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  • VA Cyclophosphamide Protocol
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Prior to the first infusion
  • Order labs within 1 week of the infusion:
    • CBC
    • Electrolytes
    • BUN/Creatinine
    • Liver profile
    • Pregnancy test
    • Urinalysis with cytology

For the first infusion
  1. Infuse 1 liter 1/2 NS prior to administration of Cyclophosphamide (Cytoxan), up to 150 cc/m2/hour.
  2. Administer antiemetics:
    • Metaclopramide (Reglan) IV 5 mg 40 minutes prior to Cyclophosphamide
    • Ondansetron (Zofran) IV 24 mg 30 minutes prior to Cyclophosphamide
  3. Instruct patient to drink 3 liters of fluid on the day of treatment and the following day.
  4. Mesna: Dose equal to 80% of the total Cyclophosphamide dose, given in 2-3 divided doses (200 mg/m2/dose), usually done every 2-3 hours.
  5. Order Cyclophosphamide using the instructions below.

For Subsequent Infusions
  1. Follow steps 1,2,3, and 4 above.
  2. Increase cyclophosphamide dose by 25% until a WBC of 2000/mm3 is reached at nadir. At that point, continue at the same dose.
    • If the dose of Cyclophosphamide reaches 1400 mg/m2 before the WBC nadirs at 2000/mm3, then the dosage increase will be limited to 100 mg/m2 each month thereafter. The maximum dose is 1600 mg/m2 irrespective of the WBC at the nadir.
    • If the WBC nadirs at less than 1500-2000/mm3, the next dose is decreased appropriately by 10-20%, depending on how low the count has fallen.
    • If the total WBC within 1 week of treatment is less than 2000/mm3, the next dose is held and CBC with differential is rechecked 1 week later or more frequently based on the actual count.
    • If the total WBC within 1 week of treatment is between 2000-3000/mm3 administer 50% of the established dose.

Ordering Cyclophosphamide through CPRS
  1. Go to "Notes".
  2. Select "New note"
  3. Select Dr. Segal as the co-signer.
  4. Open "Templates"
  5. Go to "Shared Templates" and go through the following folder
    • "Hematology/Oncology"
      • "Chemotherapy Orders Notes"
        • "Other"
  6. Select "Cyclophos-Lupus".
  7. Follow the template.
    • The "mod" blank is not needed and can be deleted from the final orders note.
    • The mg/m2 dose should come from Dr. Segal's last note.
    • Calculate the patient's body surface area (BSA):
      1. Go to
      2. Select "VertiCal"
      3. Enter the patient's height and weight to get the BSA.
  8. Submit the note just like any other note.

Lab Monitoring
  1. Obtain CBC with differential
    • Within one week prior to each infusion.
    • Post-infusion day 8
    • Post-infusion day 11
    • Post-infusion day 14
  2. Obtain urinalysis after each treatment.
    • If RBCs are detected in the post-treatment urinalysis, hydrate with another 1.5 liters and refer to urology.
  3. Obtain urinalysis and cytology yearly.
  4. Obtain cystocscopy every 1-2 years.

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