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Physician’s Orders for Rituxan Infusion WG& MPA Rituxan order form For health care professionals for patients with Wegener’s granulomatosis (WG) or microscopic polyangiitis (MPA) INDICATION: Rituxan® (rituximab), in combination with glucocorticoids, is indicated for the treatment of adult patients with Wegener’s granulomatosis (WG) and microscopic polyangiitis (MPA). Rituxan is not recommended for treatment of patients with severe active infections. Physician’s NAME Phone Fax E-mail Patient Information Premedication Patient’s name Diphenhydramine (Dose Route ) Date of birth Acetaminophen (Dose Route ) Wegener’s granulomatosis (WG) icroscopic polyangiitis (MPA) M Diagnosis Other (Dose Route ) Allergies Other relevant history Rituxan dosing Calculate the patient’s body surface area (BSA) using weight and height. Weight kg Height cm Refer to the Rituxan for WG and MPA Dosing Calculator to determine the BSA-calculated Rituxan dose. Patient’s BSA = Note: The formula for calculating BSA in the clinical trials was: BSA in m 2 = (weight in kg) 0.425 x (height in cm) 0.725 x 0.007184 Rituxan dose and infusion frequency Total Rituxan dose (mg) = Ordered Rituxan dose (mg/m)2 x patient’s BSA* Ordered Rituxan dose = mg/m2 Infusion frequency = Total Rituxan dose (mg) x Ordered Rituxan dose (mg/m)2 patient’s BSA PRN orders in the event of infusion reactions Physician’s PRN orders Medication (Dose Route ) Medication (Dose Route ) Additional instructions from the physician Ordering Physician Signature Ordering Physician Name (Print) Date CONTINUED ON REVERSE SIDE. IMPORTANT SAFETY INFORMATION: Rituxan has been associated with fatal infusion reactions, tumor lysis syndrome (TLS), severe mucocutaneous reactions, and progressive multifocal leukoencephalopathy (PML). Other serious, potentially fatal adverse reactions include hepatitis B reactivation, other infections including bacterial, fungal, new or reactivated viral infections, and cardiovascular events. Common adverse reactions include infections, nausea, diarrhea, headache, muscle spasms, anemia, and peripheral edema. For additional safety information, please see the full prescribing information, including BOXED WARNINGS and Medication Guide. WG& MPA Information About Infusion Reactions Review Medication Guide with patient prior to each infusion. If severe infusion reaction occurs After the infusion Instruct patients and family members or attendants about symptoms to watch for and what actions to take in the event of post-infusion symptoms such as1: Make sure to follow your office’s or institution’s protocol for identifying and managing infusion reactions. Interrupt the infusion Hives or rash Weakness Itching Dizziness or feeling faint Swelling of the lips, Palpitations tongue, throat, or face Sudden cough Chest pain Shortness of breath, difficulty breathing, or wheezing Medications and supportive care measures should be available and instituted as medically indicated for use in the event of a reaction during administration. These may include, but are not limited to: IV fluids Glucocorticoids Antihistamines Acetaminophen Epinephrine Bronchodilators Oxygen Instruct patients and family members or attendants to seek immediate medical attention if they notice any of the above symptoms most cases, the infusion can be resumed at 50% In of the previous rate (eg, 100 mg/h to 50 mg/h) when symptoms have completely resolved1 Limited data are available on the safety and efficacy of subsequent courses of Rituxan in patients with WG and MPA. In the active-controlled, double-blind study, subsequent courses of Rituxan were allowed for patients experiencing a relapse of disease. The safety and efficacy of retreatment with Rituxan have not been established. Common Adverse Events In a clinical trial, the most common adverse events occurring in >10% of Rituxan-treated patients (n=99) and >5% more frequently than in the cyclophosphamide group (n=98) were infections (62% vs 47%), peripheral edema (16% vs 6%), and hypertension (12% vs 5%). Fax-back infusion confirmation Administration date Administration time Notes Infusion Nurse Signature Infusion Nurse Name (Print) Date Phone Fax E-mail Reference: 1. Rituxan [package insert]. South San Francisco, CA: Biogen Idec Inc and Genentech USA, Inc; April 2011. For additional safety information, please see the full prescribing information, including BOXED WARNINGS and Medication Guide. © 2011 Genentech USA, Inc., So. San Francisco, CA and Biogen Idec Inc., Cambridge, MA RRA0000416300