PLACE LABEL HERE
REMICADE (infliximab)
INPATIENT and OUTPATIENT
ORDERS
The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
DIAGNOSIS:
Must be ordered by Gastroenterologist:  Crohn’s Disease
 Ulcerative Colitis
Must be ordered by Rheumatologist:
 Rheumatoid Arthritis  Psoriatic Arthritis
1.
Admit as Inpatient __________________________________________(reason for admission)
Place in Observation ________________________________________(reason for observation)
Place in Outpatient __________________________________________(diagnosis)
Status:
2.
Assess patient for signs/symptoms of infection or CHF; notify MD if present prior to proceeding
3.
TB Skin Test Result _________ (date __________)
4.
Patient’s Weight: ________ kg (date ____________)
5.
Normal Saline IV at keep vein open rate for Remicade (infliximab) infusion
6.
Pre-medications:  Tylenol (acetaminophen) 650 mg po x 1 dose
 Benadryl (diphenhydramine) 25 mg x 1 dose  IV  po
 Benadryl (diphenhydramine) 50 mg x 1 dose  IV  po
 Solumedrol (methylprednisolone)  40 mg  80 mg  125mg IVP over 3-5 min x 1 dose
 Other: _____________________________________________________________
7.
Dosing:
 INPATIENT: Remicade (infliximab) ________ mg/kg IV x 1 dose
 OUTPATIENT (requires a new order q 6 months):
Initial: Remicade (infliximab) ______ mg/kg or ______ mg IV x 1 on weeks 0, 2, and 6
Maintenance: Remicade (infliximab) ______ mg/kg or ______ mg IV x 1 dose q _____ weeks
Remicade (infliximab) doses within 25 mg of the nearest vial size may be rounded to that vial size
8.
Titrate infusion as follows: (use 1.2 micron filter)
Initiate infusion at 10 ml/hr x 15 min
Increase to 20 ml/hr x 15 min
Increase to 40 ml/hr x 15 min
Increase to 80 ml/hr x 15 min
Increase to 150 ml/hr x 30 min
Increase to 250 ml/hr until completion of therapy
9.
For infusion related reactions refer to the Remicade (infliximab) infusion reaction management orders (see page 2)
10. Subsequent Remicade (infliximab) infusions (check one):
 No previous reaction to Remicade (infliximab), begin at 40 ml/hr, titrate as above to infuse over 2 hrs
 No previous reaction to Remicade (infliximab) after 4th dose, begin at 100 ml/hr X 15 min then increase
to 300 ml/hr for remainer of infusion over 1 hr
 Patient with previous reaction to Remicade (infliximab) (see orders on page 2)
Send copy to pharmacy
*3-26425*
Order writer’s initials _______
FORM 3-26425 REV. 07/2012
Page 1 of 2
PLACE LABEL HERE
REMICADE (infliximab)
INPATIENT and OUTPATIENT
ORDERS
The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
Prophylaxis for Subsequent Remicade (infliximab) Infusion
Determined by previous reaction (Mild, Moderate, Severe)
 Mild
 Moderate
1. Pretreat with:
1. Pretreat with:
a. Benadryl
a. Benadryl (diphenhydramine)
(diphenhydramine)
50 mg po x 1 dose
25 mg po x 1 dose
b. Tylenol (acetaminophen)
b. Tylenol (acetaminophen)
650 mg po x 1 dose
650 mg po x 1 dose
c. Solu-Medrol (methylprednisolone)
2. Infuse Remicade (infliximab)
125 mg IVP x 1 dose
over at least 2 hrs as
2. Remicade (infliximab) 1 mg test dose
tolerated
after pre-medications, wait 20 min
3. Infuse over at least 3 hrs as tolerated
 Severe
1. Physician present at administration
2. Pretreat with:
a. Benadryl (diphenhydramine)
50 mg IV x 1 dose
b. Tylenol (acetaminophen) 650 mg po x
1 dose
c. Solu-Medrol (methylprednisolone)
125 mg IVP x 1 dose
3. Give Remicade (infliximab) 1 mg test dose
after pre-medications, wait 20 min
4. Infuse over at least 4 hrs as tolerated
Reaction Management Orders for Remicade (infliximab) Infusion
Determine reaction type based on below, then follow mild, moderate or severe treatment orders
 Mild:
1. Pruritis or rash
2. Lightheadedness with < 20
point drop in systolic bp
3. Chest tightness without
dyspnea/ wheezing
4. Headache
5. Shortness of breath
6. Warmth without temperature
elevation
7. Flushing with no throat
tightness
Treatment of mild reaction:
1. Slow Remicade (infliximab)
infusion rate to KVO
2. Benadryl (diphenhyramine)
25 mg po x 1 dose
3. Tylenol (acetaminophen)
650 mg po x 1 dose
4. Monitor vital signs q 10 min
5. Increase infusion rate as
tolerated when patient is
stabilized
______________
Date
 Moderate
1. Pruritis and/or rash
2. Hives without respiratory difficulty
3. Wheezing without dyspnea
4. Hypertension or hypotension with
greater than 20 point but less than 40
point drop or rise in systolic blood
pressure
5. Elevated temperature with rigors
 Severe (Notify Physician):
1.
Dyspnea with wheezing
2.
Dyspnea requiring ventilator support
3.
Cardiopulmonary symptoms and urticaria
4.
Hypotension with greater than 40 point drop
in systolic blood pressure
5.
Stridor (call for emergency support)
Treatment of moderate reaction:
Treatment of severe reaction (Notify Physician)
1.
Pause Remicade (infliximab) infusion 1.
Stop Remicade (infliximab) infusion
2.
Benadryl (diphenhyramine) 50 mg IVP 2.
Maintain NS at 100 ml/hr IV
x 1 dose
3.
Benadryl (diphenhyramine) 50 mg IVP x 1
3.
Tylenol (acetaminophen) 650 mg po
dose
x 1 dose
4.
Tylenol (acetaminophen) 650 mg po x 1
4.
If wheezing present:
dose
Solu-Medrol (methylprednisolone) 5.
Solu-Medrol (methylprednisolone)
125 mg IVP x 1 dose
5.
6.
125 mg IVP x 1 dose
Monitor vital signs q 10 min
6.
Restart infusion slowly after symptoms 7.
resolve and vital signs are stable
_______________
Time
Monitor vital signs q 10 min
Epinephrine (1:1000) 0.1 ml – 0.5 ml
subcutaneous prn; may repeat q 5 min x 3
doses
8.
Call for emergency support
9.
Start oxygen to keep saturation > 90%
10. Physician to determine if transfer/admission
is needed.
_________________________________
Physician Signature
___________
PID Number
Send copy to pharmacy
FORM 3-26425 REV. 07/2012
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