	Dose: 4 mg	Route: intravenous	PRN	Start: S				  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					Discharge Nursing Orders
☑	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN					☑	HEParin, porcine (PF) injection 500 Units	Dose: 500 Units	Route: intra-catheter	once PRN	Start: S			Instructions:	Concentration: 100 units/mL. Heparin flush for Implanted Vascular Access Device maintenance.				Days 2,3,4	Perform every 1 day x3		Line Care
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Nursing Orders
  	ONC NURSING COMMUNICATION 6	Interval: Once	Occurrences: --	Comments:	Adverse Events: Continuously every day, every cycle. 
To ensure compliance with these regulations/this guidance, as IND/IDE sponsor, NCI requires that AEs be submitted according to the timeframes in the AE reporting tables assigned to the protocol, using the CTEP Adverse Event Reporting System (CTEP-AERS).
		  	ONC NURSING COMMUNICATION 8	Interval: Once	Occurrences: --	Comments:	Concomitant Medications: continuously every day, every cycle. 
Please refer to section 4.0 page 24-25 for restrictions/
		  	ONC NURSING COMMUNICATION 11	Interval: Once	Occurrences: --	Comments:	May substitute IV methylprednisolone at 80% of oral dose for predniSONE or prednisoLONE if unable to take PO.
			Pre-Medications
  	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 30 minutes before chemo.			Pre-Medications
  	predniSONE (DELTASONE) tablet 100 mg	Dose: 100 mg	Route: oral	once for 1 dose	Start: S			Instructions:	o Administer 30 minutes before chemo. 
o Prednisone is part of anti-lymphoma regimen. Do NOT omit dose. Do NOT give other steroid and hold prednisone.			Chemotherapy
  	DOXOrubicin (ADRIAmycin) 10 mg/m2, vinCRIStine (ONCOVIN) 0.4 mg/m2 in sodium chloride 0.9% 250 mL chemo IVPB	Dose: --	Route: intravenous	once over 22 Hours for 1 dose			Offset: 30 Minutes	Instructions:	VESICANT; Protect from light	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DOXORUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION	Medications	10 mg/m2	Always	Yes	VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION	Medications	0.4 mg/m2	Always	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes			  	etoposide (TOPOSAR) 50 mg/m2 in sodium chloride (NON-PVC) 0.9 % 500 mL chemo IVPB	Dose: 50 mg/m2	Route: intravenous	once over 22 Hours for 1 dose			Offset: 30 Minutes	Instructions:	Administer through a 0.22 micron filter and non-PVC tubing set	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION	Medications	50 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % IV SOLP (EXCEL;NON-PVC)	QS Base	500 mL	Yes	Yes					Day 5	Perform every 1 day x1		Line Care
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Treatment Conditions
  	TREATMENT CONDITIONS	Interval: Until discontinued	Occurrences: --	Comments:	Please refer to Study Protocol for any questions or discrepancies. See Schedule of Events Calendar for sequence of diagnostic tests, examinations, and treatment administration: See Safety Parameters-for Toxicity Management and Dose Modification Guidelines: Protocol Access hyperlink:  ANHL1931_Protocol.pdf
		  	TREATMENT CONDITIONS 3	Interval: Until discontinued	Occurrences: --	Comments:	Dose Modifications and Management for Nivolumab Treatment : Refer to Section 5.0 / 5.1 Management of AEs Associated with Nivolumab
Protocol Access Hyperlink: ANHL1931_Protocol.pdf
		  	TREATMENT CONDITIONS 11	Interval: Until discontinued	Occurrences: --	Comments:	Dose Modifications and Management for  Treatment DA-EPOCH : Refer to Section 5.0 / 5.3 Management of AEs Associated with Etoposide, Doxorrubicin, Cyclophosphamide, Vincristine, Prednisone 
Protocol Access Hyperlink: ANHL1931_Protocol.pdf
		  	TREATMENT CONDITIONS 10	Interval: Until discontinued	Occurrences: --	Comments:	Dose Modifications and Management for Rituximab Treatment : Refer to Section 5.0 / 5.2 Management of AEs Associated with Rituximab
Protocol Access Hyperlink: ANHL1931_Protocol.pdf
			Nursing Orders
  	ONC NURSING COMMUNICATION 6	Interval: Once	Occurrences: --	Comments:	Adverse Events: Continuously every day, every cycle. 
To ensure compliance with these regulations/this guidance, as IND/IDE sponsor, NCI requires that AEs be submitted according to the timeframes in the AE reporting tables assigned to the protocol, using the CTEP Adverse Event Reporting System (CTEP-AERS).
		  	ONC NURSING COMMUNICATION 8	Interval: Once	Occurrences: --	Comments:	Concomitant Medications: continuously every day, every cycle. 
Please refer to section 4.0 page 24-25 for restrictions/
		  	ONC NURSING COMMUNICATION 11	Interval: Once	Occurrences: --	Comments:	May substitute IV methylprednisolone at 80% of oral dose for predniSONE or prednisoLONE if unable to take PO.
			Nursing Orders
  	ONC NURSING COMMUNICATION 16	Interval: Once	Occurrences: --	Comments:	Patient should receive myeloid growth factor support 24-72 hours after completion of the cyclophosphamide infusion.  Please coordinate with OP clinic to schedule patient within the appropriate time window or notify clinical pharmacist if inpatient administration is needed
			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: Once	Occurrences: --			Pre-Medications
  	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 30 minutes before chemo.			Pre-Medications
  	predniSONE (DELTASONE) tablet 100 mg	Dose: 100 mg	Route: oral	once for 1 dose	Start: S			Instructions:	o Administer 30 minutes before chemo. 
o Prednisone is part of anti-lymphoma regimen. Do NOT omit dose. Do NOT give other steroid and hold prednisone.			Chemotherapy
  	cyclophosphamide (CYTOXAN) 750 mg/m2 in sodium chloride 0.9% 250 mL chemo IVPB	Dose: 750 mg/m2	Route: intravenous	once over 60 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	Administer over 30 to 60 minutes immediately AFTER infusions for Etoposide/Doxorubicin/Vincristine are completed.  Usually in 250mL 0.9% NaCl. 
Refer to dose level guidelines Section 4.2.3.1	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION	Medications	750 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	250 mL	No	Yes					Day 6	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Supportive Care
  	pegfilgrastim (NEULASTA) on-body injection kit 6 mg	Dose: 6 mg	Route: subcutaneous	once for 1 dose				Instructions:	Start myeloid growth factor support 24 to 72 hours AFTER completion of the infusion of cyclophosphamide. See 4.2.3 for details.				Days 9,13,17,21	Perform every 4 days x4		Nursing Orders
  	ONC NURSING COMMUNICATION 6	Interval: --	Occurrences: --	Comments:	Adverse Events: Continuously every day, every cycle. 
To ensure compliance with these regulations/this guidance, as IND/IDE sponsor, NCI requires that AEs be submitted according to the timeframes in the AE reporting tables assigned to the protocol, using the CTEP Adverse Event Reporting System (CTEP-AERS).
		  	ONC NURSING COMMUNICATION 8	Interval: --	Occurrences: --	Comments:	Concomitant Medications: continuously every day, every cycle. 
Please refer to section 4.0 page 24-25 for restrictions
			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --					
Cycle 4	Repeat 1 time	Cycle length: 21 days	Day 1	Perform every 1 day x1		Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Line Care
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Treatment Conditions
  	TREATMENT CONDITIONS	Interval: Until discontinued	Occurrences: --	Comments:	Please refer to Study Protocol for any questions or discrepancies. See Schedule of Events Calendar for sequence of diagnostic tests, examinations, and treatment administration: See Safety Parameters-for Toxicity Management and Dose Modification Guidelines: Protocol Access hyperlink:  ANHL1931_Protocol.pdf
		  	TREATMENT CONDITIONS 3	Interval: Until discontinued	Occurrences: --	Comments:	Dose Modifications and Management for Nivolumab Treatment : Refer to Section 5.0 / 5.1 Management of AEs Associated with Nivolumab
Protocol Access Hyperlink: ANHL1931_Protocol.pdf
		  	TREATMENT CONDITIONS 11	Interval: Until discontinued	Occurrences: --	Comments:	Dose Modifications and Management for  Treatment DA-EPOCH : Refer to Section 5.0 / 5.3 Management of AEs Associated with Etoposide, Doxorrubicin, Cyclophosphamide, Vincristine, Prednisone 
Protocol Access Hyperlink: ANHL1931_Protocol.pdf
		  	TREATMENT CONDITIONS 10	Interval: Until discontinued	Occurrences: --	Comments:	Dose Modifications and Management for Rituximab Treatment : Refer to Section 5.0 / 5.2 Management of AEs Associated with Rituximab
Protocol Access Hyperlink: ANHL1931_Protocol.pdf
			Nursing Orders
  	ONC NURSING COMMUNICATION 2	Interval: Once	Occurrences: --	Comments:	Physical exam
		  	VITAL SIGNS - T/P/R/BP	Interval: Once	Occurrences: --		  	MEASURE WEIGHT	Interval: Until discontinued	Occurrences: --	Comments:	If there is a GREATER than 5% change in weight, BSA will be recalculated prior to each cycle.
		  	ONC NURSING COMMUNICATION 6	Interval: Once	Occurrences: --	Comments:	Adverse Events: Continuously every day, every cycle. 
To ensure compliance with these regulations/this guidance, as IND/IDE sponsor, NCI requires that AEs be submitted according to the timeframes in the AE reporting tables assigned to the protocol, using the CTEP Adverse Event Reporting System (CTEP-AERS).
		  	ONC NURSING COMMUNICATION 8	Interval: Once	Occurrences: --	Comments:	Concomitant Medications: continuously every day, every cycle. 
Please refer to section 4.0 page 24-25 for restrictions/
		  	ONC NURSING COMMUNICATION 11	Interval: Once	Occurrences: --	Comments:	If unable to take PO, may substitute IV methylprednisolone at 80% of oral dose for predniSONE or prednisoLONE (prednisone 100 mg= methylprednisolone 80 mg).
			Nursing Orders
  	ONC NURSING COMMUNICATION 12	Interval: Once	Occurrences: --	Comments:	Start Nivolumab PRIOR to prednisone and rituximab.
			Provider Communication
  	ONC PROVIDER COMMUNICATION	Interval: Once	Occurrences: --	Comments:	Verify Ejection Fraction prior to Cycle 1.  Ejection Fraction: ***% on *** (date).

If patient has not had a recent MUGA or ECHO, order one via order entry. A baseline cardiac evaluation with a MUGA scan or an ECHO is recommended, especially in patients with risk factors for increased cardiac toxicity. Repeated MUGA or ECHO determinations of LVEF should be performed, particularly with higher, cumulative anthracycline doses.

			Nursing Orders
  	TRANSTHORACIC ECHOCARDIOGRAM COMPLETE W CONT STRAIN 3D IF NEEDED	Interval: 1 time imaging	Occurrences: --	Comments:	As clinically indicated per institutional guidelines
		  	ECG 12-LEAD	Interval: Once	Occurrences: --	Comments:	As clinically indicated per institutional guidelines
			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: Once	Occurrences: --			Labs
  	THYROID STIMULATING HORMONE	Interval: --	Occurrences: --	Comments:	If TSH is abnormal T3 and FT4 should be evaluated.
			Labs
  	AST (SGOT)	Interval: --	Occurrences: --		  	ALT (SGPT)	Interval: --	Occurrences: --		  	TOTAL BILIRUBIN	Interval: Once	Occurrences: --		  	BILIRUBIN DIRECT	Interval: Once	Occurrences: --			Labs
  	SODIUM LEVEL	Interval: Once	Occurrences: --		  	POTASSIUM LEVEL	Interval: Once	Occurrences: --		  	CHLORIDE LEVEL	Interval: Once	Occurrences: --		  	CALCIUM LEVEL	Interval: Once	Occurrences: --		  	MAGNESIUM LEVEL	Interval: Once	Occurrences: --		  	PHOSPHORUS LEVEL	Interval: Once	Occurrences: --			Labs
  	HCG QUALITATIVE, SERUM SCREEN	Interval: Once	Occurrences: --	Comments:	ONLY for females of child bearing potential
			Treatment Conditions
  	TREATMENT CONDITIONS 13	Interval: Until discontinued	Occurrences: --	Comments:	No count requirement for Cycle 1. Subsequent cycles require ANC GREATER than or EQUAL to 1000/µL and PLTS GREATER than or EQUAL to 100,000/µL. Dosing for doxorubicin, etoposide and cyclophosphamide starts at level #1 as described in Section 4.2.3.1. 
See dose modification instructions as described in Section 5.0. Please note: patients will begin at Cycle 2 if already received one cycle of chemo-immunotherapy (See Section 3.2.5)
			Chemotherapy
  	INV-Nivolumab (ANHL1931/Pro00035735/Pingali) in sodium chloride 0.9% 100 mL IVPB	Dose: --	Route: intravenous	once over 30 Minutes for 1 dose	Start: S			Instructions:	Prepared dose contains active nivolumab in NS. Infuse intravenously over 30 minutes via 0.2 to 1.2 micron low protein binding in line filter. Flush line with NS at the end of infusion. 
HAZARDOUS - Handle with care
Caution: New Drug-Limited by Federal (USA) Law to Investigational use.
	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-NIVOLUMAB 100 MG INTRAVENOUS SOLN (ANHL1931/PRO00035735/PINGALI)	Medications	 	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes				Pre-Medications
  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer 30 minutes before rituximab.		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 30 minutes before rituximab.		  	predniSONE (DELTASONE) tablet 100 mg	Dose: 100 mg	Route: oral	once for 1 dose	Start: S			Instructions:	o Administer 30 minutes prior to the rituximb. 
o Prednisone is part of anti-lymphoma regimen. Do NOT omit dose. Do NOT give other steroid and hold prednisone.			Chemotherapy
◉	riTUXimab-abbs (TRUXIMA) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 30 Minutes	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	RiTUXimab (PF) (RITUXAN) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 30 Minutes	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	rituximab-pvvr (PF) (RUXIENCE) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 30 Minutes	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	rituximab-arrx (RIABNI) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 30 Minutes	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ARRX 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	riTUXimab-abbs (TRUXIMA) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	RiTUXimab (PF) (RITUXAN) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	RAPID INFUSION RATE:  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.

Reaction grades:

Grade 3 Reaction: Prolonged (e.g., not rapidly responsive to symptomatic medication and/or brief interruption of infusion); recurrence of symptoms following initial improvement; hospitalization indicated for clinical sequelae (e.g., renal impairment, pulmonary infiltrates).

Grade 4 Reaction: Life-threatening consequences; urgent intervention indicated (e.g., vasopressors or ventilator support).	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	rituximab-pvvr (PF) (RUXIENCE) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	rituximab-arrx (RIABNI) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ARRX 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes				Rituximab Instructions
  	VITAL SIGNS - T/P/R/BP PER UNIT PROTOCOL	Interval: Once	Occurrences: --	Comments:	1) During Rituximab infusion:
-Vitals every 15 minutes during 1st hour of infusion, THEN
-Every 30 minutes for 1 hour, THEN
-Every hour until end of infusion
-Call MD if SBP less than 90, pulse less than 60 or greater than 120, temperature greater than 38.5 degrees C
		  	ONC NURSING COMMUNICATION 26	Interval: Once	Occurrences: --	Comments:	2) Infuse antibody via pump
3) If any of the following occurs: FEVER (T greater than 38.5 degrees C), RIGORS, HYPOTENSION (30mm Hg decrease from baseline), and / or MUCOSAL CONGESTION / EDEMA, HOLD infusion until improvement of symptoms (When symptoms improve, resume infusion at HALF the previous rate)
			Rituximab Infusion Reaction Orders
  	meperidine (DEMEROL) injection (RESTRICTED) 25 mg	Dose: 25 mg	Route: intravenous	once PRN					  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	once PRN					  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	once PRN	Start: S					Rituximab Additional Orders
  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: intramuscular	once PRN	Start: S					Pre-Medications
  	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose			Offset: 2 Hours	Instructions:	Administer 30 minutes before doxorubicin/vincristine/etoposide.		  	fosaprepitant (EMEND) IVPB 150 mg	Dose: 150 mg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 2 Hours	Instructions:	Administer 30 minutes before doxorubicin/vincristine/etoposide.			Chemotherapy
  	DOXOrubicin (ADRIAmycin) 10 mg/m2, vinCRIStine (ONCOVIN) 0.4 mg/m2 in sodium chloride 0.9% 250 mL chemo IVPB	Dose: --	Route: intravenous	once over 22 Hours for 1 dose			Offset: 2.5 Hours	Instructions:	VESICANT; Protect from light	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DOXORUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION	Medications	10 mg/m2	Always	Yes	VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION	Medications	0.4 mg/m2	Always	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes			  	etoposide (TOPOSAR) 50 mg/m2 in sodium chloride (NON-PVC) 0.9 % 500 mL chemo IVPB	Dose: 50 mg/m2	Route: intravenous	once over 22 Hours for 1 dose			Offset: 2.5 Hours	Instructions:	Administer through a 0.22 micron filter and non-PVC tubing set	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION	Medications	50 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % IV SOLP (EXCEL;NON-PVC)	QS Base	500 mL	Yes	Yes				Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: Until discontinued	Occurrences: --	Comments:	Grade 1 - MILD Symptoms (cutaneous and subcutaneous symptoms only - itching, flushing, periorbital edema, rash, or runny nose)
1. Stop the infusion.
2. Place the patient on continuous monitoring.
3. Obtain vital signs.
4. Administer Normal Saline at 50 mL per hour using a new bag and new intravenous tubing.
5. If greater than or equal to 30 minutes since the last dose of Diphenhydramine, administer Diphenhydramine 25 mg intravenous once.
6. If less than 30 minutes since the last dose of Diphenhydramine, administer Cetirizine 10 mg orally and Famotidine 20 mg intravenous once.
7. Notify the treating physician.
8. If no improvement after 15 minutes, advance level of care to Grade 2 (Moderate) or Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 83	Interval: Until discontinued	Occurrences: --	Comments:	Grade 2 - MODERATE Symptoms (cardiovascular, respiratory, or gastrointestinal symptoms - shortness of breath, wheezing, nausea, vomiting, dizziness, diaphoresis, throat or chest tightness, abdominal or back pain)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
6. Administer Normal Saline at 150 mL per hour using a new bag and new intravenous tubing.
7. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous), Cetirizine 10 mg orally and Famotidine 20 mg intravenous once.
8. If no improvement after 15 minutes, advance level of care to Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 4	Interval: Until discontinued	Occurrences: --	Comments:	Grade 3 – SEVERE Symptoms (hypoxia, hypotension, or neurologic compromise – cyanosis or O2 saturation less than 92%, hypotension with systolic blood pressure less than 90 mmHg, confusion, collapse, loss of consciousness, or incontinence)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. If heart rate is less than 50 or greater than 120, or blood pressure is less than 90/50 mmHg, place patient in reclined or flattened position.
6. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
7. Administer Normal Saline at 1000 mL intravenous bolus using a new bag and new intravenous tubing.
8. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous) and Famotidine 20 mg intravenous once.
9. Administer Epinephrine (1:1000) 0.3 mg subcutaneous.
10. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	PRN	Start: S				  	cetirizine (ZyrTEC) tablet 10 mg	Dose: 10 mg	Route: oral	once PRN	Start: S				  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	PRN					  	dexAMETHasone (DECADRON) IV 4 mg	Dose: 4 mg	Route: intravenous	PRN	Start: S				  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					Discharge Nursing Orders
☑	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN					☑	HEParin, porcine (PF) injection 500 Units	Dose: 500 Units	Route: intra-catheter	once PRN	Start: S			Instructions:	Concentration: 100 units/mL. Heparin flush for Implanted Vascular Access Device maintenance.				Days 2,3,4	Perform every 1 day x3		Line Care
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Nursing Orders
  	ONC NURSING COMMUNICATION 6	Interval: Once	Occurrences: --	Comments:	Adverse Events: Continuously every day, every cycle. 
To ensure compliance with these regulations/this guidance, as IND/IDE sponsor, NCI requires that AEs be submitted according to the timeframes in the AE reporting tables assigned to the protocol, using the CTEP Adverse Event Reporting System (CTEP-AERS).
		  	ONC NURSING COMMUNICATION 8	Interval: Once	Occurrences: --	Comments:	Concomitant Medications: continuously every day, every cycle. 
Please refer to section 4.0 page 24-25 for restrictions/
		  	ONC NURSING COMMUNICATION 11	Interval: Once	Occurrences: --	Comments:	May substitute IV methylprednisolone at 80% of oral dose for predniSONE or prednisoLONE if unable to take PO.
			Pre-Medications
  	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 30 minutes before chemo.			Pre-Medications
  	predniSONE (DELTASONE) tablet 100 mg	Dose: 100 mg	Route: oral	once for 1 dose	Start: S			Instructions:	o Administer 30 minutes before chemo. 
o Prednisone is part of anti-lymphoma regimen. Do NOT omit dose. Do NOT give other steroid and hold prednisone.			Chemotherapy
  	DOXOrubicin (ADRIAmycin) 10 mg/m2, vinCRIStine (ONCOVIN) 0.4 mg/m2 in sodium chloride 0.9% 250 mL chemo IVPB	Dose: --	Route: intravenous	once over 22 Hours for 1 dose			Offset: 30 Minutes	Instructions:	VESICANT; Protect from light	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DOXORUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION	Medications	10 mg/m2	Always	Yes	VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION	Medications	0.4 mg/m2	Always	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes			  	etoposide (TOPOSAR) 50 mg/m2 in sodium chloride (NON-PVC) 0.9 % 500 mL chemo IVPB	Dose: 50 mg/m2	Route: intravenous	once over 22 Hours for 1 dose			Offset: 30 Minutes	Instructions:	Administer through a 0.22 micron filter and non-PVC tubing set	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION	Medications	50 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % IV SOLP (EXCEL;NON-PVC)	QS Base	500 mL	Yes	Yes					Day 5	Perform every 1 day x1		Line Care
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Nursing Orders
  	ONC NURSING COMMUNICATION 6	Interval: Once	Occurrences: --	Comments:	Adverse Events: Continuously every day, every cycle. 
To ensure compliance with these regulations/this guidance, as IND/IDE sponsor, NCI requires that AEs be submitted according to the timeframes in the AE reporting tables assigned to the protocol, using the CTEP Adverse Event Reporting System (CTEP-AERS).
		  	ONC NURSING COMMUNICATION 8	Interval: Once	Occurrences: --	Comments:	Concomitant Medications: continuously every day, every cycle. 
Please refer to section 4.0 page 24-25 for restrictions/
		  	ONC NURSING COMMUNICATION 11	Interval: Once	Occurrences: --	Comments:	May substitute IV methylprednisolone at 80% of oral dose for predniSONE or prednisoLONE if unable to take PO.
			Nursing Orders
  	ONC NURSING COMMUNICATION 16	Interval: Once	Occurrences: --	Comments:	Patient should receive myeloid growth factor support 24-72 hours after completion of the cyclophosphamide infusion.  Please coordinate with OP clinic to schedule patient within the appropriate time window or notify clinical pharmacist if inpatient administration is needed
			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: Once	Occurrences: --			Pre-Medications
  	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 30 minutes before chemo.			Pre-Medications
  	predniSONE (DELTASONE) tablet 100 mg	Dose: 100 mg	Route: oral	once for 1 dose	Start: S			Instructions:	o Administer 30 minutes before chemo. 
o Prednisone is part of anti-lymphoma regimen. Do NOT omit dose. Do NOT give other steroid and hold prednisone.			Chemotherapy
  	cyclophosphamide (CYTOXAN) 750 mg/m2 in sodium chloride 0.9% 250 mL chemo IVPB	Dose: 750 mg/m2	Route: intravenous	once over 60 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	Administer over 30 to 60 minutes immediately AFTER infusions for Etoposide/Doxorubicin/Vincristine are completed.  Usually in 250mL 0.9% NaCl. 
Refer to dose level guidelines Section 4.2.3.1	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION	Medications	750 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	250 mL	No	Yes					Day 6	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Supportive Care
  	pegfilgrastim (NEULASTA) on-body injection kit 6 mg	Dose: 6 mg	Route: subcutaneous	once for 1 dose				Instructions:	Start myeloid growth factor support 24 to 72 hours AFTER completion of the infusion of cyclophosphamide. See 4.2.3 for details.				Days 9,13,17	Perform every 4 days x3		Nursing Orders
  	ONC NURSING COMMUNICATION 6	Interval: --	Occurrences: --	Comments:	Adverse Events: Continuously every day, every cycle. 
To ensure compliance with these regulations/this guidance, as IND/IDE sponsor, NCI requires that AEs be submitted according to the timeframes in the AE reporting tables assigned to the protocol, using the CTEP Adverse Event Reporting System (CTEP-AERS).
		  	ONC NURSING COMMUNICATION 8	Interval: --	Occurrences: --	Comments:	Concomitant Medications: continuously every day, every cycle. 
Please refer to section 4.0 page 24-25 for restrictions
			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --				Day 21	Perform every 1 day x1		Nursing Orders
  	ONC NURSING COMMUNICATION 6	Interval: --	Occurrences: --	Comments:	Adverse Events: Continuously every day, every cycle. 
To ensure compliance with these regulations/this guidance, as IND/IDE sponsor, NCI requires that AEs be submitted according to the timeframes in the AE reporting tables assigned to the protocol, using the CTEP Adverse Event Reporting System (CTEP-AERS).
		  	ONC NURSING COMMUNICATION 8	Interval: --	Occurrences: --	Comments:	Concomitant Medications: continuously every day, every cycle. 
Please refer to section 4.0 page 24-25 for restrictions
			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --			Imaging
  	PET CT WHOLE BODY	Interval: --	Occurrences: --	Comments:	o Optional PET/CT after cycle 2. 
o Optional PET/CT after cycle 4 in patients for whom imaging after cycle 2 demonstrates increase in SUV from baseline without increase in tumor size by CT measurements.
					
Cycle 5	Repeat 1 time	Cycle length: 21 days	Day 1	Perform every 1 day x1		Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Line Care
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Treatment Conditions
  	TREATMENT CONDITIONS	Interval: Until discontinued	Occurrences: --	Comments:	Please refer to Study Protocol for any questions or discrepancies. See Schedule of Events Calendar for sequence of diagnostic tests, examinations, and treatment administration: See Safety Parameters-for Toxicity Management and Dose Modification Guidelines: Protocol Access hyperlink:  ANHL1931_Protocol.pdf
		  	TREATMENT CONDITIONS 3	Interval: Until discontinued	Occurrences: --	Comments:	Dose Modifications and Management for Nivolumab Treatment : Refer to Section 5.0 / 5.1 Management of AEs Associated with Nivolumab
Protocol Access Hyperlink: ANHL1931_Protocol.pdf
		  	TREATMENT CONDITIONS 11	Interval: Until discontinued	Occurrences: --	Comments:	Dose Modifications and Management for  Treatment DA-EPOCH : Refer to Section 5.0 / 5.3 Management of AEs Associated with Etoposide, Doxorrubicin, Cyclophosphamide, Vincristine, Prednisone 
Protocol Access Hyperlink: ANHL1931_Protocol.pdf
		  	TREATMENT CONDITIONS 10	Interval: Until discontinued	Occurrences: --	Comments:	Dose Modifications and Management for Rituximab Treatment : Refer to Section 5.0 / 5.2 Management of AEs Associated with Rituximab
Protocol Access Hyperlink: ANHL1931_Protocol.pdf
			Nursing Orders
  	ONC NURSING COMMUNICATION 2	Interval: Once	Occurrences: --	Comments:	Physical exam
		  	VITAL SIGNS - T/P/R/BP	Interval: Once	Occurrences: --		  	MEASURE WEIGHT	Interval: Until discontinued	Occurrences: --	Comments:	If there is a GREATER than 5% change in weight, BSA will be recalculated prior to each cycle.
		  	ONC NURSING COMMUNICATION 6	Interval: Once	Occurrences: --	Comments:	Adverse Events: Continuously every day, every cycle. 
To ensure compliance with these regulations/this guidance, as IND/IDE sponsor, NCI requires that AEs be submitted according to the timeframes in the AE reporting tables assigned to the protocol, using the CTEP Adverse Event Reporting System (CTEP-AERS).
		  	ONC NURSING COMMUNICATION 8	Interval: Once	Occurrences: --	Comments:	Concomitant Medications: continuously every day, every cycle. 
Please refer to section 4.0 page 24-25 for restrictions/
		  	ONC NURSING COMMUNICATION 11	Interval: Once	Occurrences: --	Comments:	If unable to take PO, may substitute IV methylprednisolone at 80% of oral dose for predniSONE or prednisoLONE (prednisone 100 mg= methylprednisolone 80 mg).
			Nursing Orders
  	ONC NURSING COMMUNICATION 12	Interval: Once	Occurrences: --	Comments:	Start Nivolumab PRIOR to prednisone and rituximab.
			Provider Communication
  	ONC PROVIDER COMMUNICATION	Interval: Once	Occurrences: --	Comments:	Verify Ejection Fraction prior to Cycle 1.  Ejection Fraction: ***% on *** (date).

If patient has not had a recent MUGA or ECHO, order one via order entry. A baseline cardiac evaluation with a MUGA scan or an ECHO is recommended, especially in patients with risk factors for increased cardiac toxicity. Repeated MUGA or ECHO determinations of LVEF should be performed, particularly with higher, cumulative anthracycline doses.

			Nursing Orders
  	TRANSTHORACIC ECHOCARDIOGRAM COMPLETE W CONT STRAIN 3D IF NEEDED	Interval: 1 time imaging	Occurrences: --	Comments:	As clinically indicated per institutional guidelines
		  	ECG 12-LEAD	Interval: Once	Occurrences: --	Comments:	As clinically indicated per institutional guidelines
			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: Once	Occurrences: --			Labs
  	THYROID STIMULATING HORMONE	Interval: Once	Occurrences: --	Comments:	If TSH is abnormal T3 and FT4 should be evaluated.
			Labs
  	AST (SGOT)	Interval: --	Occurrences: --		  	ALT (SGPT)	Interval: --	Occurrences: --		  	TOTAL BILIRUBIN	Interval: Once	Occurrences: --		  	BILIRUBIN DIRECT	Interval: Once	Occurrences: --			Labs
  	SODIUM LEVEL	Interval: Once	Occurrences: --		  	POTASSIUM LEVEL	Interval: Once	Occurrences: --		  	CHLORIDE LEVEL	Interval: Once	Occurrences: --		  	CALCIUM LEVEL	Interval: Once	Occurrences: --		  	MAGNESIUM LEVEL	Interval: Once	Occurrences: --		  	PHOSPHORUS LEVEL	Interval: Once	Occurrences: --			Labs
  	HCG QUALITATIVE, SERUM SCREEN	Interval: Once	Occurrences: --	Comments:	ONLY for females of child bearing potential
			Treatment Conditions
  	TREATMENT CONDITIONS 13	Interval: Until discontinued	Occurrences: --	Comments:	No count requirement for Cycle 1. Subsequent cycles require ANC GREATER than or EQUAL to 1000/µL and PLTS GREATER than or EQUAL to 100,000/µL. Dosing for doxorubicin, etoposide and cyclophosphamide starts at level #1 as described in Section 4.2.3.1. 
See dose modification instructions as described in Section 5.0. Please note: patients will begin at Cycle 2 if already received one cycle of chemo-immunotherapy (See Section 3.2.5)
			Chemotherapy
  	INV-Nivolumab (ANHL1931/Pro00035735/Pingali) in sodium chloride 0.9% 100 mL IVPB	Dose: --	Route: intravenous	once over 30 Minutes for 1 dose	Start: S			Instructions:	Prepared dose contains active nivolumab in NS. Infuse intravenously over 30 minutes via 0.2 to 1.2 micron low protein binding in line filter. Flush line with NS at the end of infusion. 
HAZARDOUS - Handle with care
Caution: New Drug-Limited by Federal (USA) Law to Investigational use.
	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-NIVOLUMAB 100 MG INTRAVENOUS SOLN (ANHL1931/PRO00035735/PINGALI)	Medications	 	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes				Pre-Medications
  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer 30 minutes before rituximab.		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 30 minutes before rituximab.		  	predniSONE (DELTASONE) tablet 100 mg	Dose: 100 mg	Route: oral	once for 1 dose	Start: S			Instructions:	o Administer 30 minutes prior to the rituximb. 
o Prednisone is part of anti-lymphoma regimen. Do NOT omit dose. Do NOT give other steroid and hold prednisone.			Chemotherapy
◉	riTUXimab-abbs (TRUXIMA) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 30 Minutes	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	RiTUXimab (PF) (RITUXAN) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 30 Minutes	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	rituximab-pvvr (PF) (RUXIENCE) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 30 Minutes	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	rituximab-arrx (RIABNI) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 30 Minutes	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ARRX 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	riTUXimab-abbs (TRUXIMA) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	RiTUXimab (PF) (RITUXAN) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	RAPID INFUSION RATE:  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.

Reaction grades:

Grade 3 Reaction: Prolonged (e.g., not rapidly responsive to symptomatic medication and/or brief interruption of infusion); recurrence of symptoms following initial improvement; hospitalization indicated for clinical sequelae (e.g., renal impairment, pulmonary infiltrates).

Grade 4 Reaction: Life-threatening consequences; urgent intervention indicated (e.g., vasopressors or ventilator support).	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	rituximab-pvvr (PF) (RUXIENCE) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	rituximab-arrx (RIABNI) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ARRX 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes				Rituximab Instructions
  	VITAL SIGNS - T/P/R/BP PER UNIT PROTOCOL	Interval: Once	Occurrences: --	Comments:	1) During Rituximab infusion:
-Vitals every 15 minutes during 1st hour of infusion, THEN
-Every 30 minutes for 1 hour, THEN
-Every hour until end of infusion
-Call MD if SBP less than 90, pulse less than 60 or greater than 120, temperature greater than 38.5 degrees C
		  	ONC NURSING COMMUNICATION 26	Interval: Once	Occurrences: --	Comments:	2) Infuse antibody via pump
3) If any of the following occurs: FEVER (T greater than 38.5 degrees C), RIGORS, HYPOTENSION (30mm Hg decrease from baseline), and / or MUCOSAL CONGESTION / EDEMA, HOLD infusion until improvement of symptoms (When symptoms improve, resume infusion at HALF the previous rate)
			Rituximab Infusion Reaction Orders
  	meperidine (DEMEROL) injection (RESTRICTED) 25 mg	Dose: 25 mg	Route: intravenous	once PRN					  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	once PRN					  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	once PRN	Start: S					Rituximab Additional Orders
  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: intramuscular	once PRN	Start: S					Pre-Medications
  	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose			Offset: 2 Hours	Instructions:	Administer 30 minutes before doxorubicin/vincristine/etoposide.		  	fosaprepitant (EMEND) IVPB 150 mg	Dose: 150 mg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 2 Hours	Instructions:	Administer 30 minutes before doxorubicin/vincristine/etoposide.			Chemotherapy
  	DOXOrubicin (ADRIAmycin) 10 mg/m2, vinCRIStine (ONCOVIN) 0.4 mg/m2 in sodium chloride 0.9% 250 mL chemo IVPB	Dose: --	Route: intravenous	once over 22 Hours for 1 dose			Offset: 2.5 Hours	Instructions:	VESICANT; Protect from light	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DOXORUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION	Medications	10 mg/m2	Always	Yes	VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION	Medications	0.4 mg/m2	Always	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes			  	etoposide (TOPOSAR) 50 mg/m2 in sodium chloride (NON-PVC) 0.9 % 500 mL chemo IVPB	Dose: 50 mg/m2	Route: intravenous	once over 22 Hours for 1 dose			Offset: 2.5 Hours	Instructions:	Administer through a 0.22 micron filter and non-PVC tubing set	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION	Medications	50 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % IV SOLP (EXCEL;NON-PVC)	QS Base	500 mL	Yes	Yes				Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: Until discontinued	Occurrences: --	Comments:	Grade 1 - MILD Symptoms (cutaneous and subcutaneous symptoms only - itching, flushing, periorbital edema, rash, or runny nose)
1. Stop the infusion.
2. Place the patient on continuous monitoring.
3. Obtain vital signs.
4. Administer Normal Saline at 50 mL per hour using a new bag and new intravenous tubing.
5. If greater than or equal to 30 minutes since the last dose of Diphenhydramine, administer Diphenhydramine 25 mg intravenous once.
6. If less than 30 minutes since the last dose of Diphenhydramine, administer Cetirizine 10 mg orally and Famotidine 20 mg intravenous once.
7. Notify the treating physician.
8. If no improvement after 15 minutes, advance level of care to Grade 2 (Moderate) or Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 83	Interval: Until discontinued	Occurrences: --	Comments:	Grade 2 - MODERATE Symptoms (cardiovascular, respiratory, or gastrointestinal symptoms - shortness of breath, wheezing, nausea, vomiting, dizziness, diaphoresis, throat or chest tightness, abdominal or back pain)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
6. Administer Normal Saline at 150 mL per hour using a new bag and new intravenous tubing.
7. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous), Cetirizine 10 mg orally and Famotidine 20 mg intravenous once.
8. If no improvement after 15 minutes, advance level of care to Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 4	Interval: Until discontinued	Occurrences: --	Comments:	Grade 3 – SEVERE Symptoms (hypoxia, hypotension, or neurologic compromise – cyanosis or O2 saturation less than 92%, hypotension with systolic blood pressure less than 90 mmHg, confusion, collapse, loss of consciousness, or incontinence)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. If heart rate is less than 50 or greater than 120, or blood pressure is less than 90/50 mmHg, place patient in reclined or flattened position.
6. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
7. Administer Normal Saline at 1000 mL intravenous bolus using a new bag and new intravenous tubing.
8. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous) and Famotidine 20 mg intravenous once.
9. Administer Epinephrine (1:1000) 0.3 mg subcutaneous.
10. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	PRN	Start: S				  	cetirizine (ZyrTEC) tablet 10 mg	Dose: 10 mg	Route: oral	once PRN	Start: S				  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	PRN					  	dexAMETHasone (DECADRON) IV 4 mg	Dose: 4 mg	Route: intravenous	PRN	Start: S				  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					Discharge Nursing Orders
☑	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN					☑	HEParin, porcine (PF) injection 500 Units	Dose: 500 Units	Route: intra-catheter	once PRN	Start: S			Instructions:	Concentration: 100 units/mL. Heparin flush for Implanted Vascular Access Device maintenance.				Days 2,3,4	Perform every 1 day x3		Line Care
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Nursing Orders
  	ONC NURSING COMMUNICATION 6	Interval: Once	Occurrences: --	Comments:	Adverse Events: Continuously every day, every cycle. 
To ensure compliance with these regulations/this guidance, as IND/IDE sponsor, NCI requires that AEs be submitted according to the timeframes in the AE reporting tables assigned to the protocol, using the CTEP Adverse Event Reporting System (CTEP-AERS).
		  	ONC NURSING COMMUNICATION 8	Interval: Once	Occurrences: --	Comments:	Concomitant Medications: continuously every day, every cycle. 
Please refer to section 4.0 page 24-25 for restrictions/
		  	ONC NURSING COMMUNICATION 11	Interval: Once	Occurrences: --	Comments:	May substitute IV methylprednisolone at 80% of oral dose for predniSONE or prednisoLONE if unable to take PO.
			Pre-Medications
  	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 30 minutes before chemo.			Pre-Medications
  	predniSONE (DELTASONE) tablet 100 mg	Dose: 100 mg	Route: oral	once for 1 dose	Start: S			Instructions:	o Administer 30 minutes before chemo. 
o Prednisone is part of anti-lymphoma regimen. Do NOT omit dose. Do NOT give other steroid and hold prednisone.			Chemotherapy
  	DOXOrubicin (ADRIAmycin) 10 mg/m2, vinCRIStine (ONCOVIN) 0.4 mg/m2 in sodium chloride 0.9% 250 mL chemo IVPB	Dose: --	Route: intravenous	once over 22 Hours for 1 dose			Offset: 30 Minutes	Instructions:	VESICANT; Protect from light	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DOXORUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION	Medications	10 mg/m2	Always	Yes	VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION	Medications	0.4 mg/m2	Always	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes			  	etoposide (TOPOSAR) 50 mg/m2 in sodium chloride (NON-PVC) 0.9 % 500 mL chemo IVPB	Dose: 50 mg/m2	Route: intravenous	once over 22 Hours for 1 dose			Offset: 30 Minutes	Instructions:	Administer through a 0.22 micron filter and non-PVC tubing set	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION	Medications	50 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % IV SOLP (EXCEL;NON-PVC)	QS Base	500 mL	Yes	Yes					Day 5	Perform every 1 day x1		Line Care
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Nursing Orders
  	ONC NURSING COMMUNICATION 6	Interval: Once	Occurrences: --	Comments:	Adverse Events: Continuously every day, every cycle. 
To ensure compliance with these regulations/this guidance, as IND/IDE sponsor, NCI requires that AEs be submitted according to the timeframes in the AE reporting tables assigned to the protocol, using the CTEP Adverse Event Reporting System (CTEP-AERS).
		  	ONC NURSING COMMUNICATION 8	Interval: Once	Occurrences: --	Comments:	Concomitant Medications: continuously every day, every cycle. 
Please refer to section 4.0 page 24-25 for restrictions/
		  	ONC NURSING COMMUNICATION 11	Interval: Once	Occurrences: --	Comments:	May substitute IV methylprednisolone at 80% of oral dose for predniSONE or prednisoLONE if unable to take PO.
			Nursing Orders
  	ONC NURSING COMMUNICATION 16	Interval: Once	Occurrences: --	Comments:	Patient should receive myeloid growth factor support 24-72 hours after completion of the cyclophosphamide infusion.  Please coordinate with OP clinic to schedule patient within the appropriate time window or notify clinical pharmacist if inpatient administration is needed
			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: Once	Occurrences: --			Pre-Medications
  	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 30 minutes before chemo.			Pre-Medications
  	predniSONE (DELTASONE) tablet 100 mg	Dose: 100 mg	Route: oral	once for 1 dose	Start: S			Instructions:	o Administer 30 minutes before chemo. 
o Prednisone is part of anti-lymphoma regimen. Do NOT omit dose. Do NOT give other steroid and hold prednisone.			Chemotherapy
  	cyclophosphamide (CYTOXAN) 750 mg/m2 in sodium chloride 0.9% 250 mL chemo IVPB	Dose: 750 mg/m2	Route: intravenous	once over 60 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	Administer over 30 to 60 minutes immediately AFTER infusions for Etoposide/Doxorubicin/Vincristine are completed.  Usually in 250mL 0.9% NaCl. 
Refer to dose level guidelines Section 4.2.3.1	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION	Medications	750 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	250 mL	No	Yes					Day 6	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Supportive Care
  	pegfilgrastim (NEULASTA) on-body injection kit 6 mg	Dose: 6 mg	Route: subcutaneous	once for 1 dose				Instructions:	Start myeloid growth factor support 24 to 72 hours AFTER completion of the infusion of cyclophosphamide. See 4.2.3 for details.				Days 9,13,17,21	Perform every 4 days x4		Nursing Orders
  	ONC NURSING COMMUNICATION 6	Interval: --	Occurrences: --	Comments:	Adverse Events: Continuously every day, every cycle. 
To ensure compliance with these regulations/this guidance, as IND/IDE sponsor, NCI requires that AEs be submitted according to the timeframes in the AE reporting tables assigned to the protocol, using the CTEP Adverse Event Reporting System (CTEP-AERS).
		  	ONC NURSING COMMUNICATION 8	Interval: --	Occurrences: --	Comments:	Concomitant Medications: continuously every day, every cycle. 
Please refer to section 4.0 page 24-25 for restrictions
			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --					
Cycle 6	Repeat 1 time	Cycle length: 21 days	Day 1	Perform every 1 day x1		Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Line Care
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Treatment Conditions
  	TREATMENT CONDITIONS	Interval: Until discontinued	Occurrences: --	Comments:	Please refer to Study Protocol for any questions or discrepancies. See Schedule of Events Calendar for sequence of diagnostic tests, examinations, and treatment administration: See Safety Parameters-for Toxicity Management and Dose Modification Guidelines: Protocol Access hyperlink:  ANHL1931_Protocol.pdf
		  	TREATMENT CONDITIONS 3	Interval: Until discontinued	Occurrences: --	Comments:	Dose Modifications and Management for Nivolumab Treatment : Refer to Section 5.0 / 5.1 Management of AEs Associated with Nivolumab
Protocol Access Hyperlink: ANHL1931_Protocol.pdf
		  	TREATMENT CONDITIONS 11	Interval: Until discontinued	Occurrences: --	Comments:	Dose Modifications and Management for  Treatment DA-EPOCH : Refer to Section 5.0 / 5.3 Management of AEs Associated with Etoposide, Doxorrubicin, Cyclophosphamide, Vincristine, Prednisone 
Protocol Access Hyperlink: ANHL1931_Protocol.pdf
		  	TREATMENT CONDITIONS 10	Interval: Until discontinued	Occurrences: --	Comments:	Dose Modifications and Management for Rituximab Treatment : Refer to Section 5.0 / 5.2 Management of AEs Associated with Rituximab
Protocol Access Hyperlink: ANHL1931_Protocol.pdf
			Nursing Orders
  	ONC NURSING COMMUNICATION 2	Interval: Once	Occurrences: --	Comments:	Physical exam
		  	VITAL SIGNS - T/P/R/BP	Interval: Once	Occurrences: --		  	MEASURE WEIGHT	Interval: Until discontinued	Occurrences: --	Comments:	If there is a GREATER than 5% change in weight, BSA will be recalculated prior to each cycle.
		  	ONC NURSING COMMUNICATION 6	Interval: Once	Occurrences: --	Comments:	Adverse Events: Continuously every day, every cycle. 
To ensure compliance with these regulations/this guidance, as IND/IDE sponsor, NCI requires that AEs be submitted according to the timeframes in the AE reporting tables assigned to the protocol, using the CTEP Adverse Event Reporting System (CTEP-AERS).
		  	ONC NURSING COMMUNICATION 8	Interval: Once	Occurrences: --	Comments:	Concomitant Medications: continuously every day, every cycle. 
Please refer to section 4.0 page 24-25 for restrictions/
		  	ONC NURSING COMMUNICATION 11	Interval: Once	Occurrences: --	Comments:	If unable to take PO, may substitute IV methylprednisolone at 80% of oral dose for predniSONE or prednisoLONE (prednisone 100 mg= methylprednisolone 80 mg).
			Nursing Orders
  	ONC NURSING COMMUNICATION 12	Interval: Once	Occurrences: --	Comments:	Start Nivolumab PRIOR to prednisone and rituximab.
			Provider Communication
  	ONC PROVIDER COMMUNICATION	Interval: Once	Occurrences: --	Comments:	Verify Ejection Fraction prior to Cycle 1.  Ejection Fraction: ***% on *** (date).

If patient has not had a recent MUGA or ECHO, order one via order entry. A baseline cardiac evaluation with a MUGA scan or an ECHO is recommended, especially in patients with risk factors for increased cardiac toxicity. Repeated MUGA or ECHO determinations of LVEF should be performed, particularly with higher, cumulative anthracycline doses.

			Nursing Orders
  	TRANSTHORACIC ECHOCARDIOGRAM COMPLETE W CONT STRAIN 3D IF NEEDED	Interval: 1 time imaging	Occurrences: --	Comments:	As clinically indicated per institutional guidelines
		  	ECG 12-LEAD	Interval: Once	Occurrences: --	Comments:	As clinically indicated per institutional guidelines
			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: Once	Occurrences: --			Labs
  	THYROID STIMULATING HORMONE	Interval: Once	Occurrences: --	Comments:	If TSH is abnormal T3 and FT4 should be evaluated.
			Labs
  	AST (SGOT)	Interval: --	Occurrences: --		  	ALT (SGPT)	Interval: --	Occurrences: --		  	TOTAL BILIRUBIN	Interval: Once	Occurrences: --		  	BILIRUBIN DIRECT	Interval: Once	Occurrences: --			Labs
  	SODIUM LEVEL	Interval: Once	Occurrences: --		  	POTASSIUM LEVEL	Interval: Once	Occurrences: --		  	CHLORIDE LEVEL	Interval: Once	Occurrences: --		  	CALCIUM LEVEL	Interval: Once	Occurrences: --		  	MAGNESIUM LEVEL	Interval: Once	Occurrences: --		  	PHOSPHORUS LEVEL	Interval: Once	Occurrences: --			Labs
  	HCG QUALITATIVE, SERUM SCREEN	Interval: Once	Occurrences: --	Comments:	ONLY for females of child bearing potential
			Treatment Conditions
  	TREATMENT CONDITIONS 13	Interval: Until discontinued	Occurrences: --	Comments:	No count requirement for Cycle 1. Subsequent cycles require ANC GREATER than or EQUAL to 1000/µL and PLTS GREATER than or EQUAL to 100,000/µL. Dosing for doxorubicin, etoposide and cyclophosphamide starts at level #1 as described in Section 4.2.3.1. 
See dose modification instructions as described in Section 5.0. Please note: patients will begin at Cycle 2 if already received one cycle of chemo-immunotherapy (See Section 3.2.5)
			Chemotherapy
  	INV-Nivolumab (ANHL1931/Pro00035735/Pingali) in sodium chloride 0.9% 100 mL IVPB	Dose: --	Route: intravenous	once over 30 Minutes for 1 dose	Start: S			Instructions:	Prepared dose contains active nivolumab in NS. Infuse intravenously over 30 minutes via 0.2 to 1.2 micron low protein binding in line filter. Flush line with NS at the end of infusion. 
HAZARDOUS - Handle with care
Caution: New Drug-Limited by Federal (USA) Law to Investigational use.
	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	INV-NIVOLUMAB 100 MG INTRAVENOUS SOLN (ANHL1931/PRO00035735/PINGALI)	Medications	 	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	100 mL	Yes	Yes				Pre-Medications
  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Administer 30 minutes before rituximab.		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 30 minutes before rituximab.		  	predniSONE (DELTASONE) tablet 100 mg	Dose: 100 mg	Route: oral	once for 1 dose	Start: S			Instructions:	o Administer 30 minutes prior to the rituximb. 
o Prednisone is part of anti-lymphoma regimen. Do NOT omit dose. Do NOT give other steroid and hold prednisone.			Chemotherapy
◉	riTUXimab-abbs (TRUXIMA) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 30 Minutes	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	RiTUXimab (PF) (RITUXAN) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 30 Minutes	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	rituximab-pvvr (PF) (RUXIENCE) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 30 Minutes	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	rituximab-arrx (RIABNI) 375 mg/m2 in sodium chloride 0.9% NON-INITIAL INFUSION IVPB	Dose: 375 mg/m2	Route: intravenous	once for 1 dose			Offset: 30 Minutes	Instructions:	Initiate infusion rate at a 100 mg/hour.  In the absence of infusion toxicity (SBP within 20 mmHG of baseline, PULSE between 60 and 120 and TEMP less than 38 degrees C, and no symptoms), increase rate by 100 mg/hour increments at 30 minute intervals, to a maximum rate of 400 mg/hour.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ARRX 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	 	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	 	No	Yes			◯	riTUXimab-abbs (TRUXIMA) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	RiTUXimab (PF) (RITUXAN) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	RAPID INFUSION RATE:  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.

Reaction grades:

Grade 3 Reaction: Prolonged (e.g., not rapidly responsive to symptomatic medication and/or brief interruption of infusion); recurrence of symptoms following initial improvement; hospitalization indicated for clinical sequelae (e.g., renal impairment, pulmonary infiltrates).

Grade 4 Reaction: Life-threatening consequences; urgent intervention indicated (e.g., vasopressors or ventilator support).	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	rituximab-pvvr (PF) (RUXIENCE) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes			◯	rituximab-arrx (RIABNI) 375 mg/m2 in sodium chloride 0.9% 250 mL RAPID INFUSION RATE IVPB	Dose: 375 mg/m2	Route: intravenous	once over 90 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	Do not shake.  Initiate infusion at a rate of 100mL/hour.  After 30 minutes, in the absence of infusion reactions (SBP within 20 mmHg of baseline, PULSE between 60 and 120 and Temp less than 38 degrees C, and no symptoms), increase the infusion rate to 200mL/hour.  This infusion should take 90 minutes to administer.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	RITUXIMAB-ARRX 10 MG/ML INTRAVENOUS SOLUTION	Medications	375 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	 	No	Yes				Rituximab Instructions
  	VITAL SIGNS - T/P/R/BP PER UNIT PROTOCOL	Interval: Once	Occurrences: --	Comments:	1) During Rituximab infusion:
-Vitals every 15 minutes during 1st hour of infusion, THEN
-Every 30 minutes for 1 hour, THEN
-Every hour until end of infusion
-Call MD if SBP less than 90, pulse less than 60 or greater than 120, temperature greater than 38.5 degrees C
		  	ONC NURSING COMMUNICATION 26	Interval: Once	Occurrences: --	Comments:	2) Infuse antibody via pump
3) If any of the following occurs: FEVER (T greater than 38.5 degrees C), RIGORS, HYPOTENSION (30mm Hg decrease from baseline), and / or MUCOSAL CONGESTION / EDEMA, HOLD infusion until improvement of symptoms (When symptoms improve, resume infusion at HALF the previous rate)
			Rituximab Infusion Reaction Orders
  	meperidine (DEMEROL) injection (RESTRICTED) 25 mg	Dose: 25 mg	Route: intravenous	once PRN					  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	once PRN					  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	once PRN	Start: S					Rituximab Additional Orders
  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: intramuscular	once PRN	Start: S					Pre-Medications
  	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose			Offset: 2 Hours	Instructions:	Administer 30 minutes before doxorubicin/vincristine/etoposide.		  	fosaprepitant (EMEND) IVPB 150 mg	Dose: 150 mg	Route: intravenous	once over 30 Minutes for 1 dose			Offset: 2 Hours	Instructions:	Administer 30 minutes before doxorubicin/vincristine/etoposide.			Chemotherapy
  	DOXOrubicin (ADRIAmycin) 10 mg/m2, vinCRIStine (ONCOVIN) 0.4 mg/m2 in sodium chloride 0.9% 250 mL chemo IVPB	Dose: --	Route: intravenous	once over 22 Hours for 1 dose			Offset: 2.5 Hours	Instructions:	VESICANT; Protect from light	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DOXORUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION	Medications	10 mg/m2	Always	Yes	VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION	Medications	0.4 mg/m2	Always	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes			  	etoposide (TOPOSAR) 50 mg/m2 in sodium chloride (NON-PVC) 0.9 % 500 mL chemo IVPB	Dose: 50 mg/m2	Route: intravenous	once over 22 Hours for 1 dose			Offset: 2.5 Hours	Instructions:	Administer through a 0.22 micron filter and non-PVC tubing set	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION	Medications	50 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % IV SOLP (EXCEL;NON-PVC)	QS Base	500 mL	Yes	Yes				Hematology & Oncology Hypersensitivity Reaction Standing Order
  	ONC NURSING COMMUNICATION 82	Interval: Until discontinued	Occurrences: --	Comments:	Grade 1 - MILD Symptoms (cutaneous and subcutaneous symptoms only - itching, flushing, periorbital edema, rash, or runny nose)
1. Stop the infusion.
2. Place the patient on continuous monitoring.
3. Obtain vital signs.
4. Administer Normal Saline at 50 mL per hour using a new bag and new intravenous tubing.
5. If greater than or equal to 30 minutes since the last dose of Diphenhydramine, administer Diphenhydramine 25 mg intravenous once.
6. If less than 30 minutes since the last dose of Diphenhydramine, administer Cetirizine 10 mg orally and Famotidine 20 mg intravenous once.
7. Notify the treating physician.
8. If no improvement after 15 minutes, advance level of care to Grade 2 (Moderate) or Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 83	Interval: Until discontinued	Occurrences: --	Comments:	Grade 2 - MODERATE Symptoms (cardiovascular, respiratory, or gastrointestinal symptoms - shortness of breath, wheezing, nausea, vomiting, dizziness, diaphoresis, throat or chest tightness, abdominal or back pain)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
6. Administer Normal Saline at 150 mL per hour using a new bag and new intravenous tubing.
7. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous), Cetirizine 10 mg orally and Famotidine 20 mg intravenous once.
8. If no improvement after 15 minutes, advance level of care to Grade 3 (Severe).
9. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	ONC NURSING COMMUNICATION 4	Interval: Until discontinued	Occurrences: --	Comments:	Grade 3 – SEVERE Symptoms (hypoxia, hypotension, or neurologic compromise – cyanosis or O2 saturation less than 92%, hypotension with systolic blood pressure less than 90 mmHg, confusion, collapse, loss of consciousness, or incontinence)
1. Stop the infusion.
2. Notify the CERT team and treating physician immediately.
3. Place the patient on continuous monitoring.
4. Obtain vital signs.
5. If heart rate is less than 50 or greater than 120, or blood pressure is less than 90/50 mmHg, place patient in reclined or flattened position.
6. Administer Oxygen at 2 L per minute via nasal cannula. Titrate to maintain O2 saturation of greater than or equal to 92%.
7. Administer Normal Saline at 1000 mL intravenous bolus using a new bag and new intravenous tubing.
8. Administer Hydrocortisone 100 mg intravenous (if patient has allergy to Hydrocortisone, please administer Dexamethasone 4 mg intravenous) and Famotidine 20 mg intravenous once.
9. Administer Epinephrine (1:1000) 0.3 mg subcutaneous.
10. Assess vital signs every 15 minutes until resolution of symptoms or otherwise ordered by covering physician.
		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	PRN	Start: S				  	cetirizine (ZyrTEC) tablet 10 mg	Dose: 10 mg	Route: oral	once PRN	Start: S				  	famotidine (PEPCID) injection 20 mg	Dose: 20 mg	Route: intravenous	PRN	Start: S				  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	PRN					  	dexAMETHasone (DECADRON) IV 4 mg	Dose: 4 mg	Route: intravenous	PRN	Start: S				  	epINEPHrine (ADRENALIN) 1 mg/1 mL injection 0.3 mg	Dose: 0.3 mg	Route: subcutaneous	PRN	Start: S					Discharge Nursing Orders
☑	sodium chloride 0.9 % flush 20 mL	Dose: 20 mL	Route: intravenous	PRN					☑	HEParin, porcine (PF) injection 500 Units	Dose: 500 Units	Route: intra-catheter	once PRN	Start: S			Instructions:	Concentration: 100 units/mL. Heparin flush for Implanted Vascular Access Device maintenance.				Days 2,3,4	Perform every 1 day x3		Line Care
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Nursing Orders
  	ONC NURSING COMMUNICATION 6	Interval: Once	Occurrences: --	Comments:	Adverse Events: Continuously every day, every cycle. 
To ensure compliance with these regulations/this guidance, as IND/IDE sponsor, NCI requires that AEs be submitted according to the timeframes in the AE reporting tables assigned to the protocol, using the CTEP Adverse Event Reporting System (CTEP-AERS).
		  	ONC NURSING COMMUNICATION 8	Interval: Once	Occurrences: --	Comments:	Concomitant Medications: continuously every day, every cycle. 
Please refer to section 4.0 page 24-25 for restrictions/
		  	ONC NURSING COMMUNICATION 11	Interval: Once	Occurrences: --	Comments:	May substitute IV methylprednisolone at 80% of oral dose for predniSONE or prednisoLONE if unable to take PO.
			Pre-Medications
  	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 30 minutes before chemo.			Pre-Medications
  	predniSONE (DELTASONE) tablet 100 mg	Dose: 100 mg	Route: oral	once for 1 dose	Start: S			Instructions:	o Administer 30 minutes before chemo. 
o Prednisone is part of anti-lymphoma regimen. Do NOT omit dose. Do NOT give other steroid and hold prednisone.			Chemotherapy
  	DOXOrubicin (ADRIAmycin) 10 mg/m2, vinCRIStine (ONCOVIN) 0.4 mg/m2 in sodium chloride 0.9% 250 mL chemo IVPB	Dose: --	Route: intravenous	once over 22 Hours for 1 dose			Offset: 30 Minutes	Instructions:	VESICANT; Protect from light	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DOXORUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION	Medications	10 mg/m2	Always	Yes	VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION	Medications	0.4 mg/m2	Always	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes			  	etoposide (TOPOSAR) 50 mg/m2 in sodium chloride (NON-PVC) 0.9 % 500 mL chemo IVPB	Dose: 50 mg/m2	Route: intravenous	once over 22 Hours for 1 dose			Offset: 30 Minutes	Instructions:	Administer through a 0.22 micron filter and non-PVC tubing set	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION	Medications	50 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % IV SOLP (EXCEL;NON-PVC)	QS Base	500 mL	Yes	Yes					Day 5	Perform every 1 day x1		Line Care
  	sodium chloride 0.9 % infusion 250 mL	Dose: 250 mL	Route: intravenous	once @ 30 mL/hr for 1 dose	Start: S			Instructions:	To keep vein open.			Nursing Orders
  	ONC NURSING COMMUNICATION 6	Interval: Once	Occurrences: --	Comments:	Adverse Events: Continuously every day, every cycle. 
To ensure compliance with these regulations/this guidance, as IND/IDE sponsor, NCI requires that AEs be submitted according to the timeframes in the AE reporting tables assigned to the protocol, using the CTEP Adverse Event Reporting System (CTEP-AERS).
		  	ONC NURSING COMMUNICATION 8	Interval: Once	Occurrences: --	Comments:	Concomitant Medications: continuously every day, every cycle. 
Please refer to section 4.0 page 24-25 for restrictions/
		  	ONC NURSING COMMUNICATION 11	Interval: Once	Occurrences: --	Comments:	May substitute IV methylprednisolone at 80% of oral dose for predniSONE or prednisoLONE if unable to take PO.
			Nursing Orders
  	ONC NURSING COMMUNICATION 16	Interval: Once	Occurrences: --	Comments:	Patient should receive myeloid growth factor support 24-72 hours after completion of the cyclophosphamide infusion.  Please coordinate with OP clinic to schedule patient within the appropriate time window or notify clinical pharmacist if inpatient administration is needed
			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: Once	Occurrences: --			Pre-Medications
  	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Administer 30 minutes before chemo.			Pre-Medications
  	predniSONE (DELTASONE) tablet 100 mg	Dose: 100 mg	Route: oral	once for 1 dose	Start: S			Instructions:	o Administer 30 minutes before chemo. 
o Prednisone is part of anti-lymphoma regimen. Do NOT omit dose. Do NOT give other steroid and hold prednisone.			Chemotherapy
  	cyclophosphamide (CYTOXAN) 750 mg/m2 in sodium chloride 0.9% 250 mL chemo IVPB	Dose: 750 mg/m2	Route: intravenous	once over 60 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	Administer over 30 to 60 minutes immediately AFTER infusions for Etoposide/Doxorubicin/Vincristine are completed.  Usually in 250mL 0.9% NaCl. 
Refer to dose level guidelines Section 4.2.3.1	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION	Medications	750 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	250 mL	No	Yes					Day 6	Perform every 1 day x1		Appointment Requests
  	INFUSION APPOINTMENT REQUEST	Interval: --	Occurrences: --			Supportive Care
  	pegfilgrastim (NEULASTA) on-body injection kit 6 mg	Dose: 6 mg	Route: subcutaneous	once for 1 dose				Instructions:	Start myeloid growth factor support 24 to 72 hours AFTER completion of the infusion of cyclophosphamide. See 4.2.3 for details.				Days 9,13,17	Perform every 4 days x3		Nursing Orders
  	ONC NURSING COMMUNICATION 6	Interval: --	Occurrences: --	Comments:	Adverse Events: Continuously every day, every cycle. 
To ensure compliance with these regulations/this guidance, as IND/IDE sponsor, NCI requires that AEs be submitted according to the timeframes in the AE reporting tables assigned to the protocol, using the CTEP Adverse Event Reporting System (CTEP-AERS).
		  	ONC NURSING COMMUNICATION 8	Interval: --	Occurrences: --	Comments:	Concomitant Medications: continuously every day, every cycle. 
Please refer to section 4.0 page 24-25 for restrictions
			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --					
End of Treatment	Repeat 1 time	Cycle length: 21 days	Day 1	Perform every 1 day x1		Nursing Orders
  	ONC NURSING COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	Physical exam
		  	ONC NURSING COMMUNICATION 15	Interval: --	Occurrences: --	Comments:	History
		  	VITAL SIGNS - T/P/R/BP	Interval: --	Occurrences: --		  	ONC NURSING COMMUNICATION 6	Interval: --	Occurrences: --	Comments:	Adverse Events: Continuously every day, every cycle. 
To ensure compliance with these regulations/this guidance, as IND/IDE sponsor, NCI requires that AEs be submitted according to the timeframes in the AE reporting tables assigned to the protocol, using the CTEP Adverse Event Reporting System (CTEP-AERS).
		  	ONC NURSING COMMUNICATION 8	Interval: --	Occurrences: --	Comments:	Concomitant Medications: continuously every day, every cycle. 
Please refer to section 4.0 page 24-25 for restrictions
			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --			Labs
  	AST (SGOT)	Interval: --	Occurrences: --		  	ALT (SGPT)	Interval: --	Occurrences: --		  	TOTAL BILIRUBIN	Interval: --	Occurrences: --		  	BILIRUBIN DIRECT	Interval: --	Occurrences: --			Labs
  	CREATININE LEVEL	Interval: --	Occurrences: --			Labs
  	SODIUM LEVEL	Interval: --	Occurrences: --		  	POTASSIUM LEVEL	Interval: --	Occurrences: --		  	CHLORIDE LEVEL	Interval: --	Occurrences: --		  	CALCIUM LEVEL	Interval: --	Occurrences: --		  	MAGNESIUM LEVEL	Interval: --	Occurrences: --		  	PHOSPHORUS LEVEL	Interval: --	Occurrences: --			Research Labs
  	RESEARCH STUDY SPECIMEN	Interval: --	Occurrences: --		  	RESEARCH STUDY SPECIMEN	Interval: --	Occurrences: --		  	RESEARCH STUDY SPECIMEN	Interval: --	Occurrences: --			Imaging
  	PET CT WHOLE BODY	Interval: --	Occurrences: --	Comments:	Required after cycle 6.
			Procedures
  	BIOPSY BONE MARROW	Interval: --	Occurrences: --	Comments:	o Unilateral bone marrow biopsy and aspirate.   
o If involved at diagnosis. Optional, not required.
					
Follow Up	Repeat 1 time	Cycle length: 21 days	Day 1	Perform every 1 day x1		Nursing Orders
  	ONC NURSING COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	Physical exam
		  	ONC NURSING COMMUNICATION 15	Interval: --	Occurrences: --	Comments:	History
		  	VITAL SIGNS - T/P/R/BP	Interval: --	Occurrences: --			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --			Labs
  	AST (SGOT)	Interval: --	Occurrences: --		  	ALT (SGPT)	Interval: --	Occurrences: --		  	TOTAL BILIRUBIN	Interval: --	Occurrences: --		  	BILIRUBIN DIRECT	Interval: --	Occurrences: --			Labs
  	CREATININE LEVEL	Interval: --	Occurrences: --			Labs
  	SODIUM LEVEL	Interval: --	Occurrences: --		  	POTASSIUM LEVEL	Interval: --	Occurrences: --		  	CHLORIDE LEVEL	Interval: --	Occurrences: --		  	CALCIUM LEVEL	Interval: --	Occurrences: --		  	MAGNESIUM LEVEL	Interval: --	Occurrences: --		  	PHOSPHORUS LEVEL	Interval: --	Occurrences: --			Imaging
  	CT CHEST W CONTRAST ABDOMEN W CONTRAST PELVIS W CONTRAST	Interval: --	Occurrences: --	Comments:	After cycle 2 if PET/CT not performed. Every 6 months until 2 years off therapy (6 mo, 12mo, 18mo, 2 yrs). After 2 years, only if clinically indicated
					
Relapse/Progression	Repeat 1 time	Cycle length: 21 days	Day 1	Perform every 1 day x1		Nursing Orders
  	ONC NURSING COMMUNICATION 2	Interval: --	Occurrences: --	Comments:	Physical exam
		  	ONC NURSING COMMUNICATION 15	Interval: --	Occurrences: --	Comments:	History
		  	VITAL SIGNS - T/P/R/BP	Interval: --	Occurrences: --			Research Labs
  	RESEARCH STUDY SPECIMEN	Interval: --	Occurrences: --			Labs
  	CBC WITH PLATELET AND DIFFERENTIAL	Interval: --	Occurrences: --			Labs
  	AST (SGOT)	Interval: --	Occurrences: --		  	ALT (SGPT)	Interval: --	Occurrences: --		  	TOTAL BILIRUBIN	Interval: --	Occurrences: --		  	BILIRUBIN DIRECT	Interval: --	Occurrences: --			Labs
  	CREATININE LEVEL	Interval: --	Occurrences: --			Labs
  	SODIUM LEVEL	Interval: --	Occurrences: --		  	POTASSIUM LEVEL	Interval: --	Occurrences: --		  	CHLORIDE LEVEL	Interval: --	Occurrences: --		  	CALCIUM LEVEL	Interval: --	Occurrences: --		  	MAGNESIUM LEVEL	Interval: --	Occurrences: --		  	PHOSPHORUS LEVEL	Interval: --	Occurrences: --			Imaging
  	PET CT WHOLE BODY	Interval: --	Occurrences: --