UBLITUXIMAB-XIIY (BRIUMVI) INFUSION		version 6/30/2026		

Appointment Requests 	

	
	Interval	Defer Until	Duration	
	☐	Referral to IV Infusion Room	Every 2 weeks	S	2 treatments	
		Status: Future, Expected: S, Expires: S+365, Clinic Performed
	Urgency of Scheduling: Routine		
	☐	Referral to IV Infusion Room	Every 24 weeks	S	 treatments	
		Status: Future, Expected: S, Expires: S+365, Clinic Performed
	Urgency of Scheduling: Routine		
	☑	Nursing communication	Every visit	S	Until discont'd	
		Please continue to schedule subsequent infusion appointments manually as appropriate.		

Treatment Conditions 	

	
	Interval	Defer Until	Duration	
	☑	Treatment conditions	Every visit	S	 treatments	
		o Active HBV infection -> hold therapy and notify provider 
	o Monitor for signs and symptoms of any active infection -> hold and notify until infection resolves.		

Nursing Orders 	

	
	Interval	Defer Until	Duration	
	☑	Insert Peripheral IV or Access Portacath	Every visit	S	 treatments	
		No details available for preview		
	☑	Vital signs - T/P/R/BP	Every visit	S	 treatments	
		Clinic Performed, Normal		
	☑	sodium chloride 0.9% flush 10 mL	Every visit	S	 treatments	
		10 mL, intravenous, PRN, line care, Starting when released, for 10 doses		
	☑	sodium chloride 0.9 % infusion (PERFUSION)	Every visit	S	 treatments	
		250 mL, intravenous, at 30 mL/hr, PRN, Flush bag., Starting when released, Until Discontinued		
	☑	Nursing communication	Every visit	S	 treatments	
		Please confirm serum immunoglobulin levels prior to starting treatment. If levels are low, notify the provider.		
	☑	Nursing communication	Every visit	S	 treatments	
		Use 0.9% sodium chloride ONLY.		
	☑	Nursing communication	Every visit	S	 treatments	
		Monitor patient closely during and for at least 1 hour after the completion of the first 2 infusions. Subsequent post-infusion monitoring will be at physician discretion unless infusion reaction has been observed.		
	☑	Discontinue IV	Every visit	S	 treatments	
		Normal		

Labs 	

	
	Interval	Defer Until	Duration	
	☑	CBC with Platelet and Differential	Every visit	S	 treatments	
		STAT, Status: Future, Expected: S, Expires: S+365, Clinic Collect		
	☑	Comprehensive metabolic panel	Every visit	S	 treatments	
		STAT, Status: Future, Expected: S, Expires: S+365, Clinic Collect		
	☑	Immunoglobulin G	Every visit	S	 treatments	
		STAT, Normal, Clinic Collect		
	☑	Immunoglobulin M	Every visit	S	 treatments	
		STAT, Normal, Clinic Collect		
	☑	Immunoglobulin A	Every visit	S	 treatments	
		STAT, Normal, Clinic Collect		
	☑	hCG qualitative, urine screen	Every visit	S	 treatments	
		STAT, Status: Future, Expected: S, Expires: S+365, Clinic Collect		
	☑	Hepatitis B virus (HBV) screening and diagnosis				
		Status: Future, Expected: S, Expires: S+365		

Pre-Medications 	

	
	Interval	Defer Until	Duration	
	☐	acetaminophen (TYLENOL) tablet 650 mg	Once	S	1 treatment	
		650 mg, oral, once, Starting when released
	Give 30 minutes PRIOR to infusion.
	Maximum of 4 grams of acetaminophen per day from all sources. (Cirrhosis patients maximum: 2 grams per day from all sources).		
	☐	diphenhydrAMINE (BENADRYL) tablet 25 mg	Once	S	1 treatment	
		25 mg, oral, once, Starting when released
	Give 30 minutes PRIOR to infusion.		
	☐	methylPREDNISolone sodium succinate (Solu-MEDROL) injection 100 mg	Once	S	1 treatment	
		100 mg, intravenous, once, Starting when released
	Give 30 minutes PRIOR to infusion.		

Medications 	

	
	Interval	Defer Until	Duration	
	☑	ublituximab-xiiy (BRIUMVI) 150 mg in sodium chloride 0.9% 250 mL IVPB (RESTRICTED)	Once	S	1 treatment	
		150 mg, intravenous, Administer over: 4 Hours, once, Starting when released
	Day 1
	·       Start at 10 mL per hour for the first 30 minutes 
	·       Increase to 20 mL per hour for the next 30 minutes 
	·       Increase to 35 mL per hour for the next hour 
	·       Increase to 100 mL per hour for the remaining 2 hours 
	
	For IV infusion only. Do NOT administer as IV push or bolus. Do not tube/shake. Do not infuse concomitantly with other agents.		
	☐	ublituximab-xiiy (BRIUMVI) 450 mg in sodium chloride 0.9% 250 mL IVPB (RESTRICTED)	Once	S+14	1 treatment	
		450 mg, intravenous, Administer over: 1 Hours, once, Starting S+14
	Dose 2 and subsequent infusions (450 mg): initiate infusion at 100 mL/hr for 30 minutes. If tolerated, increase to 400 mL/hr for the remainder of the infusion. Infusion duration: 1 hour. Monitor for infusion reactions during infusion and observe for at least 1 hour after completion of first 2 infusions
	For IV infusion only. Do NOT administer as IV push or bolus. Do not tube/shake. Do not infuse concomitantly with other agents.		
	☐	ublituximab-xiiy (BRIUMVI) 450 mg in sodium chloride 0.9% 250 mL IVPB (RESTRICTED)	Every 24 weeks	S+169	 treatments	
		450 mg, intravenous, Administer over: 1 Hours, once, Starting S+169
	Dose 2 and subsequent infusions (450 mg): initiate infusion at 100 mL/hr for 30 minutes. If tolerated, increase to 400 mL/hr for the remainder of the infusion. Infusion duration: 1 hour. Monitor for infusion reactions during infusion and observe for at least 1 hour after completion of first 2 infusions
	For IV infusion only. Do NOT administer as IV push or bolus. Do not tube/shake. Do not infuse concomitantly with other agents.		

Emergency Medications 	

	
	Interval	Defer Until	Duration	
	☐	diphenhydrAMINE (BENADRYL) injection 25 mg	PRN	S	 treatments	
		25 mg, intravenous, once, Starting when released		
	☐	cetirizine (ZyrTEC) tablet 10 mg	PRN	S	 treatments	
		10 mg, oral, once, Starting when released		
	☐	famotidine (PEPCID) 20 mg in sodium chloride 0.9% 10 mL injection	PRN	S	 treatments	
		20 mg, intravenous, once, Starting when released
	Dilute with 8 mL of 0.9% sodium chloride injection. Administer IV push over at least 2 minutes. Use only assigned diluent for reconstitution. Do NOT use saline flush for reconstitution or dilution.  		
	☐	hydrocortisone sodium succinate (Solu-CORTEF) injection 100 mg	PRN	S	 treatments	
		100 mg, intravenous, once, Starting when released
	Once PRN, for infusion reaction		
	☐	dexAMETHasone (DECADRON) injection 4 mg	PRN	S	 treatments	
		4 mg, intravenous, once, Starting when released		
	☐	EPINEPHrine (ADRENALIN) injection 1 mg/mL	PRN	S	 treatments	
		0.3 mg, subcutaneous, once, Starting when released		
	☐	sodium chloride 0.9 % infusion	PRN	S	 treatments	
		1,000 mL, intravenous, continuous, Starting when released, Until Discontinued
	For allergic reaction.