Download Physician`s Orders for Rituxan Infusion

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