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IP DEANGELIS - METHOTREXATE / VINCRISTINE / LEUCOVORIN / PROCARBAZINE (CYCLES 1,3,5)	

Types:      ONCOLOGY TREATMENT
Synonyms:  PRIMARY, CENTRAL, CNS, LYMPH, MTX, ONCOV, METHOT, VINCR, PROCARB, DEANGELIS, DEAN

Cycle 1	Repeat 1 time	Cycle length: 14 days	Day 1	Perform every 1 day x1		Labs
☑	COMPREHENSIVE METABOLIC PANEL	Interval: Once	Occurrences: --		☑	CBC WITH PLATELET AND DIFFERENTIAL	Interval: Once	Occurrences: --		☑	MAGNESIUM LEVEL	Interval: Once	Occurrences: --		☑	LDH	Interval: Once	Occurrences: --		☑	URIC ACID LEVEL	Interval: Once	Occurrences: --		☑	PHOSPHORUS LEVEL	Interval: Once	Occurrences: --			Labs
☑	METHOTREXATE LEVEL	Interval: Once	Occurrences: --		☑	PH, URINALYSIS	Interval: Conditional Frequency	Occurrences: --	Comments:	Draw prior to starting Methotrexate and PRN until pH GREATER than 7.  Then draw urine pH every day until MTX is LESS than 0.05
			Provider Communication
  	ONC PROVIDER COMMUNICATION 64	Interval: Once	Occurrences: --	Comments:	Verify Hep B panel status prior to cycle. Date *** of panel. Result positive/negative/pending/unknown:22867

The required components for the hepatitis B panel includes: Hepatitis B surface antigen (HBsAg), total hepatitis B core antibody (anti-HBc), and hepatitis B antibody (anti-HBs).
			Provider Communication
  	ONC PROVIDER COMMUNICATION 5	Interval: Once	Occurrences: --	Comments:	Use baseline weight to calculate dose. Adjust dose for weight gains/losses of greater than or equal to 10%.
			Provider Communication
  	ONC PROVIDER COMMUNICATION 12	Interval: Until discontinued	Occurrences: --	Comments:	Careful monitoring of pulmonary function tests should be performed prior to initiation of therapy and periodically during therapy for patients on methotrexate, lomustine, carmustine, aldesleukin, nilutamide, or bleomycin. If patient has not had baseline pulmonary function tests and/or does not have scheduled pulmonary function tests for future doses, place order via order entry.
			Provider Communication
  	ONC PROVIDER COMMUNICATION 13	Interval: Until discontinued	Occurrences: --	Comments:	Chest x-rays should be performed prior to initiation of therapy and periodically during therapy for patients on methotrexate, aldesleukin, nilutamide, or bleomycin. If patient has not had baseline chest x-ray and/or does not have scheduled chest x-rays for future doses, place order via order entry.
			Provider Communication
  	ONC PROVIDER COMMUNICATION 14	Interval: Until discontinued	Occurrences: --	Comments:	No salicylates, NSAIDS or sulfa drugs concurrent or a week before treatment starts.
			Nursing Orders
  	ONC NURSING COMMUNICATION 75	Interval: Until discontinued	Occurrences: --	Comments:	Please verify that patient has not taken any salicylates, NSAIDS or sulfa drugs concurrent or a week before treatment starts.
			Nursing Orders
  	ONC NURSING COMMUNICATION 64	Interval: Until discontinued	Occurrences: --	Comments:	Draw methotrexate level for 24 hours, 48 hours and 72 hours AFTER COMPLETION of methotrexate infusion and send STAT. Obtain level every 24 hours until methotrexate level is LESS than 0.05.

Check STAT urine pH prior to starting Methotrexate and then every 8 hours. If urine pH is LESS than 7, administer 50 mEq sodium bicarbonate and recheck in 1 hour. If still LESS than 7, repeat 50 mEq sodium bicarbonate and recheck in 1 hour. If still LESS than 7, call provider.

The syringe that the blood is sent to lab in needs to be COVERED (brown bag/paper towel) going to the lab.
			Nursing Orders
  	TREATMENT CONDITIONS 7	Interval: Until discontinued	Occurrences: --	Comments:	HOLD and notify provider if 
o ANC LESS than 1000; 
o Platelets LESS than 100,000.
			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.			Pre-Medications
☑	ondansetron (ZOFRAN) 16 mg, dexamethasone (DECADRON) 12 mg in sodium chloride 0.9% 50 mL IVPB	Dose: 16 mg	Route: intravenous	once over 10 Minutes for 1 dose	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION	Medications	16 mg	Main Ingredient	No	DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION	Medications	12 mg	Yes	No	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	50 mL	No	Yes			☐	ondansetron (ZOFRAN) tablet 16 mg	Dose: 16 mg	Route: oral	once for 1 dose	Start: S	End: S 11:30 AM			☐	dexamethasone (DECADRON) tablet 12 mg	Dose: 12 mg	Route: oral	once for 1 dose	Start: S				☐	fosaprepitant (EMEND) IVPB 150 mg	Dose: 150 mg	Route: intravenous	once over 30 Minutes for 1 dose	Start: S					Pre-Hydration
  	sodium bicarbonate 150 mEq in dextrose 5% 1,000 mL infusion	Dose: 150 mL/hr	Route: intravenous	continuous	Start: S			Instructions:	Run until methotrexate level is LESS than 0.05 micromol/L.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	850 mL	Yes	Yes	DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	LACTATED RINGERS INTRAVENOUS SOLUTION	QS Base	1,000 mL	No	Yes	MVI, ADULT WITH VIT K 3,300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION WRAPPER	Additives	10 mL	No	Yes	POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	20 mEq	No	Yes	THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION	Additives	100 mg	No	Yes	FOLIC ACID 5 MG/ML INJECTION SOLUTION	Additives	1 mg	No	Yes	MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION	Additives	 	No	Yes	CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION	Additives	 	No	Yes	ASCORBIC ACID (VITAMIN C) 500 MG/ML INTRAVENOUS SOLUTION	Additives	500 mg	No	Yes	POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION	Additives	150 mEq	Yes	Yes	SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	ZINC SULFATE 1 MG/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes	CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION	Additives	 	No	Yes	SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION	Additives	 	No	Yes				Chemotherapy
  	procarbazine (MATULANE) chemo capsule 100 mg/m2 (Treatment Plan)	Dose: 100 mg/m2	Route: oral	daily for 7 doses			Offset: 30 Minutes	Instructions:	CYTOTOXIC AGENT/DO NOT OPEN OR CRUSH. Swallow whole. Diet Alteration Required:  Avoid tyramine containing foods during and up to four weeks after MAOI therapy is discontinued.			Chemotherapy
  	vinCRIStine (ONCOVIN) 1.4 mg/m2 in sodium chloride 0.9 % 50 mL chemo IVPB	Dose: 1.4 mg/m2	Route: intravenous	once over 10 Minutes for 1 dose			Offset: 30 Minutes	Instructions:	DRUG IS A VESICANT.  FATAL IF GIVEN INTRATHECALLY.  Maximum dose = 2.8 mg.	Rule-Based Template: RULE ONCBCN VINCRISTINE 1.4 MG/M2	  Conditions:	  Modifications:	  BSA < 1.43 m2	  Set dose to 1.4 mg/m2	  BSA >= 1.43 m2	  Set dose to 2.8 mg	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION	Medications	1.4 mg/m2	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	50 mL	Yes	Yes				Chemotherapy
  	methotrexate PF 2,500 mg/m2 in sodium chloride 0.9 % 500 mL chemo IVPB	Dose: 2,500 mg/m2	Route: intravenous	once over 3 Hours for 1 dose			Offset: 60 Minutes	Instructions:	START methotrexate only after urine pH GREATER than 7.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION	Medications	2,500 mg/m2	Main Ingredient	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	500 mL	No	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	500 mL	Yes	Yes				Supportive Care
  	sodium bicarbonate 1 mEq/mL (8.4 %) injection 50 mEq	Dose: 50 mEq	Route: intravenous	every 8 hours PRN	Start: S			Instructions:	Check urine pH prior to start of methotrexate and then every shift. 
  
If urine pH is LESS than 7, administer 50 mEq sodium bicarbonate and recheck in 1 hour.
If still LESS than 7, repeat 50 mEq sodium bicarbonate and recheck in 1 hour.
If still LESS than 7, call Physician.

Continue until methotrexate levels are LESS than 0.05 or patient is discharged.			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.				Day 2	Perform every 1 day x1		Chemotherapy
  	procarbazine (MATULANE) chemo capsule 100 mg/m2 (Treatment Plan)	Dose: 100 mg/m2	Route: oral	daily for 7 doses			Offset: 30 Minutes	Instructions:	CYTOTOXIC AGENT/DO NOT OPEN OR CRUSH. Swallow whole. Diet Alteration Required:  Avoid tyramine containing foods during and up to four weeks after MAOI therapy is discontinued.			Chemotherapy
  	leucovorin IV 50 mg	Dose: 50 mg	Route: intravenous	every 6 hours over 30 Minutes	Start: S			Instructions:	Give 24 hours AFTER COMPLETION of methotrexate infusion.

Continue every 6 hours until levels are LESS than 0.05 micromol/L.				Day 8	Perform every 1 day x1		Intrathecal Injections
  	methotrexate PF 12 mg in sodium chloride 0.9% 6 mL chemo PF INTRATHECAL injection	Dose: 12 mg	Route: intrathecal	once over 5 Minutes for 1 dose	Start: S	End: S		Instructions:	Preservative free for intrathecal use.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION	Medications	12 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INJECTION SOLUTION	QS Base	5.52 mL	Yes	Yes				Chemotherapy
  	leucovorin tablet 10 mg	Dose: 10 mg	Route: oral	2 times daily for 4 doses	Start: S  9:00 PM			Instructions:	Begin the evening of intrathecal methotrexate administration on Day 8 and continue through Day 11.