Referal Form ⸻ Rituxan Name: Date: Diagnosis/Code: ► Please check the box corresponding to the weight used for dose calculation. BSA: Height: Weight: DuBois Call for weight change greater than 10% from baseline Mosteller No dose modifications required for any weight change ► Laboratory or Other Tests Related to Chemotherapy: CBC prior to treatment Other ► Dosing Guidelines/ Parameters: Provider must select one option below Hold and call provider for ANC less than or equal to 1500; Platelets less than or equal to 100,000 Hold and call provider for ANC Less than or equal to: Platelets less than or equal to Hydration Orders: Not Required No antiemetic needed" "Minimal emetogenic potential DRUG DOSE ROUTE RATE FREQUENCY, DAYS TO BE GIVEN Acetaminophen (Tylenol) 650 mg PO _____ 30 minutes pre treatment 1000 mg Diphenhydramine (Benadryl) 25 mg PO _____ 30 minutes pre treatment 50 mg IVP ► Treatment Orders: DRUG: DOSE CALCULATION DOSE SOLUTION AND VOLUME ROUTEU RATE DAYS TO BE GIVEN 1st Dose Rituximab (Rituxan) 375 mg/m2 Mix as a 1:1 mixture IVPB Initiate at 50mg/hr x 30 min Increase rate by 50mg q30 min to a max rate of 400mg/hr Infuse the remainder at 400mg/hr 1st dose only 500 mg/ m 2nd dose and beyond Rituximab (Rituxan) 375 mg/m2 Mix as a 1:1 mixture IVPB Initiate at 100mg/hr x 30 min Increase rate by 100mg q30 min to a max rate of 400mg/hr Infuse the remainder at 400mg/hr Weekly x 4 Every 28 days 500 mg/ m Every 2 months 2nd dose and beyond Rituximab (Rituxan) 375 mg/m2 Mix as a 1:1 mixture IVPB Rapid Rituxan Infuse 20% of dose over 30 minutes with rest infusing over 1 hour Every 3 weeks 500 mg/ m Date of first treatment: Date taken: /subsequent treatments may be given +/- 5 days for greater than weekly This order is good for 1 year from the date ordered ► Call referring provider for: Phone: Fax: Email: ► PROVIDER SIGNATURE: Date: Please prove you are human by selecting the plane.
