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IP COHORT B: FLU / CY / TBI + INVESTIGATIONAL BMT CTN 2203	

Types:      Research Oncology Treatment
Synonyms:  FLU, CY, TBI

Transplant	Repeat 1 time	Cycle length: 90 days	Day -6 through -1	Perform every 1 day x1			Research tolerance: -0/+0 days	Provider Communication
  	ONC PROVIDER COMMUNICATION	Interval: Once	Occurrences: --	Comments:	It is recommended that adjusted ideal body weight be used when calculating conditioning regimen chemotherapy doses (AIBW = IBW + [(0.25) x (ABW* - IBW)])
			Provider Communication
  	ONC PROVIDER COMMUNICATION 64	Interval: Once	Occurrences: --	Comments:	Verify Hep B panel status prior to cycle. Date *** of panel. Result positive/negative/pending/unknown:22867

The required components for the hepatitis B panel includes: Hepatitis B surface antigen (HBsAg), total hepatitis B core antibody (anti-HBc), and hepatitis B antibody (anti-HBs).
			Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Pre-Medications
  	fosaprepitant (EMEND) IVPB 150 mg	Dose: 150 mg	Route: intravenous	once over 60 Minutes for 1 dose			Offset: 2 Hours	Instructions:	Administer 60 minutes prior to treatment on Day -6.		  	ondansetron (ZOFRAN) 16 mg, dexAMETHasone (DECADRON) 12 mg in sodium chloride 0.9% 50 mL IVPB	Dose: 16 mg	Route: intravenous	every 24 hours over 30 Minutes for 2 doses			Offset: 2.5 Hours	Instructions:	Administer 30 minutes prior to treatment on Days -6, -5.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION	Medications	16 mg	Main Ingredient	Yes	DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION	Medications	12 mg	Yes	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	40.8 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	50 mL	No	Yes			  	ondansetron (ZOFRAN) tablet 16 mg	Dose: 16 mg	Route: oral	every 24 hours for 3 doses	Start: S+2  8:00 AM			Instructions:	Days  -4, -3, -2
		  	ondansetron (ZOFRAN) tablet 8 mg	Dose: 8 mg	Route: oral	every 8 hours for 6 doses	Start: S+5  8:00 AM			Instructions:	Day -1 (TBI)			Supportive Care
  	valACYclovir (VALTREX) tablet 500 mg	Dose: 500 mg	Route: oral	daily	Start: S				  	levoFLOXacin (LEVAQUIN) tablet 500 mg	Dose: 500 mg	Route: oral	daily at 0600 (TIME CRITICAL) for 56 doses	Start: S				  	micafungin (MYCAMINE) 100 mg in sodium chloride 0.9% 100 mL IVPB	Dose: 100 mg	Route: intravenous	every 24 hours over 1 Hours for 12 doses	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	MICAFUNGIN 100 MG INTRAVENOUS SOLUTION (RESTRICTED)	Medications	100 mg	Main Ingredient	No	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	100 mL	Yes	Yes			  	ursodiol (ACTIGALL) capsule 300 mg	Dose: 300 mg	Route: oral	3 times daily	Start: S					Antiemetics
  	prochlorperazine edisylate injection 5 mg	Dose: 5 mg	Route: intravenous	every 4 hours PRN	Start: S					Hydration
  	sodium chloride 0.9 % infusion	Dose: 125 mL	Route: intravenous	daily @ 125 mL/hr	Start: S			Instructions:	Max total volume infusion rate during chemotherapy = 350 mL/hr.
·	Start 4 hours before cyclophosphamide infusion
·	Once complete, contact provider to enter a new order with standard fluid rate, if indicated. 
Continue for 24 hours after cyclophosphamide completion

			Chemotherapy
  	fludarabine (FLUDARA) 60 mg in sodium chloride 0.9% 100 mL chemo IVPB	Dose: 60 mg	Route: intravenous	every 24 hours over 30 Minutes for 5 doses			Offset: 3 Hours	Instructions:	Day -6, -5, -4, -3, -2.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	FLUDARABINE 50 MG/2 ML INTRAVENOUS SOLUTION	Medications	60 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	97.6 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	100 mL	No	Yes			  	mesna (MESNEX) 500 mg in sodium chloride 0.9% 100 mL chemo IVPB	Dose: 500 mg	Route: intravenous	every 24 hours over 30 Minutes for 2 doses			Offset: 3.5 Hours	Instructions:	Give immediately prior to first cyclophosphamide infusion.  Administer on Day -6, -5.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	MESNA 100 MG/ML INTRAVENOUS SOLUTION THERAPY PLAN	Medications	500 mg	Main Ingredient	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	95 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	100 mL	No	Yes			  	cycloPHOSphamide (CYTOXAN) 1,450 mg, mesna (MESNEX) 1,450 mg in dextrose 5% 500 mL chemo IVPB	Dose: 14.5 mg/kg	Route: intravenous	every 24 hours over 2 Hours for 2 doses			Offset: 4 Hours	Instructions:	Day -6, -5.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	CYCLOPHOSPHAMIDE 1 GRAM/50 ML INTRAVENOUS POWDER FOR SOLUTION (RECONSTITUTED VIAL)	Medications	1,450 mg	Yes	Yes	MESNA 100 MG/ML INTRAVENOUS SOLUTION	Medications	1,450 mg	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	413 mL	Yes	Yes				Nursing Orders
  	ONC NURSING COMMUNICATION 27	Interval: Until discontinued	Occurrences: --	Comments:	***  Notify TMH Radiation Oncology (713-441-4800) of patient's admission and obtain time of TBI.
			Nursing Orders
  	ONC NURSING COMMUNICATION	Interval: Until discontinued	Occurrences: --	Comments:	Ruxolitinib will be dispensed from IDS pharmacy via a paper order.
			Acute Graft Versus Host Prophylaxis
  	ONC NURSING COMMUNICATION 83	Interval: Until discontinued	Occurrences: --	Comments:	If patient is CMV positive and will be on posaconazole, then the dose of tacrolimus should be reduced to 0.015 mg/kg.
		  	tacrolimus (PROGRAF) 0.02 mg/kg in sodium chloride (NON-PVC) 0.9 % 250 mL continuous infusion	Dose: 0.02 mg/kg	Route: intravenous	every 24 hours over 24 Hours	Start: S+3  4:00 PM			Instructions:	Start Day -3. May cause QTc prolongation.  Use the lesser of IBW or actual body weight (ABW). 	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION	Medications	0.02 mg/kg	Main Ingredient	No	SODIUM CHLORIDE 0.9 % IV SOLP (EXCEL;NON-PVC)	Base	250 mL	Yes	Yes	DEXTROSE 5 % IN WATER (D5W) IV SOLP (EXCEL; NON-PVC)	Base	250 mL	No	Yes				Hypersensitivity
  	morPHINE injection 2 mg	Dose: 2 mg	Route: intravenous	every 30 min PRN for 2 doses	Start: S			Instructions:	- Give morphine 2 mg IV X 1 PRN drug-induced rigors. If no relief in 30 minutes, may give another dose of morphine 2 mg IV X 1 PRN for drug-induced rigors.			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						Day 0	Perform every 1 day x1			Research tolerance: -0/+0 days	Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Antiemetics
  	ondansetron (ZOFRAN) IV 16 mg	Dose: 16 mg	Route: intravenous	once for 1 dose	Start: S					Pre-Medications
  	acetaminophen (TYLENOL) tablet 650 mg	Dose: 650 mg	Route: oral	once for 1 dose	Start: S			Instructions:	Premed for TRANSPLANT		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once for 1 dose	Start: S			Instructions:	Premed for TRANSPLANT		  	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	Dose: 100 mg	Route: intravenous	once for 1 dose				Instructions:	Premed for TRANSPLANT			Transplant Orders
  	ONC NURSING COMMUNICATION 55	Interval: Once	Occurrences: --	Comments:	-  Oxygen at bedside during transplantation.
-  Anaphylaxis precautions at bedside during transplant.
		  	morPHINE (PF) 2 mg/mL injection 2 mg	Dose: 2 mg	Route: intravenous	every 30 min PRN for 2 doses	Start: S			Instructions:	Maximum MME/Day: 12 MME/day for this order
- Give morphine 2 mg IV X 1 PRN drug-induced rigors If no relief in 30 minutes, may give another dose of morphine 2 mg IV X 1 PRN for drug-induced rigors.  If both oral and IV options are ordered for same pain level, administer IV if patient not able to take oral medications.

		  	EPINEPHrine (ADRENALIN) injection 1 mg/mL	Dose: 0.3 mg	Route: subcutaneous	once PRN	Start: S			Instructions:	Ending 2 days after order is released		  	diphenhydrAMINE (BENADRYL) injection 25 mg	Dose: 25 mg	Route: intravenous	once PRN	Start: S			Instructions:	Ending 2 days after order is released.		  	hydrocortisone sodium succinate (Solu-CORTEF) 100 mg in sodium chloride 0.9% 50 mL IVPB	Dose: 100 mg	Route: intravenous	once PRN over 30 Minutes	Start: S			Ingredients:	Name	Type	Dose	Selected	Adds Vol.	HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION	Medications	100 mg	Main Ingredient	No	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	Base	50 mL	No	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	Base	50 mL	Yes	Yes					Days 1 through 8, Transplant	Perform every 1 day x1			Research tolerance: -0/+0 days	Line Care
  	sodium chloride 0.9% flush 20 mL	Dose: 20 mL	Route: intravenous	PRN	Start: S					Pre-Medications
  	ondansetron ODT (ZOFRAN-ODT) disintegrating tablet 8 mg	Dose: 8 mg	Route: oral	every 8 hours scheduled	Start: S			Instructions:	Premed for TRANSPLANT; start day +1			Acute Graft Versus Host Prophylaxis
  	methotrexate Preservative Free 5 mg/m2 in sodium chloride 0.9% 50 mL chemo IVPB	Dose: 5 mg/m2	Route: intravenous	once over 15 Minutes for 1 dose	Start: S			Instructions:	HOLD UNTIL APPROVED BY CAGT. 

Day +1.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION	Medications	5 mg/m2	Main Ingredient	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	50 mL	No	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	50 mL	Yes	Yes			  	methotrexate Preservative Free 5 mg/m2 in sodium chloride 0.9% 50 mL chemo IVPB	Dose: 5 mg/m2	Route: intravenous	once over 15 Minutes for 1 dose	Start: S+2 11:00 AM			Instructions:	HOLD UNTIL APPROVED BY CAGT. 

Day +3.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION	Medications	5 mg/m2	Main Ingredient	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	50 mL	No	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	50 mL	Yes	Yes			  	methotrexate Preservative Free 5 mg/m2 in sodium chloride 0.9% 50 mL chemo IVPB	Dose: 5 mg/m2	Route: intravenous	once over 15 Minutes for 1 dose	Start: S+5 11:00 AM			Instructions:	HOLD UNTIL APPROVED BY CAGT. 

Day +6.	Ingredients:	Name	Type	Dose	Selected	Adds Vol.	METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION	Medications	5 mg/m2	Main Ingredient	Yes	DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION	QS Base	50 mL	No	Yes	SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION	QS Base	50 mL	Yes	Yes				Medications
  	tbo-filgrastim (GRANIX) injection syringe 480 mcg	Dose: 480 mcg	Route: subcutaneous	daily at 1600	Start: S+6  4:00 PM			Instructions:	Do not administer tbo-filgrastim within 24 hours before chemotherapy. 
Start on D+7			Supportive Care
  	posaconazole (NOXAFIL) tablet (RESTRICTED) 300 mg	Dose: 300 mg	Route: oral	daily	Start: S+4			Instructions:	Start on day +5