Canterbury Regional Cancer and Blood Service (Haematology) Page 1 of 12

Authorised by: Dr P Ganly Pharmacists: C Innes / B Harden August 2012 Reviewed: Apr 2016 Nov 2019

CHEMOTHERAPY MEDICATION CHART C260070

UKALL 14

Intensification / CNS prophylaxis

Height cm

Weight kg

BSA m2 Infusion rate 125 X BSA = mL/hr

Cycle length: 28 days Day 1 Limits Day 1 Limits Allergies/hypersensitivities

Antiemetics

Domperidone 10mg PO QID

± Cyclizine 50mg PO/IV TDS

Agent

Methotrexate (low dose)

Methotrexate (high dose)

Peg-Asparaginase

Folinic acid

DOSE MODIFIED: NO YES

Round

5mg

100mg

75 units (IU)

oral 7.5mg, IV 5mg

Date Date

Destination: BMTU Neuts > 0.75 X 109/L Bili 50 umol/L

Plts > 75 X 109/L AST 180 U/L

CrCl see below

Reference: UKALL14 – Protocol – v5.0 – 20/07/12

Day Date Time Agent Dose Route Instructions Rate Doctor Nurse Check Start Stop

Continuous Imatinib (Philadelphia +ve patients only) mg PO

Continuous for patients with Philadelphia positive disease. Continuous daily Imatinib, PO, aiming to escalate to 600mg, if tolerated. This should be continued until transplant wherever possible.

-1 2200 Ural Sachet® 1 PO Dissolved in 20 mL water

2200 1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125 mL/m2/hr mL/hr

1 1000 mL glucose 4 % & sodium chloride 0.18 %

+ 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125 mL/m2/hr mL/hr

1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125 mL/m2/hr mL/hr

T= -1 hr Ondansetron 8 mg PO Give 1 hour prior to chemotherapy

T= -1 hr Dexamethasone 8 mg PO Give 1 hour prior to chemotherapy

T= 0 hrs Methotrexate 300 mg/m2 mg IV In 250 mL sodium chloride

0.9 % over 1 hour 250mL/hr

T= +1 hr

Methotrexate 2700 mg/m2 mg IV In 1000 mL sodium chloride 0.9 % over 23 hours

46 mL/hr

(rate incl 50mL flush)

▪ Measure serum creatinine and calculate CrCl one week prior to methotrexate infusion. If CrCl < 80 mL/min, adjust methotrexate dose as per protocol (appendix 15) ▪ IV fluids run concurrently with chemotherapy. Check fluid balance at least 4 hourly, consider frusemide if urine output falls below 400 mL/m2 in any 4 hour period, or 1kg weight increase ▪ Urine pH must be > 7.5 before starting methotrexate - adjust sodium bicarbonate to keep pH between 7 and 8 during infusion and subsequent folinic acid rescue ▪ Stop proton pump inhibitors (omeprazole/pantoprazole/lansoprazole) the day prior to methotrexate infusion, restart once methotrexate has cleared ▪ It is recommended prophylactic trimethoprim/sulphamethoxazole (co-trimoxazole) be stopped one week before methotrexate therapy, until maintenance therapy starts ▪ Acetazolamide 250mg PO QID, starting the night before methotrexate, and continued until methotrexate cleared, can alkalinise the urine and enhance methotrexate excretion–chart on MedChart.

Canterbury Regional Cancer and Blood Service (Haematology) Page 2 of 12

Authorised by: Dr P Ganly Pharmacists: C Innes / B Harden August 2012 Reviewed: Apr 2016 Nov 2019

CHEMOTHERAPY MEDICATION CHART C260070

UKALL 14

Intensification / CNS prophylaxis

Height cm

Weight kg

BSA m2 Infusion rate 125 X BSA = mL/hr

Day Date Time Agent Dose Route Instructions Rate Doctor Nurse Check Start Stop

1 1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125 mL/m2/hr mL/hr

1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125 mL/m2/hr mL/hr

T= +12 hrs Ondansetron 8 mg PO/IV

1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125 mL/m2/hr mL/hr

1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125 mL/m2/hr mL/hr

2 1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125 mL/m2/hr mL/hr

1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125 mL/m2/hr mL/hr

Ondansetron 8 mg PO

Dexamethasone 8 mg PO

T= +24 hrs Stop Methotrexate infusion Record the amount infused

# Peg-Asparaginase 1000 units/m2 units IV In 100 mL sodium chloride 0.9 % over at least 1 hour

▪ Continue folinic acid and high dose fluids for at least 48 hours, and continue as per UKALL 14 protocol depending on methotrexate levels (appendix 15) ▪ Check Antithrombin III and Fibrinogen every 2 days while receiving Peg-Asparaginase

Canterbury Regional Cancer and Blood Service (Haematology) Page 3 of 12

Authorised by: Dr P Ganly Pharmacists: C Innes / B Harden August 2012 Reviewed: Apr 2016 Nov 2019

CHEMOTHERAPY MEDICATION CHART C260070

UKALL 14

Intensification / CNS prophylaxis

Height cm

Weight kg

BSA m2 Infusion rate 125 X BSA = mL/hr

Day Date Time Agent Dose Route Instructions Rate Doctor Nurse Check Start Stop

2

1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125mL/m2/hr mL/hr

1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125mL/m2/hr mL/hr

1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125mL/m2/hr mL/hr

T= +36 hrs Folinic acid 30 mg PO Give IV bolus if PO not tolerated T= +39 hrs Folinic acid 30 mg PO Give IV bolus if PO not tolerated

1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125mL/m2/hr ml/hr

T= +42 hrs Folinic acid 30 mg PO Give IV bolus if PO not tolerated 1000 mL glucose 4 % & sodium chloride 0.18 %

+ 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125mL/m2/hr ml/hr

T= +45 hrs Folinic acid 30 mg PO Give IV bolus if PO not tolerated ▪ Continue folinic acid and high dose fluids for at least 48 hours, and continue as per UKALL 14 protocol depending on methotrexate levels (appendix 15)

Canterbury Regional Cancer and Blood Service (Haematology) Page 4 of 12

Authorised by: Dr P Ganly Pharmacists: C Innes / B Harden August 2012 Reviewed: Apr 2016 Nov 2019

CHEMOTHERAPY MEDICATION CHART C260070

UKALL 14

Intensification / CNS prophylaxis

Height cm

Weight kg

BSA m2 Infusion rate 125 X BSA = mL/hr

Day Date Time Agent Dose Route Instructions Rate Doctor Nurse Check Start Stop

3 1000 mL glucose 4 % & sodium chloride 0.18 %

+ 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125mL/m2/hr ml/hr

Dexamethasone 8 mg PO

T= +48 hrs Folinic acid 30 mg PO Give IV bolus if PO not tolerated T= +48 hrs Methotrexate level Continue folinic acid until methotrexate level < 0.1 umol/L. Notify lab if levels required over the weekend.

1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125mL/m2/hr ml/hr

T= +51 hrs Folinic acid 30 mg PO Give IV bolus if PO not tolerated

1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125mL/m2/hr ml/hr

1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125mL/m2/hr ml/hr

Folinic acid ____ mg/m2

(frequency and dose depends on 48 hour methotrexate level) mg PO Give IV bolus if PO not tolerated

1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125mL/m2/hr ml/hr

1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125mL/m2/hr ml/hr

▪ Continue folinic acid and high dose fluids for at least 48 hours, and continue as per UKALL 14 protocol depending on methotrexate levels (appendix 15)

Canterbury Regional Cancer and Blood Service (Haematology) Page 5 of 12

Authorised by: Dr P Ganly Pharmacists: C Innes / B Harden August 2012 Reviewed: Apr 2016 Nov 2019

CHEMOTHERAPY MEDICATION CHART C260070

UKALL 14

Intensification / CNS prophylaxis

Height cm

Weight kg

BSA m2 Infusion rate 125 X BSA = mL/hr

Day Date Time Agent Dose Route Instructions Rate Doctor Nurse Check Start Stop

4 Folinic acid ____ mg/m2 mg PO Give IV bolus if PO not tolerated

1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125mL/m2/hr ml/hr

1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125mL/m2/hr ml/hr

T= +72 hrs Methotrexate level Continue folinic acid until methotrexate level < 0.1 umol/L. Notify lab if levels required over the weekend.

Folinic acid ____ mg/m2

(dose depends on 48 hour methotrexate level) mg PO Give IV bolus if PO not tolerated

1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125mL/m2/hr ml/hr

Folinic acid ____ mg/m2

(frequency and dose depends on 72 hour methotrexate level) mg PO Give IV bolus if PO not tolerated

1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125mL/m2/hr ml/hr

1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125mL/m2/hr ml/hr

Folinic acid ____ mg/m2 mg PO Give IV bolus if PO not tolerated

1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125mL/m2/hr ml/hr

▪ Continue folinic acid and high dose fluids for at least 48 hours, and continue as per UKALL 14 protocol depending on methotrexate levels (appendix 15)

Canterbury Regional Cancer and Blood Service (Haematology) Page 6 of 12

Authorised by: Dr P Ganly Pharmacists: C Innes / B Harden August 2012 Reviewed: Apr 2016 Nov 2019

CHEMOTHERAPY MEDICATION CHART C260070

UKALL 14

Intensification / CNS prophylaxis

Height cm

Weight kg

BSA m2

Infusion rate 125 X BSA = mL/hr

Day Date Time Agent Dose Route Instructions Rate Doctor Nurse Check Start Stop

5 1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125mL/m2/hr ml/hr

1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125mL/m2/hr ml/hr

Folinic acid ____ mg/m2 mg PO Give IV bolus if PO not tolerated

1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125mL/m2/hr ml/hr

T= +96 hrs Methotrexate level Continue folinic acid until methotrexate level < 0.1 umol/L. Notify lab if levels required over the weekend

Folinic acid ____ mg/m2

(dose depends on 72 hour methotrexate level) mg PO Give IV bolus if PO not tolerated

1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125mL/m2/hr ml/hr

▪ Continue folinic acid and high dose fluids for at least 48 hours, and continue as per UKALL 14 protocol depending on methotrexate levels (appendix 15) ▪ If further folinic acid required, prescribe on regular medication chart

Consultant: NZMC Reg. No:

Canterbury Regional Cancer and Blood Service (Haematology) Page 7 of 12

Authorised by: Dr P Ganly Pharmacists: C Innes / B Harden August 2012 Reviewed: Apr 2016 Nov 2019

CHEMOTHERAPY MEDICATION CHART C260070

UKALL 14

Intensification / CNS prophylaxis

Height cm

Weight kg

BSA m2 Infusion rate 125 X BSA = ml/hr

Destination: BMTU Day 15 Limits Day 15 Limits Allergies/hypersensitivities

Antiemetics

Domperidone 10mg PO QID

± Cyclizine 50mg PO/IV TDS

Agent

Methotrexate (low dose)

Methotrexate (high dose)

Peg-Asparaginase

Folinic acid

DOSE MODIFIED: NO YES

Round

5mg

100mg

75 units (IU)

oral 7.5mg, IV 5mg

Date Date

Neuts > 0.75 X 109/L Bili 50 umol/L

Plts > 75 X 109/L AST 180 U/L

CrCl see below

Reference: UKALL14 – Protocol – v5.0 – 20/07/12

NB. Above limits must be met before commencing day 15 chemotherapy

Day Date Time Agent Dose Route Instructions Rate Doctor Nurse Check Start Stop

Continuous Imatinib (Philadelphia +ve patients only) mg PO

Continuous for patients with Philadelphia positive disease. Continuous daily Imatinib, PO, aiming to escalate to 600mg, if tolerated. This should be continued until transplant whenever possible. Prescribe on regular medication chart.

14 2200 Ural Sachet® 1 PO Dissolved in 20 mL water

2200 1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125 mL/m2/hr mL/hr

15 1000 mL glucose 4 % & sodium chloride 0.18 %

+ 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125 mL/m2/hr mL/hr

1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125 mL/m2/hr mL/hr

T= -1 hr Ondansetron 8 mg PO Give 1 hour prior to chemotherapy

T= -1 hr Dexamethasone 8 mg PO Give 1 hour prior to chemotherapy

T= 0 hrs Methotrexate 300 mg/m2 mg IV

In 250 mL sodium chloride 0.9 % over 1 hour 250mL/hr

T= +1 hr

Methotrexate 2700 mg/m2 mg IV

In 1000 mL sodium chloride 0.9 % over 23 hours

46 mL/hr

(rate incl 50mL flush)

See prescribing notes over page

Canterbury Regional Cancer and Blood Service (Haematology) Page 8 of 12

Authorised by: Dr P Ganly Pharmacists: C Innes / B Harden August 2012 Reviewed: Apr 2016 Nov 2019

CHEMOTHERAPY MEDICATION CHART C260070

UKALL 14

Intensification / CNS prophylaxis

Height cm

Weight kg

BSA m2 Infusion rate 125 X BSA = ml/hr

▪ Patients with CrCl between 80-100 mL/min before the first dose of methotrexate MUST have a measured creatinine clearance (24 hour urine collection) BEFORE the second dose. If CrCl < 80

mL/min, adjust methotrexate dose as per protocol (appendix 15) ▪ IV fluids run concurrently with chemotherapy. Check fluid balance at least 4 hourly, consider frusemide if urine output falls below 400 mL/m2 in any 4 hour period, or 1kg weight increase ▪ Urine pH must be > 7.5 before starting methotrexate - adjust sodium bicarbonate to keep pH between 7 and 8 during infusion and subsequent folinic acid rescue ▪ Stop proton pump inhibitors (omeprazole/pantoprazole/lansoprazole) the day prior to methotrexate infusion, restart once methotrexate has cleared ▪ It is recommended prophylactic trimethoprim/sulphamethoxazole (co-trimoxazole) be stopped one week before methotrexate therapy, until maintenance therapy starts

▪ Acetazolamide 250mg PO QID, starting the night before methotrexate, and continued until methotrexate cleared, can alkalinise the urine and enhance methotrexate excretion–chart on MedChart.

Day Date Time Agent Dose Route Instructions Rate Doctor Nurse Check Start Stop

15 1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125 mL/m2/hr mL/hr

1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125 mL/m2/hr mL/hr

T= +12 hrs Ondansetron 8 mg PO/IV

1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125 mL/m2/hr mL/hr

1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125 mL/m2/hr mL/hr

16 1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125 mL/m2/hr mL/hr

1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125 mL/m2/hr mL/hr

▪ Continue folinic acid and high dose fluids for at least 48 hours, and continue as per UKALL 14 protocol depending on methotrexate levels (appendix 15)

Canterbury Regional Cancer and Blood Service (Haematology) Page 9 of 12

Authorised by: Dr P Ganly Pharmacists: C Innes / B Harden August 2012 Reviewed: Apr 2016 Nov 2019

CHEMOTHERAPY MEDICATION CHART C260070

UKALL 14

Intensification / CNS prophylaxis

Height cm

Weight kg

BSA m2 Infusion rate 125 X BSA = ml/hr

16 Ondansetron 8 mg PO

Dexamethasone 8 mg PO T= +24 hrs Stop Methotrexate infusion Record the amount infused

# Peg-Asparaginase 1000 units/m2 units IV

In 100 mL sodium chloride 0.9 % over at least 1 hour

1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125 mL/m2/hr mL/hr

1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125 mL/m2/hr mL/hr

1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125 mL/m2/hr mL/hr

T= +36 hrs Folinic acid 30 mg PO Give IV bolus if PO not tolerated T= +39 hrs Folinic acid 30 mg PO Give IV bolus if PO not tolerated

1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125mL/m2/hr mL/hr

T= +42 hrs Folinic acid 30 mg PO Give IV bolus if PO not tolerated 1000 mL glucose 4 % & sodium chloride 0.18 %

+ 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125mL/m2/hr mL/hr

T= +45 hrs Folinic acid 30 mg PO Give IV bolus if PO not tolerated ▪ Continue folinic acid and high dose fluids for at least 48 hours, and continue as per UKALL 14 protocol depending on methotrexate levels (appendix 15) ▪ Check Antithrombin III and Fibrinogen every 2 days while receiving Peg-Asparaginase

Canterbury Regional Cancer and Blood Service (Haematology) Page 10 of 12

Authorised by: Dr P Ganly Pharmacists: C Innes / B Harden August 2012 Reviewed: Apr 2016 Nov 2019

CHEMOTHERAPY MEDICATION CHART C260070

UKALL 14

Intensification / CNS prophylaxis

Height cm

Weight kg

BSA m2 Infusion rate 125 X BSA = ml/hr

Day Date Time Agent Dose Route Instructions Rate Doctor Nurse Check Start Stop

17 1000 mL glucose 4 % & sodium chloride 0.18 %

+ 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125mL/m2/hr mL/hr

Dexamethasone 8 mg PO

T =+48 hrs Folinic acid 30 mg PO Give IV bolus if PO not tolerated T= +48 hrs Methotrexate level Continue folinic acid until methotrexate level < 0.1 umol/L. Notify lab if levels required over the weekend.

1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125mL/m2/hr mL/hr

T= +51 hrs

Folinic acid 30 mg PO Give IV bolus if PO not tolerated

1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125mL/m2/hr mL/hr

1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125mL/m2/hr mL/hr

Folinic acid ____ mg/m2

(frequency and dose depends on 48 hour methotrexate level) mg PO Give IV bolus if PO not tolerated

1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125mL/m2/hr mL/hr

1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125mL/m2/hr mL/hr

▪ Continue folinic acid and high dose fluids for at least 48 hours, and continue as per UKALL 14 protocol depending on methotrexate levels (appendix 15)

Canterbury Regional Cancer and Blood Service (Haematology) Page 11 of 12

Authorised by: Dr P Ganly Pharmacists: C Innes / B Harden August 2012 Reviewed: Apr 2016 Nov 2019

CHEMOTHERAPY MEDICATION CHART C260070

UKALL 14

Intensification / CNS prophylaxis

Height cm

Weight kg

BSA m2 Infusion rate 125 X BSA = mL/hr

Day Date Time Agent Dose Route Instructions Rate Doctor Nurse Check Start Stop

18 Folinic acid ____ mg/m2 mg PO Give IV bolus if PO not tolerated

1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125mL/m2/hr mL/hr

1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125mL/m2/hr mL/hr

T= +72 hrs Methotrexate level Continue folinic acid until methotrexate level < 0.1 umol/L. Notify lab if levels required over the weekend.

Folinic acid ____ mg/m2

(dose depends on 48 hour methotrexate level) mg PO Give IV bolus if PO not tolerated

1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125mL/m2/hr mL/hr

Folinic acid ____ mg/m2

(frequency and dose depends on 72 hour methotrexate level) mg PO Give IV bolus if PO not tolerated

1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125mL/m2/hr mL/hr

1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125mL/m2/hr mL/hr

Folinic acid ____ mg/m2 mg PO Give IV bolus if PO not tolerated

1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125mL/m2/hr mL/hr

Canterbury Regional Cancer and Blood Service (Haematology) Page 12 of 12

Authorised by: Dr P Ganly Pharmacists: C Innes / B Harden August 2012 Reviewed: Apr 2016 Nov 2019

CHEMOTHERAPY MEDICATION CHART C260070

UKALL 14

Intensification / CNS prophylaxis

Height cm

Weight kg

BSA m2 Infusion rate 125 X BSA = mL/hr

19 1000 mL glucose 4 % & sodium chloride 0.18 %

+ 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125mL/m2/hr mL/hr

1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125mL/m2/hr mL/hr

Folinic acid ____ mg/m2 mg PO Give IV bolus if PO not tolerated 1000 mL glucose 4 % & sodium chloride 0.18 %

+ 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125mL/m2/hr mL/hr

T= +96 hrs Methotrexate level Continue folinic acid until methotrexate level < 0.1 umol/L. Notify lab if levels required over the weekend.

Folinic acid ____ mg/m2

(dose depends on 72 hour methotrexate level) mg PO Give IV bolus if PO not tolerated

1000 mL glucose 4 % & sodium chloride 0.18 % + 20 mmol potassium chloride + 50 mmol sodium bicarbonate

IV Infuse at 125mL/m2/hr mL/hr

▪ Continue folinic acid and high dose fluids for at least 48 hours, and continue as per UKALL 14 protocol depending on methotrexate levels (appendix 15) ▪ If further folinic acid required, prescribe on regular medication chart

Consultant: NZMC Reg. No: