Page 1 CYCLOPHOSPHAMIDE, DOXORUBICIN, VINCRISTINE, PREDNISONE (CHOP) INTRAVENOUS CANCER TREATMENT EDUCATION Name of the regimen and cancer drugs Your care team may refer to your treatment as “CHOP”. CHOP consists of 4 diff erent anti-cancer therapies. • C: Cyclophosphamide (sye kloe FOS fa mide); Cytoxan® • H: Doxorubicin (Dahk suhr rOO buh suhn); Hydroxydaunomycin, Adriamycin® • O: Vincristine (Vin kris teen); Oncovin® • P: Prednisone (prEd nuh sohn); Deltasone® Common uses CHOP is commonly used to treat Non-Hodgkin lymphoma. Treatment schedule Your treatment will be given into your vein through an intravenous (IV) line. This may be into a short, fl exible temporary catheter in your arm, or through a central venous catheter. A central venous catheter, or central line is a long, fl exible IV tube that empties into a very large vein next to the heart. Talk with your care team to see which will be best for you and your treatment. Each CHOP treatment is repeated every 21 days (3 weeks). This is known as one cycle. Your treatment may be given for a set number of cycles, or it will keep going until the drug, or drugs, stop working or you have side eff ects which stop you from continuing treatment.  Cyclophosphamide IV on Day 1  Doxorubicin IV on Day 1  Vincristine IV on Day 1  Prednisone taken once daily by mouth on Days 1 thru 5. Your provider will prescribe this medication for you. Take prednisone with food to avoid stomach upset. Tell your provider if you develop heartburn or acid refl ux. Avoid evening/ bedtime administration as prednisone may cause trouble sleeping. Drug DAY 1 23456 789 ... 21 Cycle 2 Day 1 Cyclophosphamide X X Doxorubicin X X Vincristine X X Prednisone XXXXX X Page 2 Other medications Other medications may be ordered for you to prevent or treat certain side eff ects. These include: Instructions: Anti-nausea and other medications You will receive medications to prevent nausea and other side eff ects just before your chemotherapy. You may get prescriptions for other medications to take at home, as below: Possible drug interactions  CHOP may interact with other drugs you are taking. Please inform your care providers of all prescription medicine, over-the-counter medications, vitamins, and herbal products that you take.  Talk with your care provider or pharmacist before taking new medications, supplements, or receiving any vaccines. Page 3 Common Side Eff ects Common side eff ects that have been known to happen in patients receiving CHOP are listed in the left side of this table. In some instances, the side eff ects may be reported less often but are still important to discuss. This table does not list all the known side eff ects for this therapy, only the ones that are experienced most often. Not every patient experiences every known side eff ect of a drug; even if you are taking the same drug as another patient, you may experience diff erent side eff ects. Options to help manage any side eff ects that do occur are included on the right side of this table. These should be discussed with your care provider. If you experience any side eff ect you cannot manage or that is not listed here, contact your care provider. Possible Side Eff ect Management Decreased white blood cells (WBCs) and increased risk for infection (neutropenia) Your WBCs should be monitored by a simple blood test. When your WBCs are low, you are at a greater risk of having an in-fection. Take the following precautions to protect yourself from infection. • Wash your hands often, especially before eating and after using the bathroom. • Avoid crowds and people with fevers, fl u, or other infection. • Bathe often for good personal hygiene. Contact your care team if you experience any signs or symptoms of an infection such as: • Fever (temperature more than 100.4°F or 38°C) • Chills • Sore throat • Burning when peeing • Tiredness that is worse than normal • A sore that becomes red, is draining, or does not heal. Check with your care team before taking any medicine for a fever or chills. Continued on the next page Page 4 Decreased hemoglobin, part of the red blood cells that carry iron and oxygen Your hemoglobin should be checked by a simple blood test. When your hemoglobin is low, you may notice that you get tired or fatigued more easily. • Try to get 7 to 8 hours of sleep per night • Avoid operating heavy machinery if you feel too tired • Find a balance between “work” and “rest” • Stay as active as possible, but know that it is okay to rest as needed, too • You might notice that you are more pale than usual Let your care team know right away if you have: • Shortness of breath • Dizziness • Fast or abnormal heartbeat Decreased platelet count and increased risk of bleeding Your platelets should be monitored by a simple blood test. When they are low, you may bruise or bleed more easily than usual. • Use caution to avoid bruises, cuts, or burns. • Blow your nose gently and do not pick your nose • Brush your teeth gently with a soft toothbrush and maintain good oral hygiene • When shaving use an electric razor instead of razor blades • Use a nail fi le instead of a nail clippers Call your care team if you have bleeding that won’t stop. Examples include: • A bloody nose that bleeds for more than 5 minutes despite pressure • A cut that continues to ooze despite pressure • Gums that bleed a lot when you fl oss or brush Seek medical help right away if you have any severe headaches, blood in your urine or stool, coughing up blood, or bleeding that you cannot stop or lasts a long time. You may need to take a break or “hold” your medication for medical or dental procedures. Talk to your care team or dentist before any scheduled procedures. Fatigue You may be more tired than usual or have less energy. • Stay as active as possible, but know it is okay to rest as needed. • Try to do some activity every day. Plan your activities, and do them at a time of day when you feel a bit more energetic. • Avoid operating heavy machinery if you feel too tired. Page 5 Numbness or tingling in hands and feet Report changes in your sense of touch, such as a burning feeling, pain on the skin or weakness. Hair loss (alopecia) • Your hair will likely grow back after treatment is over. • Some people choose to wear scarves, caps, or wigs. A short haircut prior to treatment may help with stress of hair loss. • Partial or complete hair loss is likely, usually 1-2 weeks after start of therapy. This hair loss can be all body hair. • Hair will grow back after treatment is completed, although the color and/or texture may be diff erent • It may take 3 to 6 months after therapy is completed to resume normal hair growth • Be sure to keep your head covered to protect it from the sun during the summer and cold during the winter. • If not covering your scalp during the summer months, be sure to use sunscreen when spending time outdoors. Mouth irritation or sores (stomatitis) Practice good mouth care. • Rinse your mouth often • Brush your teeth with a soft toothbrush or cotton swab after meals • Use a mild non-alcohol mouth rinse at least 4 times a day (after eating and at bedtime). One example is a mixture of 1/8 teaspoon of salt and 1/4 teaspoon of baking soda in 8 ounces of warm (not hot) water • If you have sores in your mouth, avoid using tobacco products, alcohol, and mouthwashes that contain alcohol Call your care team if you experience pain or sores in your mouth or throat. Nausea • Eat and drink slowly • Drink 8-10 glasses of water/fl uid each day unless your care provider has instructed you to limit your fl uid intake • Eat small, frequent meals throughout the day rather than a few large meals • Eat bland foods; avoid spicy, fried, and greasy foods • Avoid vigorous exercise immediately after eating • Don’t lay down immediately after eating • Avoid strong odors Let your provider know if you experience nausea or vomiting. Your provider may prescribe medication to help with nausea or vomiting. Page 6 Diarrhea (loose and/ or urgent bowel movements) Monitor how many bowel movements you have each day. • Drink 8-10 glasses of water or fl uid each day unless your care team has asked you to limit your fl uid intake. • Eat small, frequent meals throughout the day rather than a few large meals. • Eat bland, low-fi ber foods (such as bananas, applesauce, potatoes, chicken, rice, and toast). • Avoid high fi ber foods, such as raw vegetables and fruits and whole grains. • Avoid foods that cause gas, such as broccoli and beans. • Avoid foods with lactose, such as yogurt and milk. • Avoid spicy, fried, and greasy foods. Contact your care team if: • The number of bowel movements you have in a day increases by 4 or more • You feel dizzy or lightheaded Your care team may recommend an over-the-counter medication called loperamide (Imodium®) to help with your diarrhea but talk to your care team before starting this medication. Constipation Keep track of how many bowel movements you have each day. • Drink 8-10 glasses of water or fl uid each day unless your care team has asked you to limit your fl uid intake • Stay active and exercise, if possible • Eat foods high in fi ber like raw fruits and vegetables Contact your care team if you have not had a bowel movement in 3 or more days. Your care team may recommend over-the-counter medications to help with constipation. A daily stool softener such as docusate (Colace®) and/or laxative such as senna (Senakot®) may be helpful. If these do not help within 48 hours, tell your care team. Renal/bladder toxicity Cyclophosphamide may be harmful to your kidneys and bladder. Speak to your care team to know when you need to have laboratory tests done to monitor them. Increase fl uid intake to at least 2 Liters per day on day of treatment with Cyclophosphamide and for 2 days afterwards. Changes in body fl uid color Doxorubicin may cause tears, sweat, saliva, and urine to have a reddish tint for a few days after treatment. Page 7 Rare but serious side eff ects Tell your care provider if you experience any symptoms of these problems:  Bladder irritation or bleeding: report any blood in the urine or pain with urination to your care team.  Heart problems: Doxorubicin can make your heart work harder to pump blood to the rest of your body. Tell your care team if you are having shortness of breath, sudden fl uid retention, or chest pain.  CHOP may rarely cause a secondary cancer called myelodysplastic syndrome (MDS) or acute myeloid leukemia (AML). Your care team will monitor your blood cell counts during treatment and after treatment is complete.  Doxorubicin and vincristine are vesicants. If it leaks outside of the IV, it can cause severe damage to your skin. Notify your nurse right away if you feel any pain, aching, burning, itching, swelling, or redness at the site of your IV.  Tumor lysis syndrome: Some patients taking CHOP have experienced tumor lysis syndrome (TLS) when starting treatment. TLS is a condition that occurs when many cancer cells die very quickly and release their contents into the blood which can damage the kidneys and other parts of the body. Your care provider may give you a medication or do blood tests to check for this side eff ect. If you experience ANY new, worsening, or uncontrolled side eff ects, call your care team immediately. (INSTITUTIONAL CONTACT INFO) Page 8 Handling body fl uids and waste Some of the drugs you receive may be present in urine, stool, sweat, or vomit for many days after treatment. Many cancer drugs are toxic, your bodily waste may also be toxic and can be dangerous to come into contact with. Once you have started CHOP, follow the instructions below for at least two days after your treatment. This is to keep you, your loved ones, and the environment as safe as possible.  Pregnant women should avoid touching anything that may be soiled with body fl uids from the patient.  Toilet and septic systems • You may use the same toilet, septic tank, and/or sewer that you usually use. If you have a low-fl ow toilet, close the lid and fl ush twice to ensure that all waste has been discarded.  If the toilet or toilet seat becomes soiled with urine, stool, or vomit, clean the surface after every use before other people use the toliet.  Wash hands with soap and water after using the toilet for at least 20 seconds.  If you need a bedpan, be sure your caregiver knows to wear gloves to assist with cleanup and to wash the bedpan with soap and water every day.  If you do not have good control of bladder or bowels, use a disposable pad with a plastic back, a diaper, or a sheet to absorb body waste.  Wash any skin that has been exposed to body waste with soap and water.  Linens or clothing that are soiled with body fl uids or body waste should be washed separately from other linens and clothing. If you do not have a washer, place the soiled linens in a plastic bag until they can be washed.  Wash hands with soap and water after touching linens or clothing that may be soiled with body fl uids. Intimacy, sexual activity, contraception, and fertility This treatment may cause changes that can aff ect intimacy and sexuality, including desire and body image. Maintaining physical closeness and/or intimacy with loved ones can be continued during treatment. Holding hands, hugging, and kissing can be done safely. It is recommended that you talk to your care team about any restrictions or questions you may have. Some treatments can infl uence the ability to have children, also known as fertility. If you’re interested in preserving fertility, talk to your care team before treatment. Ask your healthcare provider to determine when it is safe to become pregnant after your treatment. Patients of reproductive ability should not become pregnant or get their partners pregnant while receiving Some of the drugs you receive may be present in semen and vaginal secretion for many days after treatment. You should use barrier devices, such as condoms, during sexual activity to limit exposure to body fl uids.  Talk to your care team about birth control. Not all options may be right for your treatment or cancer. Eff ective contraception could include one or more of the following: barrier methods (e.g. condoms), hormone methods (e.g. birth control pills), or surgery.  Tell your care team if you become pregnant or plan to breastfeed. Page 9 Additional resources Prescribing information links: Cyclophosphamide (Cytoxan): https://www.accessdata.fda.gov/drugsatfda_docs/label/2013/012141s090,012142s112lbl. pdf Doxorubicin (Adriamycin): https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/062921s022lbl.pdf Vincristine (Oncovin): https://www.accessdata.fda.gov/drugsatfda_docs/label/2014/071484s042lbl.pdf Prednisone (Deltasone): https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/202020s000lbl.pdf Updated – December 16, 2021 Additional instructions Important notice: The Association of Community Cancer Centers (ACCC), Hematology/Oncology Pharmacy Association (HOPA), National Community Oncology Dispensing Association, Inc. (NCODA), and Oncology Nursing Society (ONS) have collaborated in gathering information for and developing this patient education guide. This guide represents a brief summary of the therapy derived from information provided by the drug manufacturer and other resources. This guide does not cover all existing information related to the possible uses, directions, doses, precautions, warnings, interactions, adverse eff ects, or risks associated with this therapy and should not substitute for the advice of a qualifi ed healthcare professional. Provision of this guide is for informational purposes only and does not constitute or imply endorsement, recommendation, or favoring of this therapy by ACCC, HOPA, NCODA, or ONS, who assume no liability for and cannot ensure the accuracy of the information presented. The collaborators are not making any representations with respect to the medications whatsoever, and any and all decisions, with respect to such medications, are at the sole risk of the individual receiving therapy. All decisions related to receiving this therapy should be made with the guidance and under the direction of a qualifi ed healthcare professional. Permission: Intravenous Cancer Treatment Education (IVE) sheets are provided as a free educational resource for patients with cancer in need of concise, easy-to-understand information about intravenous cancer therapy. Healthcare providers are permitted to copy and distribute the sheets to patients as well as direct patients to the OCE website for information. However, commercial reproduction or reuse, as well as rebranding or reposting of any type, are strictly prohibited without permission of the copyright holder. Please email permission requests and licensing inquiries to This email address is being protected from spambots. You need JavaScript enabled to view it.. Copyright © 2021 by NCODA. All rights reserved.

Page 1 INTRAVENOUS CANCER TREATMENT EDUCATION CYTARABINE & DAUNORUBICIN (7+3) Name of the regimen and cancer drugs Your care team may refer to your treatment as 7+3. 7+3 consists of 2 different anti cancer therapies. 7: Cytarabine (sye TARE a been): Cytosar 3: Daunorubicin (daw noe ROO bi sin): Cerubidine Common uses Cytarabine & daunorubicin are used to treat acute myeloid leukemia (AML), but may be used for other treatments. Treatment schedule Your treatment will be given into your vein through an intravenous (IV) line. This may be into a short, flexible temporary catheter in your arm, or through a central venous catheter. A central venous catheter, or central line is a long, flexible IV tube that empties into a very large vein next to the heart. Talk with your care team to see which will be best for you and your treatment. Cytarabine IV on Days 1 7. Daunorubicin IV on Days 1 3. This treatment is called induction therapy. You will only receive this treatment one time. This regimen is often administered inpatient. Drug DAY 1 2 3 4 5 6 7 Cytarabine X X X X X X X Daunorubicin X X X CYTARABINE & DAUNORUBICIN (7+3) Page 2 INTRAVENOUS CANCER TREATMENT EDUCATION Other medications Other medications may be ordered for you to prevent or treat certain side effects. These include: Possible drug interactions 7+3 may interact with other drugs you are taking. Please inform your care providers of all prescription medicine, over thecounter medications, vitamins, and herbal products that you take. Talk with your care provider or pharmacist before taking new medications, supplements, or receiving any vaccines. Infection prevention There is a risk of serious infections during treatment. You may receive medications to prevent infection in the hospital, and may also get prescriptions for medications to take at home for infection prevention, as below: Blood Product Transfusions You may receive blood transfusions while you are getting treatment for your cancer. These products are given to replace blood cells or blood products lost during the course of your cancer treatment. Your physician will decide if transfusions are needed based on certain laboratory results, such as hemoglobin, hematocrit, or platelets. If you have personal or religious beliefs that prohibit the receipt of blood product transfusions, please let your care team know before treatment begins. Instructions: Anti nausea and other medications You will receive medications to prevent nausea just before your cancer treatment. You may also get prescriptions for other medications to take at home, as below: CYTARABINE & DAUNORUBICIN (7+3) Page 3 INTRAVENOUS CANCER TREATMENT EDUCATION Common Side Effects Common side effects that have been known to happen in patients receiving 7+3 are listed in the left side of this table. In some instances, the side effects may be reported less often but are still important to discuss. This table does not list all the known side effects for this therapy, only the ones that are experienced most often. Not every patient experiences every known side effect of a drug; even if you are taking the same drug as another patient, you may experience different side effects. Options to help manage any side effects that do occur are included on the right side of this table. These should be discussed with your care provider. If you experience any side effect you cannot manage or that is not listed here, contact your care provider. Possible Side Effect Management Decreased white blood cells (WBCs) and increased risk for infection Your WBCs should be monitored by a simple blood test. When your WBCs are low, you are at a greater risk of having an in fection. Take the following precautions to protect yourself from infection. • Wash your hands often, especially before eating and after using the bathroom. • Avoid crowds and people with fevers, flu, or other infection. • Bathe often for good personal hygiene. Contact your care team if you experience any signs or symptoms of an infection such as: • Fever (temperature more than 100.4°F or 38°C) • Chills • Sore throat • Burning when peeing • Tiredness that is worse than normal • A sore that becomes red, is draining, or does not heal. Check with your care team before taking any medicine for a fever or chills. Continued on the next page CYTARABINE & DAUNORUBICIN (7+3) Page 4 INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Decreased platelet count and increased risk of bleeding Your platelets should be monitored by a simple blood test. When they are low, you may bruise or bleed more easily than usual. • Use caution to avoid bruises, cuts, or burns. • Blow your nose gently and do not pick your nose • Brush your teeth gently with a soft toothbrush and maintain good oral hygiene • When shaving use an electric razor instead of razor blades • Use a nail file instead of nail clippers Call your care team if you have bleeding that won’t stop. Examples include: • A bloody nose that bleeds for more than 5 minutes despite pressure • A cut that continues to ooze despite pressure • Gums that bleed a lot when you floss or brush Seek medical help right away if you have any severe headaches, blood in your urine or stool, coughing up blood, or bleeding that you cannot stop or lasts a long time. You may need to take a break or “hold” your medication for medical or dental procedures. Talk to your care team or dentist before any scheduled procedures. Decreased hemoglobin, part of the red blood cells that carry iron and oxygen Your hemoglobin should be checked by a simple blood test. When your hemoglobin is low, you may notice that you get tired or fatigued more easily. • Try to get 7 to 8 hours of sleep per night • Avoid operating heavy machinery if you feel too tired • Find a balance between “work” and “rest” • Stay as active as possible, but know that it is okay to rest as needed, too • You might notice that you are more pale than usual Let your care team know right away if you have: • Shortness of breath • Dizziness • Fast or abnormal heartbeat Continued on the next page CYTARABINE & DAUNORUBICIN (7+3) Page 5 INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Nausea or vomiting • Take all medications as prescribed to help prevent and lessen symptoms of nausea and vomiting • Eat and drink slowly • Drink 8 10 (8 ounce) glasses of water and/or fluid (soup or broth) each day unless your care team has instructed you to limit your fluid intake • Eat small, frequent meals throughout the day rather than a few large meals • Eat bland foods; avoid spicy, fried, and greasy foods • Avoid intense exercise immediately after eating • Don’t lay down right away after eating • Wear loose fitting clothing for comfort • Avoid strong odors. Consider getting fresh air and try deep breathing. Let your care team know if you have nausea or vomiting. Your care team may prescribe medication to help with the symptoms. CYTARABINE & DAUNORUBICIN (7+3) Page 6 INTRAVENOUS CANCER TREATMENT EDUCATION Rare but serious side effects Daunorubicin is a vesicant. If it leaks outside of the IV, it can cause severe damage to your skin. Notify your nurse right away if you feel any pain, aching, burning, itching, swelling, or redness at the site of your IV. Daunorubicin can make your heart work harder to pump blood to the rest of your body. Notify your care team if you experience shortness of breath or chest pain. This regimen may cause tumor lysis syndrome when starting treatment. Your care team may do blood tests to check for this side effect. These medications may be harmful to your kidneys. Speak to your care team to know when you need to have laboratory tests done to monitor your kidneys These medications may be harmful to your liver. Speak to your care team to know when you need to have blood tests done to monitor your liver function. If you get this side effect, your doctor may change your dose or stop treatment for some time. A secondary cancer can rarely occur months or years after treatment. Your care team will check your blood cell counts even after treatment is done to monitor for this side effect. Severe allergic reactions are a rare but serious side effect of cytarabine. Right away seek medical attention if you notice difficulty breathing, swelling of the mouth or tongue, or a serious rash. If you experience ANY new, worsening, or uncontrolled side effects, call your care team immediately. (INSTITUTIONAL CONTACT INFO) CYTARABINE & DAUNORUBICIN (7+3) Page 7 INTRAVENOUS CANCER TREATMENT EDUCATION Handling body fluids and waste Some of the drugs you receive may be present in urine, stool, sweat, or vomit for many days after treatment. Many cancer drugs are toxic, your bodily waste may also be toxic and can be dangerous to come into contact with. Once you have started 7+3, follow the instructions below for at least two days after your treatment. This is to keep you, your loved ones, and the environment as safe as possible. Pregnant women should avoid touching anything that may be soiled with body fluids from the patient. Toilet and septic systems • You may use the same toilet, septic tank, and/or sewer that you usually use. If you have a low flow toilet, close the lid and flush twice to ensure that all waste has been discarded. If the toilet or toilet seat becomes soiled with urine, stool, or vomit, clean the surface after every use before other people use the toliet. Wash hands with soap and water after using the toilet for at least 20 seconds. If you need a bedpan, be sure your caregiver knows to wear gloves to assist with cleanup and to wash the bedpan with soap and water every day. If you do not have good control of bladder or bowels, use a disposable pad with a plastic back, a diaper, or a sheet to absorb body waste. Wash any skin that has been exposed to body waste with soap and water. Linens or clothing that are soiled with body fluids or body waste should be washed separately from other linens and clothing. If you do not have a washer, place the soiled linens in a plastic bag until they can be washed. Wash hands with soap and water after touching linens or clothing that may be soiled with body fluids. CYTARABINE & DAUNORUBICIN (7+3) Page 8 INTRAVENOUS CANCER TREATMENT EDUCATION Intimacy, sexual activity, contraception, and fertility This treatment may cause changes that can affect intimacy and sexuality, including desire and body image. Maintaining physical closeness and/or intimacy with loved ones can be continued during treatment. Holding hands, hugging, and kissing can be done safely. It is recommended that you talk to your care team about any restrictions or questions you may have. Some treatments can influence the ability to have children, also known as fertility. If you’re interested in preserving fertility, talk to your care team before treatment. Ask your healthcare provider to determine when it is safe to become pregnant after your treatment. Patients of reproductive ability should not become pregnant or get their partners pregnant while receiving 7+3. Some of the drugs you receive may be present in semen and vaginal secretion for many days after treatment. You should use barrier devices, such as condoms, during sexual activity to limit exposure to body fluids. Talk to your care team about birth control. Not all options may be right for your treatment or cancer. Effective contraception could include one or more of the following: barrier methods (e.g. condoms), hormone methods (e.g. birth control pills), or surgery. Tell your care team if you become pregnant or plan to breastfeed. Additional resources Additional instructions Updated – August 30, 2021 Important notice: The Association of Community Cancer Centers (ACCC), Hematology/Oncology Pharmacy Association (HOPA), National Community Oncology Dispensing Association, Inc. (NCODA), and Oncology Nursing Society (ONS) have collaborated in gathering information for and developing this patient education guide. This guide represents a brief summary of the therapy derived from information provided by the drug manufacturer and other resources. This guide does not cover all existing information related to the possible uses, directions, doses, precautions, warnings, interactions, adverse effects, or risks associated with this therapy and should not substitute for the advice of a qualified healthcare professional. Provision of this guide is for informational purposes only and does not constitute or imply endorsement, recommendation, or favoring of this therapy by ACCC, HOPA, NCODA, or ONS, who assume no liability for and cannot ensure the accuracy of the information presented. The collaborators are not making any representations with respect to the medications whatsoever, and any and all decisions, with respect to such medications, are at the sole risk of the individual receiving therapy. All decisions related to receiving this therapy should be made with the guidance and under the direction of a qualified healthcare professional. Permission: Intravenous Cancer Treatment Education (IVE) sheets are provided as a free educational resource for patients with cancer in need of concise, easy to understand information about intravenous cancer therapy. Healthcare providers are permitted to copy and distribute the sheets to patients as well as direct patients to the OCE website for information. However, commercial reproduction or reuse, as well as rebranding or reposting of any type, are strictly prohibited without permission of the copyright holder. Please email permission requests and licensing inquiries to This email address is being protected from spambots. You need JavaScript enabled to view it.. Copyright © 2021 by NCODA. All rights reserved.

Page 1 DA-EPOCH-R INTRAVENOUS CANCER TREATMENT EDUCATION DA-EPOCH-R Name of the regimen and cancer drugs Your care team may refer to your treatment as dose-adjusted (DA) EPOCH-R. DA-EPOCH-R consists of 6 different anti-cancer therapies. • E: Etoposide (ee-toh-POH-side), also called VP-16: Toposar® • P: Prednisone (PRED-nih-sone) • O: Vincristine (vin-KRIS-teen): Oncovin® • C: Cyclophosphamide (SY-kloh-FOS-fuh-mide): Cytoxan® • H: Doxorubicin (DOK-soh-ROO-bih-sin), also called H-daunorubicin: Adriamycin® • R: Rituximab (rih-TUK-sih-mab): Rituxan®, Ruxience®, Truxima®, Riabni™ Common uses EPOCH-R is most commonly used to treat Non-Hodgkin’s Lymphoma (NHL) but may be used for other diagnoses. Treatment schedule Your treatment will be given into your vein through an intravenous (IV) line. This may be into a short, flexible temporary catheter in your arm, or through a central venous catheter. A central venous catheter, or central line is a long, flexible IV tube that empties into a very large vein next to the heart. Talk with your care team to see which will be best for you and your treatment. Each DA-EPOCH-R treatment is repeated every 21 days. This is known as one cycle. Your treatment may be given for a set number of cycles, or it will keep going until the drug, or drugs, stop working or you have side effects which stop you from continuing treatment. o Etoposide continuous IV infusion over 96 hours starting on Day 1 and ending on Day 4 o Prednisone by mouth on Days 1-5 o Vincristine continuous IV infusion over 96 hours starting on Day 1 and ending on Day 4 o Cyclophosphamide IV on Day 5 o Doxorubicin continuous IV infusion over 96 hours starting on Day 1 and ending on Day 4 o Rituximab IV on Day 1 Drug Cycle 1 Day 1 2 3 4 5 6 7 8 ... 21 Cycle 2 Day 1 Etoposide Prednisone (oral tablets) Vincristine Cyclophosphamide Doxorubicin Rituximab Page 2 DA-EPOCH-R INTRAVENOUS CANCER TREATMENT EDUCATION Other medications Other medications may be ordered for you to prevent or treat certain side effects. These include: Instructions: Growth Factors Growth factors, like filgrastim, pegfilgrastim, and others, are medications used to treat neutropenia and prevent infections. Neutropenia is a condition where there are lower-than-normal white blood cells caused by some type of chemotherapy. Growth factors help the bone marrow to make more white blood cells. Anti-nausea medications You will receive medications to prevent nausea just before your cancer treatment. You may also get prescriptions for other medications to take at home, as below: Infection prevention There is a risk of serious infections during treatment. You may receive medications to prevent infection in the hospital, and may also get prescriptions for medications to take at home for infection prevention, as below: Blood product transfusions You may receive blood transfusions while you are getting treatment for your cancer. These products are given to replace blood cells or blood products lost during the course of your cancer treatment. Your physician will decide if transfusions are needed based on certain laboratory results, such as hemoglobin, hematocrit, or platelets. If you have personal or religious beliefs that prohibit the receipt of blood product transfusions, please let your care team know before treatment begins. Page 3 DA-EPOCH-R INTRAVENOUS CANCER TREATMENT EDUCATION Other medications continued Instructions: Medications to prevent side effects You will receive your medications to prevent side effects just before your cancer treatment. You may get prescriptions for other medications to take at home, as below: Medications to prevent allergic reactions You will receive medications to prevent infusion related reactions prior to starting your cancer treatment. Possible drug interactions o EPOCH-R may interact with other drugs you are taking. Please inform your care providers of all prescription medicine, over-the-counter medications, vitamins, and herbal products that you take. o Talk with your care provider or pharmacist before taking new medications, supplements, or receiving any vaccines. o Grapefruit or grapefruit juice may interact with EPOCH-R. Avoid eating or drinking these during your treatment. Page 4 DA-EPOCH-R INTRAVENOUS CANCER TREATMENT EDUCATION Common Side Effects Common side effects that have been known to happen in patients receiving DA-EPOCH-R are listed in the left side of this table. In some instances, the side effects may be reported less often but are still important to discuss. This table does not list all the known side effects for this therapy, only the ones that are experienced most often. Not every patient experiences every known side effect of a drug; even if you are taking the same drug as another patient, you may experience different side effects. Options to help manage any side effects that do occur are included on the right side of this table. These should be discussed with your care provider. If you experience any side effect you cannot manage or that is not listed here, contact your care provider. Possible Side Effect Management Decreased white blood cells (WBCs) and increased risk for infection Your WBCs should be monitored by a simple blood test. When your WBCs are low, you are at a greater risk of having an infection. Take the following precautions to protect yourself from infection. • Wash your hands often, especially before eating and after using the bathroom. • Avoid crowds and people with fevers, flu, or other infection. • Bathe often for good personal hygiene. Contact your care team if you experience any signs or symp-toms of an infection such as: • Fever (temperature more than 100.4°F or 38°C) • Chills • Sore throat • Burning when peeing • Tiredness that is worse than normal • A sore that becomes red, is draining, or does not heal. Check with your care team before taking any medicine for a fever or chills. Continued on the next page Page 5 DA-EPOCH-R INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Decreased hemoglobin, part of the red blood cells that carry iron and oxygen Your hemoglobin should be checked by a simple blood test. When your hemoglobin is low, you may notice that you get tired or fatigued more easily. • Try to get 7 to 8 hours of sleep per night • Avoid operating heavy machinery if you feel too tired • Find a balance between “work” and “rest” • Stay as active as possible, but know that it is okay to rest as needed, too • You might notice that you are more pale than usual Let your care team know right away if you have: • Shortness of breath • Dizziness • Fast or abnormal heartbeat Decreased platelet count and increased risk of bleeding Your platelets should be monitored by a simple blood test. When they are low, you may bruise or bleed more easily than usual. • Use caution to avoid bruises, cuts, or burns. • Blow your nose gently and do not pick your nose • Brush your teeth gently with a soft toothbrush and maintain good oral hygiene • When shaving use an electric razor instead of razor blades • Use a nail file instead of nail clippers Call your care team if you have bleeding that won’t stop. Examples include: • A bloody nose that bleeds for more than 5 minutes despite pressure • A cut that continues to ooze despite pressure • Gums that bleed a lot when you floss or brush Seek medical help right away if you have any severe headaches, blood in your urine or stool, coughing up blood, or bleeding that you cannot stop or lasts a long time. You may need to take a break or “hold” your medication for medical or dental procedures. Talk to your care team or dentist before any scheduled procedures. Numbness or tingling in hands and feet Report changes in your sense of touch, such as a burning feeling, pain on the skin or weakness. Continued on the next page Page 6 DA-EPOCH-R INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Fatigue • You may be more tired than usual or have less energy • Stay as active as possible, but know it is okay to rest as needed • Try to do some type of moderate activity every day • Conserve your energy. Plan your activities and do them at a time of day when you feel a bit more energetic • Follow a healthy diet and stay hydrated • Accept help from family and friends • Find healthy ways to manage stress, such as meditation, journaling, yoga, and guided imagery • Develop good sleeping habits, limit napping during the day to help you sleep better at night • Avoid operating heavy machinery if you feel too tired • Contact your care team if you experience extreme fatigue that prevents you from doing your normal daily activities Infusion reaction During your treatment, let the nurse know right away if any of these symptoms happen: • Chills or shaking • Dizziness • Fever • Itchiness or rash • Flushing • Difficulty breathing • Wheezing • Throat irritation • Cough • Congestion • Sudden back pain • Feeling faint Nausea or vomitting • Take all medications as prescribed to help prevent and lessen symptoms of nausea and vomiting • Eat and drink slowly • Drink 8-10 (8-ounce) glasses of water and/or fluid (soup or broth) each day unless your care team has instructed you to limit your fluid intake • Eat small, frequent meals throughout the day rather than a few large meals • Eat bland foods; avoid spicy, fried, and greasy foods • Avoid intense exercise immediately after eating • Don’t lay down right away after eating • Wear loose fitting clothing for comfort • Avoid strong odors. Consider getting fresh air and try deep breathing. Let your care team know if you have nausea or vomiting. Your care team may prescribe medication to help with the symptoms. Continued on the next page Page 7 DA-EPOCH-R INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Mouth irritation or sores (stomatitis or mucositis) Practice good mouth care. • Rinse your mouth often • Brush your teeth with a soft toothbrush or cotton swab after meals • Use a mild non-alcohol mouth rinse at least 4 times a day (after eating and at bedtime). One example is a mixture of 1/8 teaspoon of salt and 1/4 teaspoon of baking soda in 8 ounces of warm (not hot) water • If you have sores in your mouth, avoid using tobacco products, alcohol, and mouthwashes that contain alcohol Call your care team if you experience pain or sores in your mouth or throat. Changes in electrolyte levels and other laboratory values: • High glucose levels • You may be more tired than usual or have less energy • Stay as active as possible, but know it is okay to rest as needed • Try to do some type of moderate activity every day • Conserve your energy. Plan your activities and do them at a time of day when you feel a bit more energetic • Follow a healthy diet and stay hydrated • Accept help from family and friends • Find healthy ways to manage stress, such as meditation, journaling, yoga, and guided imagery • Develop good sleeping habits, limit napping during the day to help you sleep better at night • Avoid operating heavy machinery if you feel too tired • Contact your care team if you experience extreme fatigue that prevents you from doing your normal daily activities Constipation Keep track of how many bowel movements you have each day. • Drink 8-10 (8-ounce) glasses of water or fluid each day unless your care team has asked you to limit your fluid intake. • Stay active and exercise, if possible. • Eat foods high in fiber like raw fruits and vegetables. Contact your care team if you have not had a bowel movement in 3 or more days. Your care team may recommend over-the-counter medications to help with constipation. A daily stool softener such as docusate (Colace®) and/or laxative such as senna (Senakot®) may be helpful. If these do not help within 48 hours, tell your care team. Changes in body fluid color Doxorubicin may cause tears, sweat, saliva, and urine to have a reddish tint for a few days after treatment. Continued on the next page Page 8 DA-EPOCH-R INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Reactivation of Hepatitis B Virus (HBV) This medication can cause hepatitis B virus (HBV) reactivation in patients previously infected with HBV. • You may be tested for HBV prior to beginning treatment with this medication. • Be sure your healthcare provider is aware of any previous HBV diagnosis and treatment, if known. • Patients with past HBV infection may need preventative antiviral medication while receiving and for months after completing this medication. • Additional routine monitoring of HBV levels may be needed in patients who were previously infected with HBV. Rare but serious side effects Tell your care provider if you experience any symptoms of these problems: o Infusion reaction: Rituximab can cause an infusion reactions. During your treatment, let the nurse know right away if any of these symptoms happen: chills or shaking, dizziness, fever, itchiness or rash, flushing, difficulty breathing, wheezing, sudden back pain, or feeling faint. o Cardiomyopathy: Doxorubicin, Cyclophosphamide and Rituximab can make your heart work harder to pump blood to the rest of your body. Notify your care team immediately if you experience shortness of breath, chest pain, or tightness. o Hepatic toxicity: Doxorubicin, Cyclophosphamide, Vincristine may be harmful to your liver. Speak to your care team to know when you need to have blood tests done to monitor your liver function. If you get this side effect, your doctor may change your dose or stop treatment for some time. o Intestinal obstruction: Rituximab and vincristine can cause blockages to form in the large or small intestine. Seek medical attention if you develop severe abdominal pain or other symptoms of intestinal obstruction. o Hemorrhagic cystitis (bladder irritation): Cyclophosphamide can cause irritation of the bladder walls, leading to blood in the urine. It can be prevented by drinking plenty of fluids (8-10 eight ounce) glasses per day and emptying bladder frequently, especially before bed. o Tumor lysis syndrome: Rituximab, Doxorubicin and Vincristine may cause tumor lysis syndrome when starting treatment. Your care team may do blood tests to check for this side effect. o Secondary Malignancy: A secondary cancer can rarely occur months or years after treatment with cyclophosphamide, doxorubicin, and etoposide. Your care team will check your blood cell counts even after treatment is done to monitor for this side effect. o Live vaccines: Talk to your care team before getting any vaccines while taking rituximab. o Vesicant extravasation: Doxorubicin and vincristine are vesicants. If it leaks outside of the IV, it can cause severe damage to your skin. Notify your nurse right away if you feel any pain, aching, burning, itching, swelling, or redness at the site of your IV. If you experience ANY new, worsening, or uncontrolled side effects, call your care team immediately. Page 9 DA-EPOCH-R INTRAVENOUS CANCER TREATMENT EDUCATION Handling body fluids and waste Some of the drugs you receive may be present in urine, stool, sweat, or vomit for many days after treatment. Many cancer drugs are toxic, your bodily waste may also be toxic and can be dangerous to come into contact with. Once you have started EPOCH-R, follow the instructions below for at least five days after your treatment. This is to keep you, your loved ones, and the environment as safe as possible. o Pregnant women should avoid touching anything that may be soiled with body fluids from the patient. o Toilet and septic systems • You may use the same toilet, septic tank, and/or sewer that you usually use. If you have a low-flow toilet, close the lid and flush twice to ensure that all waste has been discarded. o If the toilet or toilet seat becomes soiled with urine, stool, or vomit, clean the surface after every use before other people use the toliet. o Wash hands with soap and water after using the toilet for at least 20 seconds. o If you need a bedpan, be sure your caregiver knows to wear gloves to assist with cleanup and to wash the bedpan with soap and water every day. o If you do not have good control of bladder or bowels, use a disposable pad with a plastic back, a diaper, or a sheet to absorb body waste. o Wash any skin that has been exposed to body waste with soap and water. o Linens or clothing that are soiled with body fluids or body waste should be washed separately from other linens and clothing. If you do not have a washer, place the soiled linens in a plastic bag until they can be washed. o Wash hands with soap and water after touching linens or clothing that may be soiled with body fluids. Intimacy, sexual activity, contraception, and fertility This treatment may cause changes that can affect intimacy and sexuality, including desire and body image. Maintaining physical closeness and/or intimacy with loved ones can be continued during treatment. Holding hands, hugging, and kissing can be done safely. It is recommended that you talk to your care team about any restrictions or questions you may have. Some treatments can influence the ability to have children, also known as fertility. If you’re interested in preserving fertility, talk to your care team before treatment. Ask your healthcare provider to determine when it is safe to become pregnant after your treatment. Patients of reproductive ability should not become pregnant or get their partners pregnant while receiving EPOCH-R. Some of the drugs you receive may be present in semen and vaginal secretion for many days after treatment. You should use barrier devices, such as condoms, during sexual activity to limit exposure to body fluids. o Talk to your care team about birth control. Not all options may be right for your treatment or cancer. Effective contraception could include one or more of the following: barrier methods (e.g. condoms), hormone methods (e.g. birth control pills), or surgery. o Tell your care team if you become pregnant or plan to breastfeed. Page 10 DA-EPOCH-R INTRAVENOUS CANCER TREATMENT EDUCATION Additional resources Prescribing information link Etoposide (Toposar®): https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=6dfedeff-a807-4405- a482-2f7109ad31c9&type=display Prednisone: https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=10fe5a3b-84dc-4600-87c2- b80c97ce18cf&type=display Vincristine (Oncovin®): https://www.accessdata.fda.gov/drugsatfda_docs/label/2014/071484s042lbl.pdf Cyclophosphamide (Cytoxan®): https://www.accessdata.fda.gov/drugsatfda_docs/ label/2013/012141s090,012142s112lbl.pdf Doxorubicin (Adriamycin®): https://www.accessdata.fda.gov/drugsatfda_docs/label/2013/050467s073lbl.pdf Rituximab (Rituxan®) (This drug is offered in several different brands. To find out what you’re using, talk to your care team): https://www.gene.com/download/pdf/rituxan_prescribing.pdf Additional instructions Updated – February 1, 2023 Important notice: The Association of Community Cancer Centers (ACCC), Hematology/Oncology Pharmacy Association (HOPA), National Community Oncology Dispensing Association, Inc. (NCODA), and Oncology Nursing Society (ONS) have collaborated in gathering information for and developing this patient education guide. This guide represents a brief summary of the therapy derived from information provided by the drug manufacturer and other resources. This guide does not cover all existing information related to the possible uses, directions, doses, precautions, warnings, interactions, adverse effects, or risks associated with this therapy and should not substitute for the advice of a qualified healthcare professional. Provision of this guide is for informational purposes only and does not constitute or imply endorsement, recommendation, or favoring of this therapy by ACCC, HOPA, NCODA, or ONS, who assume no liability for and cannot ensure the accuracy of the information presented. The collaborators are not making any representations with respect to the medications whatsoever, and any and all decisions, with respect to such medications, are at the sole risk of the individual receiving therapy. All decisions related to receiving this therapy should be made with the guidance and under the direction of a qualified healthcare professional. Permission: Intravenous Cancer Treatment Education (IVE) sheets are provided as a free educational resource for patients with cancer in need of concise, easy-to-understand information about intravenous cancer therapy. Healthcare providers are permitted to copy and distribute the sheets to patients as well as direct patients to the OCE website for information. However, commercial reproduction or reuse, as well as rebranding or reposting of any type, are strictly prohibited without permission of the copyright holder. Please email permission requests and licensing inquiries to This email address is being protected from spambots. You need JavaScript enabled to view it.. Copyright © 2021 by NCODA. All rights reserved.

INTRAVENOUS CANCER TREATMENT EDUCATION DARATUMUMAB DARATUMUMAB Name of the regimen and cancer drugs Daratumumab (DAYR uh TOOM yoo mab): Darzalex® OR Daratumumab and hyaluronidase subcutaneous (DAYR uh TOOM yoo mab... HY al yoo RAH nih days): Darzalex Faspro® Common uses This regimen is most commonly used for multiple myeloma but may be used for other diagnoses. Treatment schedule Your treatment will be given subcutaneous (SubQ) injection or into your vein through an intravenous (IV) line. This may be into a short, flexible temporary catheter in your arm, or through a central venous catheter. A central venous catheter, or central line is a long, flexible IV tube that empties into a very large vein next to the heart. Talk with your care team to see which will be best for you and your treatment. Each daratumumab treatment is dosed throughout a 28-day period. This is known as one cycle. Your treatment may be given for a set number of cycles, or it will keep going until the drug, or drugs, stop working or you have side effects which stop you from continuing treatment. Daratumumab IV or SubQ given on Days 1, 8, 15, and 22 for 2 cycles (cycles 1 and 2) Drug Day Daratumumab 1 2 ... 8 9 ... 15 16 ... 22 23 ... FOLLOWED BY: Daratumumab IV or SubQ given on days 1 and 15 for 4 cycles (cycles 3-6) Drug Day Daratumumab 1 2 ... 8 9 ... 15 16 ... 22 23 ... 28 Next Cycle Day 1 28 FOLLOWED BY: Daratumumab IV or SubQ given on day 1 (starting cycle 7) Drug Day Daratumumab 1 2 ... 8 9 ... 15 16 ... 22 23 ... Next Cycle Day 1 28 Next Cycle Day 1 Page 1 Page 2 DARATUMUMAB INTRAVENOUS CANCER TREATMENT EDUCATION DARATUMUMAB Other medications Other medications may be ordered for you to prevent or treat certain side effects. These include: Instructions: Medications to prevent side effects You will receive your medications to prevent side effects just before your cancer treatment. You may get prescriptions for other medications to take at home, as below: Medications to prevent allergic reactions You will receive medications to prevent infusion related reactions prior to starting your cancer treatment. Infection prevention There is a risk of serious infections during treatment. You may receive medications to prevent infection in the hospital, and may also get prescriptions for medications to take at home for infection prevention, as below: Possible drug interactions Daratumumab may interact with other drugs you are taking. Please inform your care providers of all prescription medicine, over-the-counter medications, vitamins, and herbal products that you take. Talk with your care provider or pharmacist before taking new medications, supplements, or receiving any vaccines. Grapefruit or grapefruit juice may interact with daratumumab. Avoid eating or drinking these during your treatment Page 3 DARATUMUMAB INTRAVENOUS CANCER TREATMENT EDUCATION Common Side Effects Common side effects that have been known to happen in patients receiving daratumumab are listed in the left side of this table. In some instances, the side effects may be reported less often but are still important to discuss. This table does not list all the known side effects for this therapy, only the ones that are experienced most often. Not every patient experiences every known side effect of a drug; even if you are taking the same drug as another patient, you may experience different side effects. Options to help manage any side effects that do occur are included on the right side of this table. These should be discussed with your care provider. If you experience any side effect you cannot manage or that is not listed here, contact your care provider. Possible Side Effect Management Decreased white blood cells (WBCs) and increased risk for infection Your WBCs should be monitored by a simple blood test. When your WBCs are low, you are at a greater risk of having an infection. Take the following precautions to protect yourself from infection. • Wash your hands often, especially before eating and after using the bathroom. • Avoid crowds and people with fevers, flu, or other infection. • Bathe often for good personal hygiene. Contact your care team if you experience any signs or symptoms of an infection such as: • Fever (temperature more than 100.4°F or 38°C) • Chills • Sore throat • Burning when peeing • Tiredness that is worse than normal • A sore that becomes red, is draining, or does not heal Check with your care team before taking any medicine for a fever or chills. Decreased platelet count and increased risk of bleeding Your platelets should be monitored by a simple blood test. When they are low, you may bruise or bleed more easily than usual. • Use caution to avoid bruises, cuts, or burns • Blow your nose gently and do not pick your nose • Brush your teeth gently with a soft toothbrush and maintain good oral hygiene • When shaving use an electric razor instead of razor blades • Use a nail file instead of a nail clippers Call your care team if you have bleeding that won’t stop. Examples include: • A bloody nose that bleeds for more than 5 minutes despite pressure • A cut that continues to ooze despite pressure • Gums that bleed a lot when you floss or brush Seek medical help right away if you have any severe headaches, blood in your urine or stool, coughing up blood, or bleeding that you cannot stop or lasts a long time. Continued on the next page Page 4 DARATUMUMAB INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Decreased platelet count and increased risk of bleeding (continued) You may need to take a break or “hold” your medication for medical or dental procedures. Talk to your care team or dentist before any scheduled procedures. Decreased hemoglobin, part of the red blood cells that carry iron and oxygen Your hemoglobin should be checked by a simple blood test. When your hemoglobin is low, you may notice that you get tired or fatigued more easily. • Try to get 7 to 8 hours of sleep per night • Avoid operating heavy machinery if you feel too tired • Find a balance between “work” and “rest” • Stay as active as possible, but know that it is okay to rest as needed, too • You might notice that you are more pale than usual Let your care team know right away if you have: • Shortness of breath • Dizziness • Fast or abnormal heartbeat • Headache Fatigue • You may be more tired than usual or have less energy • Stay as active as possible, but know it is okay to rest as needed • Try to do some type of moderate activity every day • Conserve your energy. Plan your activities and do them at a time of day when you feel a bit more energetic • Follow a healthy diet and stay hydrated • Accept help from family and friends • Find healthy ways to manage stress, such as meditation, journaling, yoga, and guided imagery • Develop good sleeping habits, limit napping during the day to help you sleep better at night • Avoid operating heavy machinery if you feel too tired • Contact your care team if you experience extreme fatigue that prevents you from doing your normal daily activities Infusion reaction During your treatment, let the nurse know right away if any of these symptoms happen: • Chills or shaking • Dizziness • Fever • Itchiness or rash • Flushing Continued on the next page INTRAVENOUS CANCER TREATMENT EDUCATION DARATUMUMAB Possible Side Effect Infusion reaction (continued) Management During your treatment, let the nurse know right away if any of these symptoms happen: • Difficulty breathing • Wheezing • Throat irritation • Cough • Congestion • Sudden back pain • Feeling faint Rare but serious side effects Tell your care provider if you experience any symptoms of these problems: Interference with blood tests: Daratumumab alters the results of certain lab tests. You should inform all of your health care providers that you are taking daratumumab. Shingles, cold sores, and genital sores: Daratumumab may cause reactivation of the virus that causes cold sores around the mouth or genital sores. It may also cause reactivation of the virus that causes chicken pox and leads to shingles. Your doctor will give you a medication to decrease the chance of the viruses being reactivated, but let your doctor know right away if you notice any new mouth sores, genital sores, or painful body rashes. If you experience ANY new, worsening, or uncontrolled side effects, call your care team immediately. Page 5 INTRAVENOUS CANCER TREATMENT EDUCATION DARATUMUMAB Handling body fluids and waste Some of the drugs you receive may be present in urine, stool, sweat, or vomit for many days after treatment. Many cancer drugs are toxic, your bodily waste may also be toxic and can be dangerous to come into contact with. Once you have started daratumumab, follow the instructions below for at least two days after your treatment. This is to keep you, your loved ones, and the environment as safe as possible. Pregnant women should avoid touching anything that may be soiled with body fluids from the patient. Toilet and septic systems • You may use the same toilet, septic tank, and/or sewer that you usually use. If you have a low-flow toilet, close the lid and flush twice to ensure that all waste has been discarded. If the toilet or toilet seat becomes soiled with urine, stool, or vomit, clean the surface after every use before other people use the toliet. Wash hands with soap and water after using the toilet for at least 20 seconds. If you need a bedpan, be sure your caregiver knows to wear gloves to assist with cleanup and to wash the bedpan with soap and water every day. If you do not have good control of bladder or bowels, use a disposable pad with a plastic back, a diaper, or a sheet to absorb body waste. Wash any skin that has been exposed to body waste with soap and water. Linens or clothing that are soiled with body fluids or body waste should be washed separately from other linens and clothing. If you do not have a washer, place the soiled linens in a plastic bag until they can be washed. Wash hands with soap and water after touching linens or clothing that may be soiled with body fluids. Intimacy, sexual activity, contraception, and fertility This treatment may cause changes that can affect intimacy and sexuality, including desire and body image. Maintaining physical closeness and/or intimacy with loved ones can be continued during treatment. Holding hands, hugging, and kissing can be done safely. It is recommended that you talk to your care team about any restrictions or questions you may have. Some treatments can influence the ability to have children, also known as fertility. If you’re interested in preserving fertility, talk to your care team before treatment. Ask your healthcare provider to determine when it is safe to become pregnant after your treatment. Patients of reproductive ability should not become pregnant or get their partners pregnant while receiving daratumumab. Some of the drugs you receive may be present in semen and vaginal secretion for many days after treatment. You should use barrier devices, such as condoms, during sexual activity to limit exposure to body fluids. Talk to your care team about birth control. Not all options may be right for your treatment or cancer. Effective contraception could include one or more of the following: barrier methods (e.g. condoms), hormone methods (e.g. birth control pills), or surgery. Tell your care team if you become pregnant or plan to breastfeed. Page 6 INTRAVENOUS CANCER TREATMENT EDUCATION DARATUMUMAB Additional resources Prescribing information: Daratumumab (Darzalex): https://www.accessdata.fda.gov/drugsatfda_docs/label/2023/761036s044lbl.pdf Daratumumab and hyaluronidase (Darzalex Faspro): https://www.accessdata.fda.gov/drugsatfda_docs/ label/2022/761145s018lbl.pdf Product website: Daratumumab (Darzalex): https://www.darzalex.com/ Additional instructions Updated – January 25, 2024 Important notice: The Association of Community Cancer Centers (ACCC), Hematology/Oncology Pharmacy Association (HOPA), National Community Oncology Dispensing Association, Inc. (NCODA), and Oncology Nursing Society (ONS) have collaborated in gathering information for and developing this patient education guide. This guide represents a brief summary of the therapy derived from information provided by the drug manufacturer and other resources. This guide does not cover all existing information related to the possible uses, directions, doses, precautions, warnings, interactions, adverse effects, or risks associated with this therapy and should not substitute for the advice of a qualified healthcare professional. Provision of this guide is for informational purposes only and does not constitute or imply endorsement, recommendation, or favoring of this therapy by ACCC, HOPA, NCODA, or ONS, who assume no liability for and cannot ensure the accuracy of the information presented. The collaborators are not making any representations with respect to the medications whatsoever, and any and all decisions, with respect to such medications, are at the sole risk of the individual receiving therapy. All decisions related to receiving this therapy should be made with the guidance and under the direction of a qualified healthcare professional. Permission: Intravenous Cancer Treatment Education (IVE) sheets are provided as a free educational resource for patients with cancer in need of concise, easy-to-understand information about intravenous cancer therapy. Healthcare providers are permitted to copy and distribute the sheets to patients as well as direct patients to the OCE website for information. However, commercial reproduction or reuse, as well as rebranding or reposting of any type, are strictly prohibited without permission of the copyright holder. Please email permission requests and licensing inquiries to This email address is being protected from spambots. You need JavaScript enabled to view it.. Copyright © 2023 by NCODA. All rights reserved. Page 7

Page 1 INTRAVENOUS CANCER TREATMENT EDUCATION THP DECITABINE Name of the regimen and cancer drugs Decitabine (deh-SY-tuh-been): Dacogen® Common uses Decitabine is most commonly used for the treatment of myelodysplastic syndromes (MDS) but may be used for other diagnoses. Treatment schedule Your treatment will be given into your vein through an intravenous (IV) line. This may be into a short, flexible temporary catheter in your arm, or through a central venous catheter. A central venous catheter, or central line is a long, flexible IV tube that empties into a very large vein next to the heart. Talk with your care team to see which will be best for you and your treatment. Each decitabine treatment is repeated every 42 days or every 28 days. This is known as one cycle. Your treatment may be given for a set number of cycles, or it will keep going until the drug, or drugs, stop working or you have side effects which stop you from continuing treatment. o Decitabine IV given on Days 1-3 OR o Decitabine IV given on days 1-5 Other medications Other medications may be ordered for you to prevent or treat certain side effects. These include: Instructions: Growth factors Growth factors, like filgrastim, pegfilgrastim, and others, are medications used to treat neutropenia and prevent infections. Neutropenia is a condition where there are lower-thannormal white blood cells caused by some type of chemotherapy. Growth factors help the bone marrow to make more white blood cells. Drug Cycle 1 Day 1 2 3 4 5 6 7 8 ... 42 Cycle 2 Day 1 Decitabine Drug Cycle 1 Day 1 2 3 4 5 6 7 8 ... 28 Cycle 2 Day 1 Decitabine DECITABINE Page 2 INTRAVENOUS CANCER TREATMENT EDUCATION DECITABINE Possible drug interactions o Decitabine may interact with other drugs you are taking. Please inform your care providers of all prescription medicine, over-the-counter medications, vitamins, and herbal products that you take. o Talk with your care provider or pharmacist before taking new medications, supplements, or receiving any vaccines. Do not receive any live vaccines while on treatment with decitabine. o Grapefruit or grapefruit juice may interact with decitabine. Avoid eating or drinking these during your treatment Other medications (continued) Instructions: Anti-nausea medications You will receive medications to prevent nausea just before your cancer treatment. You may also get prescriptions for other medications to take at home, as below: Medicatons to prevent side effects You will receive your medications to prevent side effects just before your cancer treatment. You may get prescriptions for other medications to take at home, as below: Infection prevention There is a risk of serious infections during treatment. You may receive medications to prevent infection in the hospital, and may also get prescriptions for medications to take at home for infection prevention, as below: Page 3 INTRAVENOUS CANCER TREATMENT EDUCATION THP DECITABINE Common Side Effects Common side effects that have been known to happen in patients receiving decitabine are listed in the left side of this table. In some instances, the side effects may be reported less often but are still important to discuss. This table does not list all the known side effects for this therapy, only the ones that are experienced most often. Not every patient experiences every known side effect of a drug; even if you are taking the same drug as another patient, you may experience different side effects. Options to help manage any side effects that do occur are included on the right side of this table. These should be discussed with your care provider. If you experience any side effect you cannot manage or that is not listed here, contact your care provider. Possible Side Effect Management Decreased white blood cells (WBCs) and increased risk for infection Your WBCs should be monitored by a simple blood test. When your WBCs are low, you are at a greater risk of having an infection. Take the following precautions to protect yourself from infection. • Wash your hands often, especially before eating and after using the bathroom. • Avoid crowds and people with fevers, flu, or other infections. • Bathe often for good personal hygiene. Contact your care team if you experience any signs or symptoms of an infection such as: • Fever (temperature more than 100.4°F or 38°C) • Chills • Sore throat • Burning when peeing • Tiredness that is worse than normal • A sore that becomes red, is draining, or does not heal. Check with your care team before taking any medicine for a fever or chills. Decreased platelet count and increased risk of bleeding Your platelets should be monitored by a simple blood test. When they are low, you may bruise or bleed more easily than usual. • Use caution to avoid bruises, cuts, or burns • Blow your nose gently and do not pick your nose • Brush your teeth gently with a soft toothbrush and maintain good oral hygiene • When shaving use an electric razor instead of razor blades • Use a nail file instead of a nail clippers Call your care team if you have bleeding that won’t stop. Examples include: • A bloody nose that bleeds for more than 5 minutes despite pressure • A cut that continues to ooze despite pressure • Gums that bleed a lot when you floss or brush Seek medical help right away if you have any severe headaches, blood in your urine or stool, coughing up blood, or bleeding that you cannot stop or lasts a long time. You may need to take a break or “hold” your medication for medical or dental procedures. Talk to your care team or dentist before any scheduled procedures. Continued on the next page Page 4 INTRAVENOUS CANCER TREATMENT EDUCATION DECITABINE Possible Side Effect Management Decreased hemoglobin, part of the red blood cells that carry iron and oxygen Your hemoglobin should be checked by a simple blood test. When your hemoglobin is low, you may notice that you get tired or fatigued more easily. • Try to get 7 to 8 hours of sleep per night • Avoid operating heavy machinery if you feel too tired • Find a balance between “work” and “rest” • Stay as active as possible, but know that it is okay to rest as needed, too • You might notice that you are more pale than usual Let your care team know right away if you have: • Shortness of breath • Dizziness • Fast or abnormal heartbeat Nausea or vomiting • Take all medications as prescribed to help prevent and lessen symptoms of nausea and vomiting. • Eat and drink slowly. • Drink 8-10 (8-ounce) glasses of water and/or fluid (soup or broth) each day unless your care team has instructed you to limit your fluid intake. • Eat small, frequent meals throughout the day rather than a few large meals. • Eat bland foods; avoid spicy, fried, and greasy foods. • Avoid intense exercise immediately after eating. • Don’t lay down right away after eating. • Wear loose-fitting clothing for comfort. • Avoid strong odors. Consider getting fresh air and try deep breathing. Let your care team know if you have nausea or vomiting. Your care team may prescribe medication to help with the symptoms. Diarrhea (loose and/ or urgent bowel movements) Monitor how many bowel movements you have each day. • Drink 8-10 (8-ounce) glasses of water or fluid each day unless your care team has asked you to limit your fluid intake. • Eat small, frequent meals throughout the day rather than a few large meals. • Eat bland, low-fiber foods (such as bananas, applesauce, potatoes, chicken, rice, and toast). • Avoid high fiber foods, such as raw vegetables and fruits and whole grains. • Avoid foods that cause gas, such as broccoli and beans. • Avoid foods with lactose, such as yogurt and milk. • Avoid spicy, fried, and greasy foods. Contact your care team if: • The number of bowel movements you have in a day increases by 4 or more. • You feel dizzy or lightheaded. Your care team may recommend an over-the-counter medication or prescribe something to help manage your symptoms. Continued on the next page Page 5 INTRAVENOUS CANCER TREATMENT EDUCATION THP DECITABINE Possible Side Effect Management Constipation Keep track of how many bowel movements you have each day. • Drink 8-10 (8-ounce) glasses of water or fluid each day unless your care team has asked you to limit your fluid intake. • Stay active and exercise, if possible. • Eat foods high in fiber like raw fruits and vegetables. Contact your care team if you have not had a bowel movement in 3 or more days. Your care team may recommend over-the-counter medications to help with constipation. A daily stool softener such as docusate (Colace®) and/or laxative such as senna (Senakot®) may be helpful. If these do not help within 48 hours, tell your care team. Fatigue • You may be more tired than usual or have less energy • Stay as active as possible, but know it is okay to rest as needed • Try to do some type of moderate activity every day • Conserve your energy. Plan your activities and do them at a time of day when you feel a bit more energetic • Follow a healthy diet and stay hydrated • Accept help from family and friends • Find healthy ways to manage stress, such as meditation, journaling, yoga, and guided imagery • Develop good sleeping habits, limit napping during the day to help you sleep better at night • Avoid operating heavy machinery if you feel too tired • Contact your care team if you experience extreme fatigue that prevents you from doing your normal daily activities Rare but serious side effects o If you experience ANY new, worsening, or uncontrolled side effects, call your care team immediately. Page 6 INTRAVENOUS CANCER TREATMENT EDUCATION DECITABINE Handling body fluids and waste Some of the drugs you receive may be present in urine, stool, sweat, or vomit for many days after treatment. Many cancer drugs are toxic, your bodily waste may also be toxic and can be dangerous to come into contact with. Once you have started decitabine, follow the instructions below for at least two days after your treatment. This is to keep you, your loved ones, and the environment as safe as possible. o Pregnant women should avoid touching anything that may be soiled with body fluids from the patient. o Toilet and septic systems • You may use the same toilet, septic tank, and/or sewer that you usually use. If you have a low-flow toilet, close the lid and flush twice to ensure that all waste has been discarded. o If the toilet or toilet seat becomes soiled with urine, stool, or vomit, clean the surface after every use before other people use the toliet. o Wash hands with soap and water after using the toilet for at least 20 seconds. o If you need a bedpan, be sure your caregiver knows to wear gloves to assist with cleanup and to wash the bedpan with soap and water every day. o If you do not have good control of bladder or bowels, use a disposable pad with a plastic back, a diaper, or a sheet to absorb body waste. o Wash any skin that has been exposed to body waste with soap and water. o Linens or clothing that are soiled with body fluids or body waste should be washed separately from other linens and clothing. If you do not have a washer, place the soiled linens in a plastic bag until they can be washed. o Wash hands with soap and water after touching linens or clothing that may be soiled with body fluids. Intimacy, sexual activity, contraception, and fertility This treatment may cause changes that can affect intimacy and sexuality, including desire and body image. Maintaining physical closeness and/or intimacy with loved ones can be continued during treatment. Holding hands, hugging, and kissing can be done safely. It is recommended that you talk to your care team about any restrictions or questions you may have. Some treatments can influence the ability to have children, also known as fertility. If you’re interested in preserving fertility, talk to your care team before treatment. Ask your healthcare provider to determine when it is safe to become pregnant after your treatment. Patients of reproductive ability should not become pregnant or get their partners pregnant while receiving decitabine. Some of the drugs you receive may be present in semen and vaginal secretion for many days after treatment. You should use barrier devices, such as condoms, during sexual activity to limit exposure to body fluids. o Talk to your care team about birth control. Not all options may be right for your treatment or cancer. Effective contraception could include one or more of the following: barrier methods (e.g. condoms), hormone methods (e.g. birth control pills), or surgery. o Tell your care team if you become pregnant or plan to breastfeed. Page 7 INTRAVENOUS CANCER TREATMENT EDUCATION THP DECITABINE Additional resources Prescribing information: https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/021790s021lbl.pdf Additional instructions Updated – August 26, 2023 Important notice: The Association of Community Cancer Centers (ACCC), Hematology/Oncology Pharmacy Association (HOPA), National Community Oncology Dispensing Association, Inc. (NCODA), and Oncology Nursing Society (ONS) have collaborated in gathering information for and developing this patient education guide. This guide represents a brief summary of the therapy derived from information provided by the drug manufacturer and other resources. This guide does not cover all existing information related to the possible uses, directions, doses, precautions, warnings, interactions, adverse effects, or risks associated with this therapy and should not substitute for the advice of a qualified healthcare professional. Provision of this guide is for informational purposes only and does not constitute or imply endorsement, recommendation, or favoring of this therapy by ACCC, HOPA, NCODA, or ONS, who assume no liability for and cannot ensure the accuracy of the information presented. The collaborators are not making any representations with respect to the medications whatsoever, and any and all decisions, with respect to such medications, are at the sole risk of the individual receiving therapy. All decisions related to receiving this therapy should be made with the guidance and under the direction of a qualified healthcare professional. Permission: Intravenous Cancer Treatment Education (IVE) sheets are provided as a free educational resource for patients with cancer in need of concise, easy-to-understand information about intravenous cancer therapy. Healthcare providers are permitted to copy and distribute the sheets to patients as well as direct patients to the OCE website for information. However, commercial reproduction or reuse, as well as rebranding or reposting of any type, are strictly prohibited without permission of the copyright holder. Please email permission requests and licensing inquiries to This email address is being protected from spambots. You need JavaScript enabled to view it.. Copyright © 2021 by NCODA. All rights reserved.

Page 1 DEXAMETHASONE, CYTARABINE, AND CISPLATIN (DHAP) INTRAVENOUS CANCER TREATMENT EDUCATION DEXAMETHASONE, CYTARABINE, AND CISPLATIN (DHAP) Name of the regimen and cancer drugs Your care team may refer to your treatment as DHAP. DHAP consists of 3 different anti-cancer therapies. • D: Dexamethasone (DEK-suh-MEH-thuh-sone): Decadron • H: High Dose • A: Cytarabine (sy-TAYR-uh-been): Cytosar-U, Ara-C • P: Cisplatin (sis-PLA-tin): Platinol Common uses This regimen is mostly commonly used for Diffuse Large B-Cell Lymphoma but may be used for other diagnoses. Treatment schedule Your treatment will be given into your vein through an intravenous (IV) line. This may be into a short, flexible temporary catheter in your arm, or through a central venous catheter. A central venous catheter, or central line is a long, flexible IV tube that empties into a very large vein next to the heart. Talk with your care team to see which will be best for you and your treatment. Each DHAP treatment is repeated every 21 or 28 days. This is known as one cycle. Your treatment may be given for a set number of cycles, or it will keep going until the drug, or drugs, stop working or you have side effects which stop you from continuing treatment. o Dexamethasone IV or oral given on Days 1-4 o Cytarabine IV over 3 hours every 12 hours for 2 doses given on Day 2 o Cisplatin IV continuous infusion over 24 hours beginning on Day 1 and ending on Day 2 Drug Cycle 1 Day 1 2 3 4 5 6 7 8 ... 21 Cycle 2 Day 1 2 Dexamethasone Cytarabine Cisplatin Page 2 DEXAMETHASONE, CYTARABINE, AND CISPLATIN (DHAP) INTRAVENOUS CANCER TREATMENT EDUCATION Other medications Other medications may be ordered for you to prevent or treat certain side effects. These include: Instructions: Growth Factors Growth factors, like filgrastim, pegfilgrastim, and others, are medications used to treat neutropenia and prevent infections. Neutropenia is a condition where there are lower-than-normal white blood cells caused by some type of chemotherapy. Growth factors help the bone marrow to make more white blood cells. Anti-nausea medication other medications You will receive medications to prevent nausea and other side effects just before your chemotherapy. You may get prescriptions for other medications to take at home, as below: Infection prevention There is a risk of serious infections during treatment. You may receive medications to prevent infection in the hospital, and may also get prescriptions for medications to take at home for infection prevention, as below: Medications to prevent allergic reactions You will receive medications to prevent infusion related reactions prior to starting your cancer treatment. Possible drug interactions o DHAP may interact with other drugs you are taking. Please inform your care providers of all prescription medicine, overthe-counter medications, vitamins, and herbal products that you take. o Talk with your care provider or pharmacist before taking new medications, supplements, or receiving any vaccines. o Grapefruit or grapefruit juice may interact with DHAP. Avoid eating or drinking these during your treatment. Page 3 DEXAMETHASONE, CYTARABINE, AND CISPLATIN (DHAP) INTRAVENOUS CANCER TREATMENT EDUCATION Common Side Effects Common side effects that have been known to happen in patients receiving DHAP are listed in the left side of this table. In some instances, the side effects may be reported less often but are still important to discuss. This table does not list all the known side effects for this therapy, only the ones that are experienced most often. Not every patient experiences every known side effect of a drug; even if you are taking the same drug as another patient, you may experience different side effects. Options to help manage any side effects that do occur are included on the right side of this table. These should be discussed with your care provider. If you experience any side effect you cannot manage or that is not listed here, contact your care provider. Possible Side Effect Management Decreased white blood cells (WBCs) and increased risk for infection Your WBCs should be monitored by a simple blood test. When your WBCs are low, you are at a greater risk of having an infection. Take the following precautions to protect yourself from infection. • Wash your hands often, especially before eating and after using the bathroom. • Avoid crowds and people with fevers, flu, or other infection. • Bathe often for good personal hygiene. Contact your care team if you experience any signs or symp-toms of an infection such as: • Fever (temperature more than 100.4°F or 38°C) • Chills • Sore throat • Burning when peeing • Tiredness that is worse than normal • A sore that becomes red, is draining, or does not heal. Check with your care team before taking any medicine for a fever or chills. Continued on the next page Page 4 DEXAMETHASONE, CYTARABINE, AND CISPLATIN (DHAP) INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Decreased platelet count and increased risk of bleeding Your platelets should be monitored by a simple blood test. When they are low, you may bruise or bleed more easily than usual. • Use caution to avoid bruises, cuts, or burns. • Blow your nose gently and do not pick your nose • Brush your teeth gently with a soft toothbrush and maintain good oral hygiene • When shaving use an electric razor instead of razor blades • Use a nail file instead of nail clippers Call your care team if you have bleeding that won’t stop. Examples include: • A bloody nose that bleeds for more than 5 minutes despite pressure • A cut that continues to ooze despite pressure • Gums that bleed a lot when you floss or brush Seek medical help right away if you have any severe headaches, blood in your urine or stool, coughing up blood, or bleeding that you cannot stop or lasts a long time. You may need to take a break or “hold” your medication for medical or dental procedures. Talk to your care team or dentist before any scheduled procedures. Decreased hemoglobin, part of the red blood cells that carry iron and oxygen Your hemoglobin should be checked by a simple blood test. When your hemoglobin is low, you may notice that you get tired or fatigued more easily. • Try to get 7 to 8 hours of sleep per night • Avoid operating heavy machinery if you feel too tired • Find a balance between “work” and “rest” • Stay as active as possible, but know that it is okay to rest as needed, too • You might notice that you are more pale than usual Let your care team know right away if you have: • Shortness of breath • Dizziness • Fast or abnormal heartbeat Changes in kidney function Your care team will routinely monitor your kidney function using a simple blood test. Contact your care team if you notice any of the following: • Decreased amount of urination • Unusual swelling in your legs and feet Continued on the next page Page 5 DEXAMETHASONE, CYTARABINE, AND CISPLATIN (DHAP) INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Nausea or vomiting • Take all medications as prescribed to help prevent and lessen symptoms of nausea and vomiting • Eat and drink slowly • Drink 8-10 (8-ounce) glasses of water and/or fluid (soup or broth) each day unless your care team has instructed you to limit your fluid intake • Eat small, frequent meals throughout the day rather than a few large meals • Eat bland foods; avoid spicy, fried, and greasy foods • Avoid intense exercise immediately after eating • Don’t lay down right away after eating • Wear loose fitting clothing for comfort • Avoid strong odors. Consider getting fresh air and try deep breathing. Let your care team know if you have nausea or vomiting. Your care team may prescribe medication to help with the symptoms. Mouth irritation or sores (stomatitis or mucositis) Practice good mouth care. • Rinse your mouth often • Brush your teeth with a soft toothbrush or cotton swab after meals • Use a mild non-alcohol mouth rinse at least 4 times a day (after eating and at bedtime). One example is a mixture of 1/8 teaspoon of salt and 1/4 teaspoon of baking soda in 8 ounces of warm (not hot) water • If you have sores in your mouth, avoid using tobacco products, alcohol, and mouthwashes that contain alcohol Call your care team if you experience pain or sores in your mouth or throat. Changes in electrolyte levels and other laboratory values: • Low magnesium levels • Low potassium levels • Low calcium levels Changes in some lab values may occur and will be monitored by a simple blood test. • You may not feel any symptoms if the changes are mild and they usually are not a sign of a serious problem. • More severe changes may occur, which can be a sign of a serious problem. Notify your care team if you have any of the following: • Shortness of breath • Chest discomfort • Weakness or fatigue • New aches and pains • Headaches • Dizziness • Swelling of your legs or feet • Red or brown colored urine Continued on the next page Page 6 DEXAMETHASONE, CYTARABINE, AND CISPLATIN (DHAP) INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Numbness or tingling in the hands or feet Report changes in your sense of touch, such as a burning feeling, pain on the skin or weakness. Hair loss (alopecia) • Hair will likely grow back after treatment is completed, although the color and/or texture may be different. • Some people choose to wear scarves, caps, or wigs. A short haircut prior to treatment may help with stress of hair loss. • Partial or complete hair loss is likely, usually 1-2 weeks after start of therapy. This hair loss can be all body hair. • It may take 3 to 6 months after therapy is completed to resume normal hair growth. • Be sure to keep your head covered to protect it from the sun during the summer and cold during the winter. • If not covering your scalp during the summer months, be sure to use sunscreen when spending time outdoors. Rare but serious side effects Tell your care provider if you experience any symptoms of these problems: o Central neurotoxicity: Cytarabine can cause changes to your balance, confusion, dizziness, or headache. Your care team will monitor you regularly throughout treatment. o Pulmonary toxicity: Cytarabine may result in serious and fatal lung toxicity. If you start to experience shortness of breath, fatigue, breathlessness, or discomfort/worsening of symptoms while lying on your back, immediately contact your care team. o Hepatic toxicity: Cytarabine may be harmful to your liver. Speak to your care team to know when you need to have blood tests done to monitor your liver function. If you get this side effect, your doctor may change your dose or stop treatment for some time. o Conjunctivitis: Cytarabine may cause eye pain, blurred vision, tearing, and light sensitivity. You may receive eye drops to prevent this side effect from occurring. o Vesicant extravasation: Cisplatin is a vesicant at higher concentrations. If it leaks outside of the IV, it can cause severe damage to your skin. Notify your nurse right away if you feel any pain, aching, burning, itching, swelling, or redness at the site of your IV. o Ototoxicity: Cisplatin may be harmful to your sense of hearing. Inform your care team if you have any ringing in the ears, hearing loss, or any other change in hearing. o Secondary Malignancy: A secondary cancer can rarely occur months or years after treatment with cisplatin. Your care team will check your blood cell counts even after treatment is done to monitor for this side effect. Page 7 DEXAMETHASONE, CYTARABINE, AND CISPLATIN (DHAP) INTRAVENOUS CANCER TREATMENT EDUCATION Rare but serious side effects (cont.) o Cytarabine syndrome: this regimen may cause cytarabine syndrome, a rare condition of several symptoms that appear after receiving cytarabine. Tell your care team if you develop any fever, muscle pain, bone pain, chest pain, eye pain, or rash after your treatment. o Tumor lysis syndrome: this regimen may cause tumor lysis syndrome, a rapid destruction of cancer cells that can cause organ dysfunction when starting treatment. Your care team may do blood tests to check for this side effect. o Hypersensitivity Reactions: Severe allergic reactions are a rare but serious side effect of this regimen. Seek medical attention right away if you notice difficulty breathing, swelling of the mouth or tongue, or a serious rash. If you experience ANY new, worsening, or uncontrolled side effects, call your care team immediately. Handling body fluids and waste Some of the drugs you receive may be present in urine, stool, sweat, or vomit for many days after treatment. Many cancer drugs are toxic, your bodily waste may also be toxic and can be dangerous to come into contact with. Once you have started DHAP, follow the instructions below for at least two days after your treatment. This is to keep you, your loved ones, and the environment as safe as possible. o Pregnant women should avoid touching anything that may be soiled with body fluids from the patient. o Toilet and septic systems • You may use the same toilet, septic tank, and/or sewer that you usually use. If you have a low-flow toilet, close the lid and flush twice to ensure that all waste has been discarded. o If the toilet or toilet seat becomes soiled with urine, stool, or vomit, clean the surface after every use before other people use the toliet. o Wash hands with soap and water after using the toilet for at least 20 seconds. o If you need a bedpan, be sure your caregiver knows to wear gloves to assist with cleanup and to wash the bedpan with soap and water every day. o If you do not have good control of bladder or bowels, use a disposable pad with a plastic back, a diaper, or a sheet to absorb body waste. o Wash any skin that has been exposed to body waste with soap and water. o Linens or clothing that are soiled with body fluids or body waste should be washed separately from other linens and clothing. If you do not have a washer, place the soiled linens in a plastic bag until they can be washed. o Wash hands with soap and water after touching linens or clothing that may be soiled with body fluids. Page 8 DEXAMETHASONE, CYTARABINE, AND CISPLATIN (DHAP) INTRAVENOUS CANCER TREATMENT EDUCATION Important notice: The Association of Community Cancer Centers (ACCC), Hematology/Oncology Pharmacy Association (HOPA), National Community Oncology Dispensing Association, Inc. (NCODA), and Oncology Nursing Society (ONS) have collaborated in gathering information for and developing this patient education guide. This guide represents a brief summary of the therapy derived from information provided by the drug manufacturer and other resources. This guide does not cover all existing information related to the possible uses, directions, doses, precautions, warnings, interactions, adverse effects, or risks associated with this therapy and should not substitute for the advice of a qualified healthcare professional. Provision of this guide is for informational purposes only and does not constitute or imply endorsement, recommendation, or favoring of this therapy by ACCC, HOPA, NCODA, or ONS, who assume no liability for and cannot ensure the accuracy of the information presented. The collaborators are not making any representations with respect to the medications whatsoever, and any and all decisions, with respect to such medications, are at the sole risk of the individual receiving therapy. All decisions related to receiving this therapy should be made with the guidance and under the direction of a qualified healthcare professional. Permission: Intravenous Cancer Treatment Education (IVE) sheets are provided as a free educational resource for patients with cancer in need of concise, easy-to-understand information about intravenous cancer therapy. Healthcare providers are permitted to copy and distribute the sheets to patients as well as direct patients to the OCE website for information. However, commercial reproduction or reuse, as well as rebranding or reposting of any type, are strictly prohibited without permission of the copyright holder. Please email permission requests and licensing inquiries to This email address is being protected from spambots. You need JavaScript enabled to view it.. Copyright © 2021 by NCODA. All rights reserved. Intimacy, sexual activity, contraception, and fertility This treatment may cause changes that can affect intimacy and sexuality, including desire and body image. Maintaining physical closeness and/or intimacy with loved ones can be continued during treatment. Holding hands, hugging, and kissing can be done safely. It is recommended that you talk to your care team about any restrictions or questions you may have. Some treatments can influence the ability to have children, also known as fertility. If you’re interested in preserving fertility, talk to your care team before treatment. Ask your healthcare provider to determine when it is safe to become pregnant after your treatment. Patients of reproductive ability should not become pregnant or get their partners pregnant while receiving DHAP. Some of the drugs you receive may be present in semen and vaginal secretion for many days after treatment. You should use barrier devices, such as condoms, during sexual activity to limit exposure to body fluids. o Talk to your care team about birth control. Not all options may be right for your treatment or cancer. Effective contraception could include one or more of the following: barrier methods (e.g. condoms), hormone methods (e.g. birth control pills), or surgery. o Tell your care team if you become pregnant or plan to breastfeed. Additional resources Prescribing information link Dexamethasone: https://www.accessdata.fda.gov/drugsatfda_docs/label/2004/11664slr062_decadron_lbl.pdf Cytarabine: https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/071868s032lbl.pdf Cisplatin: https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/018057s089lbl.pdf Updated – April 5, 2022

Page 1 DEXAMETHASONE, CYTARABINE, AND OXALIPLATIN (DHAX) INTRAVENOUS CANCER TREATMENT EDUCATION Name of the regimen and cancer drugs Your care team may refer to your treatment as DHAX. DHAX consists of 3 different anti-cancer therapies. • Dexamethasone (DEK-suh-MEH-thuh-sone) • Cytarabine (sy-TAYR-uh-been) • Oxaliplatin (ok-SA-lih-pla-tin) Common uses This regimen is most commonly used for Diffuse Large B-Cell Lymphoma but may be used for other treatments. Treatment schedule Your treatment will be given into your vein through an intravenous (IV) line. This may be into a short, flexible temporary catheter in your arm, or through a central venous catheter. A central venous catheter, or central line is a long, flexible IV tube that empties into a very large vein next to the heart. Talk with your care team to see which will be best for you and your treatment. Each DHAX treatment is repeated every 21 days. This is known as one cycle. Your treatment may be given for a set number of cycles, or it will keep going until the drug, or drugs, stop working or you have side effects which stop you from continuing o Dexamethasone IV or oral given on Days 1-4 o Cytarabine IV for 2 doses given on Day 2 o Oxaliplatin IV given on Day 1 Drug Cycle 1 Day 1 2 3 4 5 6 7 8 ... 21 Cycle 2 Day 1 2 Dexamethasone Cytarabine Oxaliplatin Page 2 Other medications Other medications may be ordered for you to prevent or treat certain side effects. These include: Instructions: Growth Factors Growth factors, like filgrastim, pegfilgrastim, and others, are medications used to treat neutropenia and prevent infections. Neutropenia is a condition where there are lower-than-normal white blood cells caused by some type of chemotherapy. Growth factors help the bone marrow to make more white blood cells. Anti-nausea medication other medications You will receive medications to prevent nausea and other side effects just before your chemotherapy. You may get prescriptions for other medications to take at home, as below: Infection prevention There is a risk of serious infections during treatment. You may receive medications to prevent infection in the hospital, and may also get prescriptions for medications to take at home for infection prevention, as below: Possible drug interactions o DHAX may interact with other drugs you are taking. Please inform your care providers of all prescription medicine, overthe-counter medications, vitamins, and herbal products that you take. o Talk with your care provider or pharmacist before taking new medications, supplements, or receiving any vaccines. o Grapefruit or grapefruit juice may interact with DHAX. Avoid eating or drinking these during your treatment. Page 3 Common Side Effects Common side effects that have been known to happen in patients receiving DHAX are listed in the left side of this table. In some instances, the side effects may be reported less often but are still important to discuss. This table does not list all the known side effects for this therapy, only the ones that are experienced most often. Not every patient experiences every known side effect of a drug; even if you are taking the same drug as another patient, you may experience different side effects. Options to help manage any side effects that do occur are included on the right side of this table. These should be discussed with your care provider. If you experience any side effect you cannot manage or that is not listed here, contact your care provider. Possible Side Effect Management Decreased white blood cells (WBCs) and increased risk for infection Your WBCs should be monitored by a simple blood test. When your WBCs are low, you are at a greater risk of having an in-fection. Take the following precautions to protect yourself from infection. • Wash your hands often, especially before eating and after using the bathroom. • Avoid crowds and people with fevers, flu, or other infection. • Bathe often for good personal hygiene. Contact your care team if you experience any signs or symp-toms of an infection such as: • Fever (temperature more than 100.4°F or 38°C) • Chills • Sore throat • Burning when peeing • Tiredness that is worse than normal • A sore that becomes red, is draining, or does not heal. Check with your care team before taking any medicine for a fever or chills. Continued on the next page Page 4 Decreased platelet count and increased risk of bleeding Your platelets should be monitored by a simple blood test. When they are low, you may bruise or bleed more easily than usual. • Use caution to avoid bruises, cuts, or burns. • Blow your nose gently and do not pick your nose • Brush your teeth gently with a soft toothbrush and maintain good oral hygiene • When shaving use an electric razor instead of razor blades • Use a nail file instead of nail clippers Call your care team if you have bleeding that won’t stop. Examples include: • A bloody nose that bleeds for more than 5 minutes despite pressure • A cut that continues to ooze despite pressure • Gums that bleed a lot when you floss or brush Seek medical help right away if you have any severe headaches, blood in your urine or stool, coughing up blood, or bleeding that you cannot stop or lasts a long time. You may need to take a break or “hold” your medication for medical or dental procedures. Talk to your care team or dentist before any scheduled procedures. Decreased hemoglobin, part of the red blood cells that carry iron and oxygen Your hemoglobin should be checked by a simple blood test. When your hemoglobin is low, you may notice that you get tired or fatigued more easily. • Try to get 7 to 8 hours of sleep per night • Avoid operating heavy machinery if you feel too tired • Find a balance between “work” and “rest” • Stay as active as possible, but know that it is okay to rest as needed, too • You might notice that you are more pale than usual Let your care team know right away if you have: • Shortness of breath • Dizziness • Fast or abnormal heartbeat Eye changes • This medication may cause blurred vision, dry eyes, or eye pain. • Report changes in eyesight to your care team. Sensitivity to cold Oxaliplatin can cause you to be VERY sensitive to cold for 3-7 days after treatment. • Avoid exposure to cold temperatures or touching cold objects • Avoid cold drinks, ice, and cold food. Use a straw when drinking cold liquids • Wear gloves when reaching into the freezer or handling cold objects • Wear gloves and cover mouth with a scarf during cold weather Page 5 Nausea or vomiting • Take all medications as prescribed to help prevent and lessen symptoms of nausea and vomiting • Eat and drink slowly • Drink 8-10 (8-ounce) glasses of water and/or fluid (soup or broth) each day unless your care team has instructed you to limit your fluid intake • Eat small, frequent meals throughout the day rather than a few large meals • Eat bland foods; avoid spicy, fried, and greasy foods • Avoid intense exercise immediately after eating • Don’t lay down right away after eating • Wear loose fitting clothing for comfort • Avoid strong odors. Consider getting fresh air and try deep breathing. Let your care team know if you have nausea or vomiting. Your care team may prescribe medication to help with the symptoms. Rare but serious side effects Tell your care provider if you experience any symptoms of these problems: o Central neurotoxicity, Cytarabine can cause changes to your balance, confusion, dizziness, or headache. Your care team will monitor you regularly throughout treatment. Inpatient treatment only. o Pulmonary toxicity: oxaliplatin may result in serious and fatal lung toxicity. If you start to experience shortness of breath, fatigue, breathlessness, or discomfort/worsening of symptoms while lying on your back, immediately contact your prescriber. o Hepatic toxicity: Cytarabine and oxaliplatin may be harmful to your liver. Speak to your care team to know when you need to have blood tests done to monitor your liver function. If you get this side effect, your doctor may change your dose or stop treatment for some time. o Tumor lysis syndrome: DHAX regimen may cause tumor lysis syndrome when starting treatment. Your care team may do blood tests to check for this side effect. o Hypersensitivity Reactions: Severe allergic reactions are a rare but serious side effect of DHAX regimen. Seek medical attention right away if you notice difficulty breathing, swelling of the mouth or tongue, or a serious rash. o Reversible posterior leukoencephalopathy syndrome: A condition called reversible posterior leukoencephalopathy syndrome can occur while taking oxaliplatin. Call your care team right away if you have headaches, seizures, confusion or changes in vision. o Vesicant extravasation: oxaliplatin is an irritant with vesicant-like properties. If it leaks outside of the IV, it can cause severe damage to your skin. Notify your nurse right away if you feel any pain, aching, burning, itching, swelling, or redness at the site of your IV. If you experience ANY new, worsening, or uncontrolled side effects, call your care team immediately. Handling body fluids and waste Some of the drugs you receive may be present in urine, stool, sweat, or vomit for many days after treatment. Many cancer drugs are toxic, your bodily waste may also be toxic and can be dangerous to come into contact with. Once you have started DHAX, follow the instructions below for at least two days after your treatment. This is to keep you, your loved ones, and the environment as safe as possible. o Pregnant women should avoid touching anything that may be soiled with body fluids from the patient. o Toilet and septic systems • You may use the same toilet, septic tank, and/or sewer that you usually use. If you have a low-flow toilet, close the lid and flush twice to ensure that all waste has been discarded. o If the toilet or toilet seat becomes soiled with urine, stool, or vomit, clean the surface after every use before other people use the toliet. o Wash hands with soap and water after using the toilet for at least 20 seconds. o If you need a bedpan, be sure your caregiver knows to wear gloves to assist with cleanup and to wash the bedpan with soap and water every day. o If you do not have good control of bladder or bowels, use a disposable pad with a plastic back, a diaper, or a sheet to absorb body waste. o Wash any skin that has been exposed to body waste with soap and water. o Linens or clothing that are soiled with body fluids or body waste should be washed separately from other linens and clothing. If you do not have a washer, place the soiled linens in a plastic bag until they can be washed. o Wash hands with soap and water after touching linens or clothing that may be soiled with body fluids. Intimacy, sexual activity, contraception, and fertility This treatment may cause changes that can affect intimacy and sexuality, including desire and body image. Maintaining physical closeness and/or intimacy with loved ones can be continued during treatment. Holding hands, hugging, and kissing can be done safely. It is recommended that you talk to your care team about any restrictions or questions you may have. Some treatments can influence the ability to have children, also known as fertility. If you’re interested in preserving fertility, talk to your care team before treatment. Ask your healthcare provider to determine when it is safe to become pregnant after your treatment. Patients of reproductive ability should not become pregnant or get their partners pregnant while receiving DHAX. Some of the drugs you receive may be present in semen and vaginal secretion for many days after treatment. You should use barrier devices, such as condoms, during sexual activity to limit exposure to body fluids. o Talk to your care team about birth control. Not all options may be right for your treatment or cancer. Effective contraception could include one or more of the following: barrier methods (e.g. condoms), hormone methods (e.g. birth control pills), or surgery. o Tell your care team if you become pregnant or plan to breastfeed. Page 7 Additional resources Product website Dexamethasone: https://www.drugs.com/dexamethasone.html Cytarabine: https://www.drugs.com/mtm/cytarabine.html Oxaliplatin: https://www.drugs.com/mtm/oxaliplatin.html Prescribing information link Dexamethasone: https://www.accessdata.fda.gov/drugsatfda_docs/label/2004/11664slr062_decadron_lbl.pdf Cytarabine: https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/071868s032lbl.pdf Oxaliplatin: https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/021492s016lbl.pdf Additional instructions Updated – April 5, 2022 Important notice: The Association of Community Cancer Centers (ACCC), Hematology/Oncology Pharmacy Association (HOPA), National Community Oncology Dispensing Association, Inc. (NCODA), and Oncology Nursing Society (ONS) have collaborated in gathering information for and developing this patient education guide. This guide represents a brief summary of the therapy derived from information provided by the drug manufacturer and other resources. This guide does not cover all existing information related to the possible uses, directions, doses, precautions, warnings, interactions, adverse effects, or risks associated with this therapy and should not substitute for the advice of a qualified healthcare professional. Provision of this guide is for informational purposes only and does not constitute or imply endorsement, recommendation, or favoring of this therapy by ACCC, HOPA, NCODA, or ONS, who assume no liability for and cannot ensure the accuracy of the information presented. The collaborators are not making any representations with respect to the medications whatsoever, and any and all decisions, with respect to such medications, are at the sole risk of the individual receiving therapy. All decisions related to receiving this therapy should be made with the guidance and under the direction of a qualified healthcare professional. Permission: Intravenous Cancer Treatment Education (IVE) sheets are provided as a free educational resource for patients with cancer in need of concise, easy-to-understand information about intravenous cancer therapy. Healthcare providers are permitted to copy and distribute the sheets to patients as well as direct patients to the OCE website for information. However, commercial reproduction or reuse, as well as rebranding or reposting of any type, are strictly prohibited without permission of the copyright holder. Please email permission requests and licensing inquiries to This email address is being protected from spambots. You need JavaScript enabled to view it.. Copyright © 2021 by NCODA. All rights reserved.

Page 1 DEXAMETHASONE, CYTARABINE, AND OXALIPLATIN (DHAX) INTRAVENOUS CANCER TREATMENT EDUCATION Name of the regimen and cancer drugs Your care team may refer to your treatment as DHAX. DHAX consists of 3 different anti-cancer therapies. • Dexamethasone (DEK-suh-MEH-thuh-sone) • Cytarabine (sy-TAYR-uh-been) • Oxaliplatin (ok-SA-lih-pla-tin) Common uses This regimen is most commonly used for Diffuse Large B-Cell Lymphoma but may be used for other treatments. Treatment schedule Your treatment will be given into your vein through an intravenous (IV) line. This may be into a short, flexible temporary catheter in your arm, or through a central venous catheter. A central venous catheter, or central line is a long, flexible IV tube that empties into a very large vein next to the heart. Talk with your care team to see which will be best for you and your treatment. Each DHAX treatment is repeated every 21 days. This is known as one cycle. Your treatment may be given for a set number of cycles, or it will keep going until the drug, or drugs, stop working or you have side effects which stop you from continuing o Dexamethasone IV or oral given on Days 1-4 o Cytarabine IV for 2 doses given on Day 2 o Oxaliplatin IV given on Day 1 Drug Cycle 1 Day 1 2 3 4 5 6 7 8 ... 21 Cycle 2 Day 1 2 Dexamethasone Cytarabine Oxaliplatin Page 2 Other medications Other medications may be ordered for you to prevent or treat certain side effects. These include: Instructions: Growth Factors Growth factors, like filgrastim, pegfilgrastim, and others, are medications used to treat neutropenia and prevent infections. Neutropenia is a condition where there are lower-than-normal white blood cells caused by some type of chemotherapy. Growth factors help the bone marrow to make more white blood cells. Anti-nausea medication other medications You will receive medications to prevent nausea and other side effects just before your chemotherapy. You may get prescriptions for other medications to take at home, as below: Infection prevention There is a risk of serious infections during treatment. You may receive medications to prevent infection in the hospital, and may also get prescriptions for medications to take at home for infection prevention, as below: Possible drug interactions o DHAX may interact with other drugs you are taking. Please inform your care providers of all prescription medicine, overthe-counter medications, vitamins, and herbal products that you take. o Talk with your care provider or pharmacist before taking new medications, supplements, or receiving any vaccines. o Grapefruit or grapefruit juice may interact with DHAX. Avoid eating or drinking these during your treatment. Page 3 Common Side Effects Common side effects that have been known to happen in patients receiving DHAX are listed in the left side of this table. In some instances, the side effects may be reported less often but are still important to discuss. This table does not list all the known side effects for this therapy, only the ones that are experienced most often. Not every patient experiences every known side effect of a drug; even if you are taking the same drug as another patient, you may experience different side effects. Options to help manage any side effects that do occur are included on the right side of this table. These should be discussed with your care provider. If you experience any side effect you cannot manage or that is not listed here, contact your care provider. Possible Side Effect Management Decreased white blood cells (WBCs) and increased risk for infection Your WBCs should be monitored by a simple blood test. When your WBCs are low, you are at a greater risk of having an in-fection. Take the following precautions to protect yourself from infection. • Wash your hands often, especially before eating and after using the bathroom. • Avoid crowds and people with fevers, flu, or other infection. • Bathe often for good personal hygiene. Contact your care team if you experience any signs or symp-toms of an infection such as: • Fever (temperature more than 100.4°F or 38°C) • Chills • Sore throat • Burning when peeing • Tiredness that is worse than normal • A sore that becomes red, is draining, or does not heal. Check with your care team before taking any medicine for a fever or chills. Continued on the next page Page 4 Decreased platelet count and increased risk of bleeding Your platelets should be monitored by a simple blood test. When they are low, you may bruise or bleed more easily than usual. • Use caution to avoid bruises, cuts, or burns. • Blow your nose gently and do not pick your nose • Brush your teeth gently with a soft toothbrush and maintain good oral hygiene • When shaving use an electric razor instead of razor blades • Use a nail file instead of nail clippers Call your care team if you have bleeding that won’t stop. Examples include: • A bloody nose that bleeds for more than 5 minutes despite pressure • A cut that continues to ooze despite pressure • Gums that bleed a lot when you floss or brush Seek medical help right away if you have any severe headaches, blood in your urine or stool, coughing up blood, or bleeding that you cannot stop or lasts a long time. You may need to take a break or “hold” your medication for medical or dental procedures. Talk to your care team or dentist before any scheduled procedures. Decreased hemoglobin, part of the red blood cells that carry iron and oxygen Your hemoglobin should be checked by a simple blood test. When your hemoglobin is low, you may notice that you get tired or fatigued more easily. • Try to get 7 to 8 hours of sleep per night • Avoid operating heavy machinery if you feel too tired • Find a balance between “work” and “rest” • Stay as active as possible, but know that it is okay to rest as needed, too • You might notice that you are more pale than usual Let your care team know right away if you have: • Shortness of breath • Dizziness • Fast or abnormal heartbeat Eye changes • This medication may cause blurred vision, dry eyes, or eye pain. • Report changes in eyesight to your care team. Sensitivity to cold Oxaliplatin can cause you to be VERY sensitive to cold for 3-7 days after treatment. • Avoid exposure to cold temperatures or touching cold objects • Avoid cold drinks, ice, and cold food. Use a straw when drinking cold liquids • Wear gloves when reaching into the freezer or handling cold objects • Wear gloves and cover mouth with a scarf during cold weather Page 5 Nausea or vomiting • Take all medications as prescribed to help prevent and lessen symptoms of nausea and vomiting • Eat and drink slowly • Drink 8-10 (8-ounce) glasses of water and/or fluid (soup or broth) each day unless your care team has instructed you to limit your fluid intake • Eat small, frequent meals throughout the day rather than a few large meals • Eat bland foods; avoid spicy, fried, and greasy foods • Avoid intense exercise immediately after eating • Don’t lay down right away after eating • Wear loose fitting clothing for comfort • Avoid strong odors. Consider getting fresh air and try deep breathing. Let your care team know if you have nausea or vomiting. Your care team may prescribe medication to help with the symptoms. Rare but serious side effects Tell your care provider if you experience any symptoms of these problems: o Central neurotoxicity, Cytarabine can cause changes to your balance, confusion, dizziness, or headache. Your care team will monitor you regularly throughout treatment. Inpatient treatment only. o Pulmonary toxicity: oxaliplatin may result in serious and fatal lung toxicity. If you start to experience shortness of breath, fatigue, breathlessness, or discomfort/worsening of symptoms while lying on your back, immediately contact your prescriber. o Hepatic toxicity: Cytarabine and oxaliplatin may be harmful to your liver. Speak to your care team to know when you need to have blood tests done to monitor your liver function. If you get this side effect, your doctor may change your dose or stop treatment for some time. o Tumor lysis syndrome: DHAX regimen may cause tumor lysis syndrome when starting treatment. Your care team may do blood tests to check for this side effect. o Hypersensitivity Reactions: Severe allergic reactions are a rare but serious side effect of DHAX regimen. Seek medical attention right away if you notice difficulty breathing, swelling of the mouth or tongue, or a serious rash. o Reversible posterior leukoencephalopathy syndrome: A condition called reversible posterior leukoencephalopathy syndrome can occur while taking oxaliplatin. Call your care team right away if you have headaches, seizures, confusion or changes in vision. o Vesicant extravasation: oxaliplatin is an irritant with vesicant-like properties. If it leaks outside of the IV, it can cause severe damage to your skin. Notify your nurse right away if you feel any pain, aching, burning, itching, swelling, or redness at the site of your IV. If you experience ANY new, worsening, or uncontrolled side effects, call your care team immediately. Handling body fluids and waste Some of the drugs you receive may be present in urine, stool, sweat, or vomit for many days after treatment. Many cancer drugs are toxic, your bodily waste may also be toxic and can be dangerous to come into contact with. Once you have started DHAX, follow the instructions below for at least two days after your treatment. This is to keep you, your loved ones, and the environment as safe as possible. o Pregnant women should avoid touching anything that may be soiled with body fluids from the patient. o Toilet and septic systems • You may use the same toilet, septic tank, and/or sewer that you usually use. If you have a low-flow toilet, close the lid and flush twice to ensure that all waste has been discarded. o If the toilet or toilet seat becomes soiled with urine, stool, or vomit, clean the surface after every use before other people use the toliet. o Wash hands with soap and water after using the toilet for at least 20 seconds. o If you need a bedpan, be sure your caregiver knows to wear gloves to assist with cleanup and to wash the bedpan with soap and water every day. o If you do not have good control of bladder or bowels, use a disposable pad with a plastic back, a diaper, or a sheet to absorb body waste. o Wash any skin that has been exposed to body waste with soap and water. o Linens or clothing that are soiled with body fluids or body waste should be washed separately from other linens and clothing. If you do not have a washer, place the soiled linens in a plastic bag until they can be washed. o Wash hands with soap and water after touching linens or clothing that may be soiled with body fluids. Intimacy, sexual activity, contraception, and fertility This treatment may cause changes that can affect intimacy and sexuality, including desire and body image. Maintaining physical closeness and/or intimacy with loved ones can be continued during treatment. Holding hands, hugging, and kissing can be done safely. It is recommended that you talk to your care team about any restrictions or questions you may have. Some treatments can influence the ability to have children, also known as fertility. If you’re interested in preserving fertility, talk to your care team before treatment. Ask your healthcare provider to determine when it is safe to become pregnant after your treatment. Patients of reproductive ability should not become pregnant or get their partners pregnant while receiving DHAX. Some of the drugs you receive may be present in semen and vaginal secretion for many days after treatment. You should use barrier devices, such as condoms, during sexual activity to limit exposure to body fluids. o Talk to your care team about birth control. Not all options may be right for your treatment or cancer. Effective contraception could include one or more of the following: barrier methods (e.g. condoms), hormone methods (e.g. birth control pills), or surgery. o Tell your care team if you become pregnant or plan to breastfeed. Page 7 Additional resources Product website Dexamethasone: https://www.drugs.com/dexamethasone.html Cytarabine: https://www.drugs.com/mtm/cytarabine.html Oxaliplatin: https://www.drugs.com/mtm/oxaliplatin.html Prescribing information link Dexamethasone: https://www.accessdata.fda.gov/drugsatfda_docs/label/2004/11664slr062_decadron_lbl.pdf Cytarabine: https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/071868s032lbl.pdf Oxaliplatin: https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/021492s016lbl.pdf Additional instructions Updated – April 5, 2022 Important notice: The Association of Community Cancer Centers (ACCC), Hematology/Oncology Pharmacy Association (HOPA), National Community Oncology Dispensing Association, Inc. (NCODA), and Oncology Nursing Society (ONS) have collaborated in gathering information for and developing this patient education guide. This guide represents a brief summary of the therapy derived from information provided by the drug manufacturer and other resources. This guide does not cover all existing information related to the possible uses, directions, doses, precautions, warnings, interactions, adverse effects, or risks associated with this therapy and should not substitute for the advice of a qualified healthcare professional. Provision of this guide is for informational purposes only and does not constitute or imply endorsement, recommendation, or favoring of this therapy by ACCC, HOPA, NCODA, or ONS, who assume no liability for and cannot ensure the accuracy of the information presented. The collaborators are not making any representations with respect to the medications whatsoever, and any and all decisions, with respect to such medications, are at the sole risk of the individual receiving therapy. All decisions related to receiving this therapy should be made with the guidance and under the direction of a qualified healthcare professional. Permission: Intravenous Cancer Treatment Education (IVE) sheets are provided as a free educational resource for patients with cancer in need of concise, easy-to-understand information about intravenous cancer therapy. Healthcare providers are permitted to copy and distribute the sheets to patients as well as direct patients to the OCE website for information. However, commercial reproduction or reuse, as well as rebranding or reposting of any type, are strictly prohibited without permission of the copyright holder. Please email permission requests and licensing inquiries to This email address is being protected from spambots. You need JavaScript enabled to view it.. Copyright © 2021 by NCODA. All rights reserved.

Page 1 INTRAVENOUS CANCER TREATMENT EDUCATION THP ABVD ABVD Name of the regimen and cancer drugs Your care team may refer to your treatment as ABVD. The regimen consists of 4 different anti-cancer therapies: • A: Doxorubicin hydrochloride (DOK soh ROO bih sin HY droh KLOR ide): Adriamycin® • B: Bleomycin sulfate (blee oh MY sin SUL fayt) • V: Vinblastine sulfate (vin BLAS teen SUL fayt): Velban® • D: Dacarbazine (duh KAR buh zeen): DTIC-DOME® Common uses This regimen is most commonly used to Hodkin’s Lymphoma. Treatment schedule Your treatment will be given into your vein through an intravenous (IV) line. This may be into a short, flexible temporary catheter in your arm, or through a central venous catheter. A central venous catheter, or central line is a long, flexible IV tube that empties into a very large vein next to the heart. Talk with your care team to see which will be best for you and your treatment. Each ABVD treatment is given on days 1 and 15, every 28 days. This is known as one cycle. Your treatment may be given for a set number of cycles, ranging from 2-6 cycles, and it may be administered in combination with radiation therapy. o Doxorubicin IV is given on days 1 and 15. o Bleomycin IV is given on days 1 and 15. o Vinblastine IV is given on days 1 and 15. o Dacarbazine IV is given on days 1 and 15. Drug Cycle 1 Day 1 2 3 4 ... 15 16 17 18 ... 28 Cycle 2 Day 1 Doxorubicin Bleomycins Vinblastine Dacarbazine Page 2 ABVD Possible drug interactions o ABVD may interact with other drugs you are taking. Please inform your care providers of all prescription medicine, over-the-counter medications, vitamins, and herbal products that you take. o Talk with your care provider or pharmacist before taking new medications, supplements, or receiving any vaccines. o Grapefruit or grapefruit juice may interact with ABVD. Avoid eating or drinking these during your treatment. Other medications Other medications may be ordered for you to prevent or treat certain side effects. These include: Instructions: Anti-nausea medications You will receive medications to prevent nausea just before your cancer treatment. You may get prescriptions for other medications to take at home, as below: Medications to prevent allergic reactions You will receive medications to prevent infusion related reactions prior to starting your cancer treatment. Page 3 Common Side Effects Common side effects that have been known to happen in patients receiving the ABVD regimen are listed in the left side of this table. In some instances, the side effects may be reported less often but are still important to discuss. This table does not list all the known side effects for this therapy, only the ones that are experienced most often. Not every patient experiences every known side effect of a drug; even if you are taking the same drug as another patient, you may experience different side effects. Options to help manage any side effects that do occur are included on the right side of this table. These should be discussed with your care provider. If you experience any side effect you cannot manage or that is not listed here, contact your care provider. Possible Side Effect Management Decreased white blood cells (WBCs) and increased risk for infection Your WBCs should be monitored by a simple blood test. When your WBCs are low, you are at a greater risk of having an infection. Take the following precautions to protect yourself from infection. • Wash your hands often, especially before eating and after using the bathroom. • Avoid crowds and people with fevers, flu, or other infections. • Bathe often for good personal hygiene. Contact your care team if you experience any signs or symptoms of an infection such as: • Fever (temperature more than 100.4°F or 38°C) • Chills • Sore throat • Burning when peeing • Tiredness that is worse than normal • A sore that becomes red, is draining, or does not heal. Check with your care team before taking any medicine for a fever or chills. Decreased platelet count and increased risk of bleeding Your platelets should be monitored by a simple blood test. When they are low, you may bruise or bleed more easily than usual. • Use caution to avoid bruises, cuts, or burns • Blow your nose gently and do not pick your nose • Brush your teeth gently with a soft toothbrush and maintain good oral hygiene • When shaving use an electric razor instead of razor blades • Use a nail file instead of a nail clippers Call your care team if you have bleeding that won’t stop. Examples include: • A bloody nose that bleeds for more than 5 minutes despite pressure • A cut that continues to ooze despite pressure • Gums that bleed a lot when you floss or brush Seek medical help right away if you have any severe headaches, blood in your urine or stool, coughing up blood, or bleeding that you cannot stop or lasts a long time. You may need to take a break or “hold” your medication for medical or dental procedures. Talk to your care team or dentist before any scheduled procedures. Continued on the next page Page 4 Decreased hemoglobin, part of the red blood cells that carry iron and oxygen Your hemoglobin should be checked by a simple blood test. When your hemoglobin is low, you may notice that you get tired or fatigued more easily. • Try to get 7 to 8 hours of sleep per night • Avoid operating heavy machinery if you feel too tired • Find a balance between “work” and “rest” • Stay as active as possible, but know that it is okay to rest as needed, too • You might notice that you are more pale than usual Let your care team know right away if you have: • Shortness of breath • Dizziness • Fast or abnormal heartbeat Hair loss (alopecia) • Hair will likely grow back after treatment is completed, although the color and/or texture may be different. • It may take 3 to 6 months after therapy is completed to resume normal hair growth. • Some people choose to wear scarves, caps, or wigs. A short haircut prior to treatment may help with stress of hair loss. • Partial or complete hair loss is likely, usually 1-2 weeks after start of therapy. This hair loss can be all body hair. • Be sure to keep your head covered to protect it from the sun during the summer and cold during the winter. • If not covering your scalp during the summer months, be sure to use sunscreen when spending time outdoors. Nausea or vomiting • Take all medications as prescribed to help prevent and lessen symptoms of nausea and vomiting. • Eat and drink slowly. • Drink 8-10 (8-ounce) glasses of water and/or fluid (soup or broth) each day unless your care team has instructed you to limit your fluid intake. • Eat small, frequent meals throughout the day rather than a few large meals. • Eat bland foods; avoid spicy, fried, and greasy foods. • Avoid intense exercise immediately after eating. • Don’t lay down right away after eating. • Wear loose-fitting clothing for comfort. • Avoid strong odors. Consider getting fresh air and try deep breathing. Let your care team know if you have nausea or vomiting. Your care team may prescribe medication to help with the symptoms. Changes in body fluid color Doxorubicin may cause tears, sweat, saliva, and urine to have a reddish tint for a few days after Page 5 Rash or itchy skin Keep your skin moisturized with creams and moisturizing lotions to decrease the risk of rash or itchiness and wear loose fitting clothing. • Avoid using perfumes and cologne as these products may increase rash symptoms. • Avoid being in the heat for long periods of time. • Your provider may recommend an over-the-counter antihistamine or a topical cream. • Sunlight can make symptoms worse • Avoid sun exposure as much as possible to decrease the risk of sunburn. The highest exposure to UV (ultra-violet) radiation occurs between the hours of 10am and 4pm. • Wear long-sleeved clothing, with UV protection if possible. • Wear broad-brimmed hats. • Apply broad-spectrum sunscreen (UVA/UVB) with at least SPF 30 as often as directed on the bottle. • Use lip balm with at least SPF 30 • Avoid tanning beds If your rash or itching continues to worsen, contact your care team. Constipation Keep track of how many bowel movements you have each day. • Drink 8-10 (8-ounce) glasses of water or fluid each day unless your care team has asked you to limit your fluid intake • Stay active and exercise, if possible • Eat foods high in fiber like raw fruits and vegetables Contact your care team if you have not had a bowel movement in 3 or more days Your care team may recommend over-the-counter medications to help with constipation. A daily stool softener such as docusate (Colace®) and/or laxative such as senna (Senakot®) may be helpful. If these do not help within 48 hours, tell your care team. Mouth irritation or sores (stomatitis or mucositis) Practice good mouth care. • Rinse your mouth after meals and at bedtime, and more frequently if you develop sores in your mouth • Brush your teeth with a soft toothbrush or cotton swab after meals • Use a mild non-alcohol mouth rinse at least 4 times a day (after eating and at bedtime). One example is a mixture of 1/8 teaspoon of salt and 1/4 teaspoon of baking soda in 8 ounces of warm (not hot) water • Avoid acidic, hot or spicy foods and beverages, and rough foods that might irritate the mouth • If you have sores in your mouth, avoid using tobacco products, alcohol, and mouthwashes that contain alcohol Call your care team if you experience pain or sores in your mouth or throat. Page 6 Rare but serious side effects Tell your care provider if you experience any symptoms of these problems: o The ABVD regimen may cause harm to the fetus if administered to pregnant women. Please contact your healthcare professional if you are or suspect that you are pregnant, as this may result in an alternative treatment plan. o A secondary cancer can rarely occur months or years after treatment. Your care team will check your blood cell counts even after treatment is done to monitor for this side effect. o The ABVD regimen may be harmful to your liver. Speak to your care team to know when you need to have blood tests done to monitor your liver function. o Doxorubicin hydrochloride and vinblastine sulfate are vesicants. If these medications leak outside of the IV, it can cause severe damage to your skin. Notify your nurse right away if you feel any pain, aching, burning, itching, swelling, or redness at the site of your IV. o Doxorubicin Hydrochloride may affect your heart’s ability to pump blood. Prior to starting treatment, you might need a test to measure your heart function. Tell your healthcare provider right away if you experience new or worsening shortness of breath, chest pain, irregular heartbeat, or swelling of your ankles or legs. o These medications can rarely cause an infusion or post-infusion reaction. During your treatment, let the nurse know right away if any of these symptoms happen: chills or shaking, confusion, dizziness, fever, itchiness or rash, flushing, difficulty breathing, wheezing, throat irritation, cough, congestion, sudden back pain, or feeling faint. If symptoms occur outside of the clinic, seek medical attention right away and inform your care team. o Bleomycin sulfate may result in serious lung toxicity. Prior to starting treatment, you might need pulmonary function tests to assess your lung function. When taking Bleomycin sulfate, if you start to experience shortness of breath, fatigue, breathlessness, or discomfort/worsening of symptoms while lying on your back, please immediately contact your prescriber. o Vinblastine may cause numbness, pain, or burning in your hands or feet. Talk to your care team about ways to resolve this side effect. If you experience ANY new, worsening, or uncontrolled side effects, call your care team immediately. Page 7 Handling body fluids and waste Some of the drugs you receive may be present in urine, stool, sweat, or vomit for many days after treatment. Many cancer drugs are toxic, your bodily waste may also be toxic and can be dangerous to come into contact with. Once you have started ABVD, follow the instructions below for at least seven days after your treatment. This is to keep you, your loved ones, and the environment as safe as possible. o Pregnant women should avoid touching anything that may be soiled with body fluids from the patient. o Toilet and septic systems • You may use the same toilet, septic tank, and/or sewer that you usually use. If you have a low-flow toilet, close the lid and flush twice to ensure that all waste has been discarded. o If the toilet or toilet seat becomes soiled with urine, stool, or vomit, clean the surface after every use before other people use the toliet. o Wash hands with soap and water after using the toilet for at least 20 seconds. o If you need a bedpan, be sure your caregiver knows to wear gloves to assist with cleanup and to wash the bedpan with soap and water every day. o If you do not have good control of bladder or bowels, use a disposable pad with a plastic back, a diaper, or a sheet to absorb body waste. o Wash any skin that has been exposed to body waste with soap and water. o Linens or clothing that are soiled with body fluids or body waste should be washed separately from other linens and clothing. If you do not have a washer, place the soiled linens in a plastic bag until they can be washed. o Wash hands with soap and water after touching linens or clothing that may be soiled with body fluids. Intimacy, sexual activity, contraception, and fertility This treatment may cause changes that can affect intimacy and sexuality, including desire and body image. Maintaining physical closeness and/or intimacy with loved ones can be continued during treatment. Holding hands, hugging, and kissing can be done safely. It is recommended that you talk to your care team about any restrictions or questions you may have. Some treatments can influence the ability to have children, also known as fertility. If you’re interested in preserving fertility, talk to your care team before treatment. Ask your healthcare provider to determine when it is safe to become pregnant after your treatment. Patients of reproductive ability should not become pregnant or get their partners pregnant while receiving ABVD. Some of the drugs you receive may be present in semen and vaginal secretion for many days after treatment. You should use barrier devices, such as condoms, during sexual activity to limit exposure to body fluids. o Talk to your care team about birth control. Not all options may be right for your treatment or cancer. Effective contraception could include one or more of the following: barrier methods (e.g. condoms), hormone methods (e.g. birth control pills), or surgery. o Tell your care team if you become pregnant or plan to breastfeed. Page 8 Additional resources Prescribing information: Doxorubicin: https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/062921s022lbl.pdf Bleomycin: https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=e629ba5a-4e08-4249-9551- af6dbd98a7e4&type=display Vinblastine: https://pdf.hres.ca/dpd_pm/00019154.PDF Dacarbazine: https://www.pfizer.ca/sites/default/files/201902/Dacarbazine_PM_E_221511_25Jan2019.pdf Additional instructions Updated – November 1, 2022 Important notice: The Association of Community Cancer Centers (ACCC), Hematology/Oncology Pharmacy Association (HOPA), National Community Oncology Dispensing Association, Inc. (NCODA), and Oncology Nursing Society (ONS) have collaborated in gathering information for and developing this patient education guide. This guide represents a brief summary of the therapy derived from information provided by the drug manufacturer and other resources. This guide does not cover all existing information related to the possible uses, directions, doses, precautions, warnings, interactions, adverse effects, or risks associated with this therapy and should not substitute for the advice of a qualified healthcare professional. Provision of this guide is for informational purposes only and does not constitute or imply endorsement, recommendation, or favoring of this therapy by ACCC, HOPA, NCODA, or ONS, who assume no liability for and cannot ensure the accuracy of the information presented. The collaborators are not making any representations with respect to the medications whatsoever, and any and all decisions, with respect to such medications, are at the sole risk of the individual receiving therapy. All decisions related to receiving this therapy should be made with the guidance and under the direction of a qualified healthcare professional. Permission: Intravenous Cancer Treatment Education (IVE) sheets are provided as a free educational resource for patients with cancer in need of concise, easy-to-understand information about intravenous cancer therapy. Healthcare providers are permitted to copy and distribute the sheets to patients as well as direct patients to the OCE website for information. However, commercial reproduction or reuse, as well as rebranding or reposting of any type, are strictly prohibited without permission of the copyright holder. Please email permission requests and licensing inquiries to This email address is being protected from spambots. You need JavaScript enabled to view it.. Copyright © 2021 by NCODA. All rights reserved.

Page 1 ESHAP+R Rituximab INTRAVENOUS CANCER TREATMENT EDUCATION ESHAP Name of the regimen and cancer drugs Your care team may refer to your treatment as ESHAP. ESHAP consists of 4 different anti-cancer therapies. • E: Etoposide (ee-toh-POH-side): Vepesid • S: Methylprednisolone (MEH-thul-pred-NIH-suh-lone): Medrol, Solu-Medrol • HA: Cytarabine (sy-TAYR-uh-been): High-dose Ara-C, Cytosar-U, Tarabine PFS • P: Cisplatin (sis-PLA-tin): Platinol Common uses This regimen is mostly commonly used for Diffuse Large B-Cell Lymphoma but may be used for other diagnoses. Treatment schedule Your treatment will be given into your vein through an intravenous (IV) line. This may be into a short, flexible temporary catheter in your arm, or through a central venous catheter. A central venous catheter, or central line is a long, flexible IV tube that empties into a very large vein next to the heart. Talk with your care team to see which will be best for you and your treatment. Each ESHAP treatment is repeated every 21 or 28 days. This is known as one cycle. Your treatment may be given for a set number of cycles, or it will keep going until the drug, or drugs, stop working or you have side effects which stop you from continuing treatment. o Etoposide IV given on Days 1-4 o Methylprednisolone IV given on Days 1-5 o Cytarabine IV given on Day 5 o Cisplatin IV continuously given on Days 1-4 Drug Cycle 1 Day 1 2 3 4 5 6 7 8 ... 21 Cycle 2 Day 1 Etoposide Methylprednisolone Cytarabine Cisplatin Page 2 ESHAP INTRAVENOUS CANCER TREATMENT EDUCATION Other medications Other medications may be ordered for you to prevent or treat certain side effects. These include: Instructions: Growth Factors Growth factors, like filgrastim, pegfilgrastim, and others, are medications used to treat neutropenia and prevent infections. Neutropenia is a condition where there are lower-than-normal white blood cells caused by some type of chemotherapy. Growth factors help the bone marrow to make more white blood cells. Anti-nausea medication other medications You will receive medications to prevent nausea and other side effects just before your chemotherapy. You may get prescriptions for other medications to take at home, as below: Infection prevention There is a risk of serious infections during treatment. You may receive medications to prevent infection in the hospital, and may also get prescriptions for medications to take at home for infection prevention, as below: Eye drops You will receive eye drops to prevent eye problems from your cancer treatment starting prior to therapy. Eye drops may be given continuously during the treatment cycle or continued only for several days after. In addition to eye drops, you may be required to see an eye doctor prior to each dose of treatment. Use eye drops as directed below Possible drug interactions o ESHAP may interact with other drugs you are taking. Please inform your care providers of all prescription medicine, overthe-counter medications, vitamins, and herbal products that you take. o Talk with your care provider or pharmacist before taking new medications, supplements, or receiving any vaccines. o Grapefruit or grapefruit juice may interact with ESHAP. Avoid eating or drinking these during your treatment. Page 3 ESHAP INTRAVENOUS CANCER TREATMENT EDUCATION Common Side Effects Common side effects that have been known to happen in patients receiving ESHAP are listed in the left side of this table. In some instances, the side effects may be reported less often but are still important to discuss. This table does not list all the known side effects for this therapy, only the ones that are experienced most often. Not every patient experiences every known side effect of a drug; even if you are taking the same drug as another patient, you may experience different side effects. Options to help manage any side effects that do occur are included on the right side of this table. These should be discussed with your care provider. If you experience any side effect you cannot manage or that is not listed here, contact your care provider. Possible Side Effect Management Decreased white blood cells (WBCs) and increased risk for infection Your WBCs should be monitored by a simple blood test. When your WBCs are low, you are at a greater risk of having an infection. Take the following precautions to protect yourself from infection. • Wash your hands often, especially before eating and after using the bathroom. • Avoid crowds and people with fevers, flu, or other infection. • Bathe often for good personal hygiene. Contact your care team if you experience any signs or symp-toms of an infection such as: • Fever (temperature more than 100.4°F or 38°C) • Chills • Sore throat • Burning when peeing • Tiredness that is worse than normal • A sore that becomes red, is draining, or does not heal. Check with your care team before taking any medicine for a fever or chills. Continued on the next page Page 4 ESHAP INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Decreased platelet count and increased risk of bleeding Your platelets should be monitored by a simple blood test. When they are low, you may bruise or bleed more easily than usual. • Use caution to avoid bruises, cuts, or burns. • Blow your nose gently and do not pick your nose • Brush your teeth gently with a soft toothbrush and maintain good oral hygiene • When shaving use an electric razor instead of razor blades • Use a nail file instead of nail clippers Call your care team if you have bleeding that won’t stop. Examples include: • A bloody nose that bleeds for more than 5 minutes despite pressure • A cut that continues to ooze despite pressure • Gums that bleed a lot when you floss or brush Seek medical help right away if you have any severe headaches, blood in your urine or stool, coughing up blood, or bleeding that you cannot stop or lasts a long time. You may need to take a break or “hold” your medication for medical or dental procedures. Talk to your care team or dentist before any scheduled procedures. Decreased hemoglobin, part of the red blood cells that carry iron and oxygen Your hemoglobin should be checked by a simple blood test. When your hemoglobin is low, you may notice that you get tired or fatigued more easily. • Try to get 7 to 8 hours of sleep per night • Avoid operating heavy machinery if you feel too tired • Find a balance between “work” and “rest” • Stay as active as possible, but know that it is okay to rest as needed, too • You might notice that you are more pale than usual Let your care team know right away if you have: • Shortness of breath • Dizziness • Fast or abnormal heartbeat Continued on the next page Page 5 ESHAP INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Nausea or vomiting • Take all medications as prescribed to help prevent and lessen symptoms of nausea and vomiting • Eat and drink slowly • Drink 8-10 (8-ounce) glasses of water and/or fluid (soup or broth) each day unless your care team has instructed you to limit your fluid intake • Eat small, frequent meals throughout the day rather than a few large meals • Eat bland foods; avoid spicy, fried, and greasy foods • Avoid intense exercise immediately after eating • Don’t lay down right away after eating • Wear loose fitting clothing for comfort • Avoid strong odors. Consider getting fresh air and try deep breathing. Let your care team know if you have nausea or vomiting. Your care team may prescribe medication to help with the symptoms. Hair loss (alopecia) • Hair will likely grow back after treatment is completed, although the color and/or texture may be different. • Some people choose to wear scarves, caps, or wigs. A short haircut prior to treatment may help with stress of hair loss. • Partial or complete hair loss is likely, usually 1-2 weeks after start of therapy. This hair loss can be all body hair. • It may take 3 to 6 months after therapy is completed to resume normal hair growth. • Be sure to keep your head covered to protect it from the sun during the summer and cold during the winter. • If not covering your scalp during the summer months, be sure to use sunscreen when spending time outdoors. Diarrhea (loose and/ or urgent bowel movements) Monitor how many bowel movements you have each day. • Drink 8-10 (8-ounce) glasses of water or fluid each day unless your care team has asked you to limit your fluid intake. • Eat small, frequent meals throughout the day rather than a few large meals. • Eat bland, low-fiber foods (such as bananas, applesauce, potatoes, chicken, rice, and toast). • Avoid high fiber foods, such as raw vegetables and fruits and whole grains. • Avoid foods that cause gas, such as broccoli and beans. • Avoid foods with lactose, such as yogurt and milk. • Avoid spicy, fried, and greasy foods. Contact your care team if: • The number of bowel movements you have in a day increases by 4 or more • You feel dizzy or lightheaded Talk with your care team if you believe you have diarrhea. They may recommend an over-thecounter medication or prescribe something to help keep it under control. Continued on the next page Page 6 ESHAP INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Constipation Keep track of how many bowel movements you have each day. • Drink 8-10 (8-ounce) glasses of water or fluid each day unless your care team has asked you to limit your fluid intake. • Stay active and exercise, if possible. • Eat foods high in fiber like raw fruits and vegetables. Contact your care team if you have not had a bowel movement in 3 or more days. Your care team may recommend over-the-counter medications to help with constipation. A daily stool softener such as docusate (Colace®) and/or laxative such as senna (Senakot®) may be helpful. If these do not help within 48 hours, tell your care team. Taste changes Some people may have a metallic or bitter taste in their mouth. To help with taste changes: • Choose and prepare foods that look and smell good to you. • Use plastic spoons, forks, or knives if food tastes like metal. • Flavor foods with spices or juices to change taste. • Suck on mints or chew gum to mask taste. • Brush teeth before and after eating with a soft bristle toothbrush. • Avoid smoking. Notify your doctor if you are having trouble eating or are losing weight. Numbness or tingling in hands and feet Report changes in your sense of touch, such as a burning feeling, pain on the skin or weakness. Changes in kidney function Your kidney function will be checked regularly by a simple blood test. Contact your care team if you notice any of the following. • Decreased amount of urination • Unusual swelling in your legs and feet Continued on the next page Page 7 ESHAP INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Low electrolytes in your bloodstream (magnesium, potassium, calcium) • Low magnesium levels • Low potassium levels • Low calcium Changes in some lab values may occur and will be monitored by a simple blood test. • You may not feel any symptoms if the changes are mild and they usually are not a sign of a serious problem. • More severe changes may occur, which can be a sign of a serious problem. Notify your care team if you have any of the following: • Shortness of breath • Chest discomfort • Weakness or fatigue • New aches and pains • Headaches • Dizziness • Swelling of your legs or feet • Red or brown colored urine Rare but serious side effects Tell your care provider if you experience any symptoms of these problems: o Central neurotoxicity: Cytarabine can cause changes to your balance, confusion, dizziness, or headache. Your care team will monitor you regularly throughout treatment. Inpatient treatment only. o Conjunctivitis: Cytarabine may cause eye pain, blurred vision, tearing, and light sensitivity. You may receive eye treatments to prevent this side effect from occurring. o Vesicant extravasation: Cisplatin is a vesicant at higher concentrations. If it leaks outside of the IV, it can cause severe damage to your skin. Notify your nurse right away if you feel any pain, aching, burning, itching, swelling, or redness at the site of your IV. o Ototoxicity: Cisplatin may be harmful to your sense of hearing. Inform your care team if you have any ringing in the ears, hearing loss, or any other change in hearing. o Secondary Malignancy: A secondary cancer can rarely occur months or years after treatment with etoposide and cisplatin. Your care team will check your blood cell counts even after treatment is done to monitor for this side effect. o Cytarabine syndrome: this regimen may cause cytarabine syndrome, a rare condition of several symptoms that appear after receiving cytarabine. Tell your care team if you develop any fever, muscle pain, bone pain, chest pain, eye pain, or rash after your treatment. o Tumor lysis syndrome: this regimen may cause tumor lysis syndrome, a rapid destruction of cancer cells that can cause organ dysfunction, when starting treatment. Your care team may do blood tests to check for this side effect. o Hypersensitivity Reactions: Severe allergic reactions are a rare but serious side effect of this regimen. Seek medical attention right away if you notice difficulty breathing, swelling of the mouth or tongue, or a serious rash. If you experience ANY new, worsening, or uncontrolled side effects, call your care team immediately. Page 8 ESHAP INTRAVENOUS CANCER TREATMENT EDUCATION Handling body fluids and waste Some of the drugs you receive may be present in urine, stool, sweat, or vomit for many days after treatment. Many cancer drugs are toxic, your bodily waste may also be toxic and can be dangerous to come into contact with. Once you have started ESHAP, follow the instructions below for at least two days after your treatment. This is to keep you, your loved ones, and the environment as safe as possible. o Pregnant women should avoid touching anything that may be soiled with body fluids from the patient. o Toilet and septic systems • You may use the same toilet, septic tank, and/or sewer that you usually use. If you have a low-flow toilet, close the lid and flush twice to ensure that all waste has been discarded. o If the toilet or toilet seat becomes soiled with urine, stool, or vomit, clean the surface after every use before other people use the toliet. o Wash hands with soap and water after using the toilet for at least 20 seconds. o If you need a bedpan, be sure your caregiver knows to wear gloves to assist with cleanup and to wash the bedpan with soap and water every day. o If you do not have good control of bladder or bowels, use a disposable pad with a plastic back, a diaper, or a sheet to absorb body waste. o Wash any skin that has been exposed to body waste with soap and water. o Linens or clothing that are soiled with body fluids or body waste should be washed separately from other linens and clothing. If you do not have a washer, place the soiled linens in a plastic bag until they can be washed. o Wash hands with soap and water after touching linens or clothing that may be soiled with body fluids. Intimacy, sexual activity, contraception, and fertility This treatment may cause changes that can affect intimacy and sexuality, including desire and body image. Maintaining physical closeness and/or intimacy with loved ones can be continued during treatment. Holding hands, hugging, and kissing can be done safely. It is recommended that you talk to your care team about any restrictions or questions you may have. Some treatments can influence the ability to have children, also known as fertility. If you’re interested in preserving fertility, talk to your care team before treatment. Ask your healthcare provider to determine when it is safe to become pregnant after your treatment. Patients of reproductive ability should not become pregnant or get their partners pregnant while receiving ESHAP. Some of the drugs you receive may be present in semen and vaginal secretion for many days after treatment. You should use barrier devices, such as condoms, during sexual activity to limit exposure to body fluids. o Talk to your care team about birth control. Not all options may be right for your treatment or cancer. Effective contraception could include one or more of the following: barrier methods (e.g. condoms), hormone methods (e.g. birth control pills), or surgery. o Tell your care team if you become pregnant or plan to breastfeed. Page 9 ESHAP INTRAVENOUS CANCER TREATMENT EDUCATION Important notice: The Association of Community Cancer Centers (ACCC), Hematology/Oncology Pharmacy Association (HOPA), National Community Oncology Dispensing Association, Inc. (NCODA), and Oncology Nursing Society (ONS) have collaborated in gathering information for and developing this patient education guide. This guide represents a brief summary of the therapy derived from information provided by the drug manufacturer and other resources. This guide does not cover all existing information related to the possible uses, directions, doses, precautions, warnings, interactions, adverse effects, or risks associated with this therapy and should not substitute for the advice of a qualified healthcare professional. Provision of this guide is for informational purposes only and does not constitute or imply endorsement, recommendation, or favoring of this therapy by ACCC, HOPA, NCODA, or ONS, who assume no liability for and cannot ensure the accuracy of the information presented. The collaborators are not making any representations with respect to the medications whatsoever, and any and all decisions, with respect to such medications, are at the sole risk of the individual receiving therapy. All decisions related to receiving this therapy should be made with the guidance and under the direction of a qualified healthcare professional. Permission: Intravenous Cancer Treatment Education (IVE) sheets are provided as a free educational resource for patients with cancer in need of concise, easy-to-understand information about intravenous cancer therapy. Healthcare providers are permitted to copy and distribute the sheets to patients as well as direct patients to the OCE website for information. However, commercial reproduction or reuse, as well as rebranding or reposting of any type, are strictly prohibited without permission of the copyright holder. Please email permission requests and licensing inquiries to This email address is being protected from spambots. You need JavaScript enabled to view it.. Copyright © 2021 by NCODA. All rights reserved. Additional resources Product website Etoposide: https://www.drugs.com/mtm/etoposide.html Methylprednisolone: https://www.drugs.com/methylprednisolone.html Cytarabine: https://www.drugs.com/mtm/cytarabine.html Cisplatin: https://www.drugs.com/pro/cisplatin.html Prescribing information link Etoposide: https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/020457s016lbl.pdf Methylprednisolone: https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/011153s075lbl.pdf Cytarabine: https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/071868s032lbl.pdf Cisplatin: https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/018057s089lbl.pdf Additional instructions Updated – May 18, 2022

Page 1 ESHAP INTRAVENOUS CANCER TREATMENT EDUCATION ESHAP Name of the regimen and cancer drugs Your care team may refer to your treatment as ESHAP. ESHAP consists of 4 different anti-cancer therapies. • E: Etoposide (ee-toh-POH-side): Vepesid • S: Methylprednisolone (MEH-thul-pred-NIH-suh-lone): Medrol, Solu-Medrol • HA: Cytarabine (sy-TAYR-uh-been): High-dose Ara-C, Cytosar-U, Tarabine PFS • P: Cisplatin (sis-PLA-tin): Platinol Common uses This regimen is mostly commonly used for Diffuse Large B-Cell Lymphoma but may be used for other diagnoses. Treatment schedule Your treatment will be given into your vein through an intravenous (IV) line. This may be into a short, flexible temporary catheter in your arm, or through a central venous catheter. A central venous catheter, or central line is a long, flexible IV tube that empties into a very large vein next to the heart. Talk with your care team to see which will be best for you and your treatment. Each ESHAP treatment is repeated every 21 or 28 days. This is known as one cycle. Your treatment may be given for a set number of cycles, or it will keep going until the drug, or drugs, stop working or you have side effects which stop you from continuing treatment. o Etoposide IV given on Days 1-4 o Methylprednisolone IV given on Days 1-5 o Cytarabine IV given on Day 5 o Cisplatin IV continuously given on Days 1-4 Drug Cycle 1 Day 1 2 3 4 5 6 7 8 ... 21 Cycle 2 Day 1 Etoposide Methylprednisolone Cytarabine Cisplatin Page 2 ESHAP INTRAVENOUS CANCER TREATMENT EDUCATION Other medications Other medications may be ordered for you to prevent or treat certain side effects. These include: Instructions: Growth Factors Growth factors, like filgrastim, pegfilgrastim, and others, are medications used to treat neutropenia and prevent infections. Neutropenia is a condition where there are lower-than-normal white blood cells caused by some type of chemotherapy. Growth factors help the bone marrow to make more white blood cells. Anti-nausea medication other medications You will receive medications to prevent nausea and other side effects just before your chemotherapy. You may get prescriptions for other medications to take at home, as below: Infection prevention There is a risk of serious infections during treatment. You may receive medications to prevent infection in the hospital, and may also get prescriptions for medications to take at home for infection prevention, as below: Eye drops You will receive eye drops to prevent eye problems from your cancer treatment starting prior to therapy. Eye drops may be given continuously during the treatment cycle or continued only for several days after. In addition to eye drops, you may be required to see an eye doctor prior to each dose of treatment. Use eye drops as directed below Possible drug interactions o ESHAP may interact with other drugs you are taking. Please inform your care providers of all prescription medicine, overthe-counter medications, vitamins, and herbal products that you take. o Talk with your care provider or pharmacist before taking new medications, supplements, or receiving any vaccines. o Grapefruit or grapefruit juice may interact with ESHAP. Avoid eating or drinking these during your treatment. Page 3 ESHAP INTRAVENOUS CANCER TREATMENT EDUCATION Common Side Effects Common side effects that have been known to happen in patients receiving ESHAP are listed in the left side of this table. In some instances, the side effects may be reported less often but are still important to discuss. This table does not list all the known side effects for this therapy, only the ones that are experienced most often. Not every patient experiences every known side effect of a drug; even if you are taking the same drug as another patient, you may experience different side effects. Options to help manage any side effects that do occur are included on the right side of this table. These should be discussed with your care provider. If you experience any side effect you cannot manage or that is not listed here, contact your care provider. Possible Side Effect Management Decreased white blood cells (WBCs) and increased risk for infection Your WBCs should be monitored by a simple blood test. When your WBCs are low, you are at a greater risk of having an infection. Take the following precautions to protect yourself from infection. • Wash your hands often, especially before eating and after using the bathroom. • Avoid crowds and people with fevers, flu, or other infection. • Bathe often for good personal hygiene. Contact your care team if you experience any signs or symp-toms of an infection such as: • Fever (temperature more than 100.4°F or 38°C) • Chills • Sore throat • Burning when peeing • Tiredness that is worse than normal • A sore that becomes red, is draining, or does not heal. Check with your care team before taking any medicine for a fever or chills. Continued on the next page Page 4 ESHAP INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Decreased platelet count and increased risk of bleeding Your platelets should be monitored by a simple blood test. When they are low, you may bruise or bleed more easily than usual. • Use caution to avoid bruises, cuts, or burns. • Blow your nose gently and do not pick your nose • Brush your teeth gently with a soft toothbrush and maintain good oral hygiene • When shaving use an electric razor instead of razor blades • Use a nail file instead of nail clippers Call your care team if you have bleeding that won’t stop. Examples include: • A bloody nose that bleeds for more than 5 minutes despite pressure • A cut that continues to ooze despite pressure • Gums that bleed a lot when you floss or brush Seek medical help right away if you have any severe headaches, blood in your urine or stool, coughing up blood, or bleeding that you cannot stop or lasts a long time. You may need to take a break or “hold” your medication for medical or dental procedures. Talk to your care team or dentist before any scheduled procedures. Decreased hemoglobin, part of the red blood cells that carry iron and oxygen Your hemoglobin should be checked by a simple blood test. When your hemoglobin is low, you may notice that you get tired or fatigued more easily. • Try to get 7 to 8 hours of sleep per night • Avoid operating heavy machinery if you feel too tired • Find a balance between “work” and “rest” • Stay as active as possible, but know that it is okay to rest as needed, too • You might notice that you are more pale than usual Let your care team know right away if you have: • Shortness of breath • Dizziness • Fast or abnormal heartbeat Continued on the next page Page 5 ESHAP INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Nausea or vomiting • Take all medications as prescribed to help prevent and lessen symptoms of nausea and vomiting • Eat and drink slowly • Drink 8-10 (8-ounce) glasses of water and/or fluid (soup or broth) each day unless your care team has instructed you to limit your fluid intake • Eat small, frequent meals throughout the day rather than a few large meals • Eat bland foods; avoid spicy, fried, and greasy foods • Avoid intense exercise immediately after eating • Don’t lay down right away after eating • Wear loose fitting clothing for comfort • Avoid strong odors. Consider getting fresh air and try deep breathing. Let your care team know if you have nausea or vomiting. Your care team may prescribe medication to help with the symptoms. Hair loss (alopecia) • Hair will likely grow back after treatment is completed, although the color and/or texture may be different. • Some people choose to wear scarves, caps, or wigs. A short haircut prior to treatment may help with stress of hair loss. • Partial or complete hair loss is likely, usually 1-2 weeks after start of therapy. This hair loss can be all body hair. • It may take 3 to 6 months after therapy is completed to resume normal hair growth. • Be sure to keep your head covered to protect it from the sun during the summer and cold during the winter. • If not covering your scalp during the summer months, be sure to use sunscreen when spending time outdoors. Diarrhea (loose and/ or urgent bowel movements) Monitor how many bowel movements you have each day. • Drink 8-10 (8-ounce) glasses of water or fluid each day unless your care team has asked you to limit your fluid intake. • Eat small, frequent meals throughout the day rather than a few large meals. • Eat bland, low-fiber foods (such as bananas, applesauce, potatoes, chicken, rice, and toast). • Avoid high fiber foods, such as raw vegetables and fruits and whole grains. • Avoid foods that cause gas, such as broccoli and beans. • Avoid foods with lactose, such as yogurt and milk. • Avoid spicy, fried, and greasy foods. Contact your care team if: • The number of bowel movements you have in a day increases by 4 or more • You feel dizzy or lightheaded Talk with your care team if you believe you have diarrhea. They may recommend an over-thecounter medication or prescribe something to help keep it under control. Continued on the next page Page 6 ESHAP INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Constipation Keep track of how many bowel movements you have each day. • Drink 8-10 (8-ounce) glasses of water or fluid each day unless your care team has asked you to limit your fluid intake. • Stay active and exercise, if possible. • Eat foods high in fiber like raw fruits and vegetables. Contact your care team if you have not had a bowel movement in 3 or more days. Your care team may recommend over-the-counter medications to help with constipation. A daily stool softener such as docusate (Colace®) and/or laxative such as senna (Senakot®) may be helpful. If these do not help within 48 hours, tell your care team. Taste changes Some people may have a metallic or bitter taste in their mouth. To help with taste changes: • Choose and prepare foods that look and smell good to you. • Use plastic spoons, forks, or knives if food tastes like metal. • Flavor foods with spices or juices to change taste. • Suck on mints or chew gum to mask taste. • Brush teeth before and after eating with a soft bristle toothbrush. • Avoid smoking. Notify your doctor if you are having trouble eating or are losing weight. Numbness or tingling in hands and feet Report changes in your sense of touch, such as a burning feeling, pain on the skin or weakness. Changes in kidney function Your kidney function will be checked regularly by a simple blood test. Contact your care team if you notice any of the following. • Decreased amount of urination • Unusual swelling in your legs and feet Continued on the next page Page 7 ESHAP INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Low electrolytes in your bloodstream (magnesium, potassium, calcium) • Low magnesium levels • Low potassium levels • Low calcium Changes in some lab values may occur and will be monitored by a simple blood test. • You may not feel any symptoms if the changes are mild and they usually are not a sign of a serious problem. • More severe changes may occur, which can be a sign of a serious problem. Notify your care team if you have any of the following: • Shortness of breath • Chest discomfort • Weakness or fatigue • New aches and pains • Headaches • Dizziness • Swelling of your legs or feet • Red or brown colored urine Rare but serious side effects Tell your care provider if you experience any symptoms of these problems: o Central neurotoxicity: Cytarabine can cause changes to your balance, confusion, dizziness, or headache. Your care team will monitor you regularly throughout treatment. Inpatient treatment only. o Conjunctivitis: Cytarabine may cause eye pain, blurred vision, tearing, and light sensitivity. You may receive eye treatments to prevent this side effect from occurring. o Vesicant extravasation: Cisplatin is a vesicant at higher concentrations. If it leaks outside of the IV, it can cause severe damage to your skin. Notify your nurse right away if you feel any pain, aching, burning, itching, swelling, or redness at the site of your IV. o Ototoxicity: Cisplatin may be harmful to your sense of hearing. Inform your care team if you have any ringing in the ears, hearing loss, or any other change in hearing. o Secondary Malignancy: A secondary cancer can rarely occur months or years after treatment with etoposide and cisplatin. Your care team will check your blood cell counts even after treatment is done to monitor for this side effect. o Cytarabine syndrome: this regimen may cause cytarabine syndrome, a rare condition of several symptoms that appear after receiving cytarabine. Tell your care team if you develop any fever, muscle pain, bone pain, chest pain, eye pain, or rash after your treatment. o Tumor lysis syndrome: this regimen may cause tumor lysis syndrome, a rapid destruction of cancer cells that can cause organ dysfunction, when starting treatment. Your care team may do blood tests to check for this side effect. o Hypersensitivity Reactions: Severe allergic reactions are a rare but serious side effect of this regimen. Seek medical attention right away if you notice difficulty breathing, swelling of the mouth or tongue, or a serious rash. If you experience ANY new, worsening, or uncontrolled side effects, call your care team immediately. Page 8 ESHAP INTRAVENOUS CANCER TREATMENT EDUCATION Handling body fluids and waste Some of the drugs you receive may be present in urine, stool, sweat, or vomit for many days after treatment. Many cancer drugs are toxic, your bodily waste may also be toxic and can be dangerous to come into contact with. Once you have started ESHAP, follow the instructions below for at least two days after your treatment. This is to keep you, your loved ones, and the environment as safe as possible. o Pregnant women should avoid touching anything that may be soiled with body fluids from the patient. o Toilet and septic systems • You may use the same toilet, septic tank, and/or sewer that you usually use. If you have a low-flow toilet, close the lid and flush twice to ensure that all waste has been discarded. o If the toilet or toilet seat becomes soiled with urine, stool, or vomit, clean the surface after every use before other people use the toliet. o Wash hands with soap and water after using the toilet for at least 20 seconds. o If you need a bedpan, be sure your caregiver knows to wear gloves to assist with cleanup and to wash the bedpan with soap and water every day. o If you do not have good control of bladder or bowels, use a disposable pad with a plastic back, a diaper, or a sheet to absorb body waste. o Wash any skin that has been exposed to body waste with soap and water. o Linens or clothing that are soiled with body fluids or body waste should be washed separately from other linens and clothing. If you do not have a washer, place the soiled linens in a plastic bag until they can be washed. o Wash hands with soap and water after touching linens or clothing that may be soiled with body fluids. Intimacy, sexual activity, contraception, and fertility This treatment may cause changes that can affect intimacy and sexuality, including desire and body image. Maintaining physical closeness and/or intimacy with loved ones can be continued during treatment. Holding hands, hugging, and kissing can be done safely. It is recommended that you talk to your care team about any restrictions or questions you may have. Some treatments can influence the ability to have children, also known as fertility. If you’re interested in preserving fertility, talk to your care team before treatment. Ask your healthcare provider to determine when it is safe to become pregnant after your treatment. Patients of reproductive ability should not become pregnant or get their partners pregnant while receiving ESHAP. Some of the drugs you receive may be present in semen and vaginal secretion for many days after treatment. You should use barrier devices, such as condoms, during sexual activity to limit exposure to body fluids. o Talk to your care team about birth control. Not all options may be right for your treatment or cancer. Effective contraception could include one or more of the following: barrier methods (e.g. condoms), hormone methods (e.g. birth control pills), or surgery. o Tell your care team if you become pregnant or plan to breastfeed. Page 9 ESHAP INTRAVENOUS CANCER TREATMENT EDUCATION Important notice: The Association of Community Cancer Centers (ACCC), Hematology/Oncology Pharmacy Association (HOPA), National Community Oncology Dispensing Association, Inc. (NCODA), and Oncology Nursing Society (ONS) have collaborated in gathering information for and developing this patient education guide. This guide represents a brief summary of the therapy derived from information provided by the drug manufacturer and other resources. This guide does not cover all existing information related to the possible uses, directions, doses, precautions, warnings, interactions, adverse effects, or risks associated with this therapy and should not substitute for the advice of a qualified healthcare professional. Provision of this guide is for informational purposes only and does not constitute or imply endorsement, recommendation, or favoring of this therapy by ACCC, HOPA, NCODA, or ONS, who assume no liability for and cannot ensure the accuracy of the information presented. The collaborators are not making any representations with respect to the medications whatsoever, and any and all decisions, with respect to such medications, are at the sole risk of the individual receiving therapy. All decisions related to receiving this therapy should be made with the guidance and under the direction of a qualified healthcare professional. Permission: Intravenous Cancer Treatment Education (IVE) sheets are provided as a free educational resource for patients with cancer in need of concise, easy-to-understand information about intravenous cancer therapy. Healthcare providers are permitted to copy and distribute the sheets to patients as well as direct patients to the OCE website for information. However, commercial reproduction or reuse, as well as rebranding or reposting of any type, are strictly prohibited without permission of the copyright holder. Please email permission requests and licensing inquiries to This email address is being protected from spambots. You need JavaScript enabled to view it.. Copyright © 2021 by NCODA. All rights reserved. Additional resources Product website Etoposide: https://www.drugs.com/mtm/etoposide.html Methylprednisolone: https://www.drugs.com/methylprednisolone.html Cytarabine: https://www.drugs.com/mtm/cytarabine.html Cisplatin: https://www.drugs.com/pro/cisplatin.html Prescribing information link Etoposide: https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/020457s016lbl.pdf Methylprednisolone: https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/011153s075lbl.pdf Cytarabine: https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/071868s032lbl.pdf Cisplatin: https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/018057s089lbl.pdf Additional instructions Updated – May 18, 2022

Page 1 FLUDARABINE, CYTARABINE, FILGRASTIM (FLAG) INTRAVENOUS CANCER TREATMENT EDUCATION Name of the regimen and cancer drugs Your care team may refer to your treatment as FLAG. FLAG consists of 3 different anti-cancer therapies. • Fludarabine (floo-DAR-uh-been): Fludara • Cytarabine (sy-TAYR-uh-been): Cytosar • Filgrastim (fil-GRAS-tim): Granix; Neupogen; Nivestym; Zarxio Common uses This regimen is mostly commonly used to treat acute myeloid leukemia (AML), but may be used for other treatments. Treatment schedule Your treatment will be given into your vein through an intravenous (IV) line. This may be into a short, flexible temporary catheter in your arm, or through a central venous catheter. A central venous catheter, or central line is a long, flexible IV tube that empties into a very large vein next to the heart. Talk with your care team to see which will be best for you and your treatment. Each FLAG treatment is typically given for a set number of cycles. o Fludarabine IV over 30 minutes daily on Days 1-5 o Cytarabine IV over 4 hours starting 4 hours after fludarabine daily Days 1-5 o Filgrastim subcutaneous daily on Days 0-5 Drug Cycle 1 Day 0 1 2 3 4 5 ... ... Cycle 2 Day 1 Fludarabine Cytarabine Filgrastim Page 2 Other medications Other medications may be ordered for you to prevent or treat certain side effects. These include: Instructions: Growth Factors Growth factors, like filgrastim, pegfilgrastim, and others, are medications used to treat neutropenia and prevent infections. Neutropenia is a condition where there are lower-than-normal white blood cells caused by some type of chemotherapy. Growth factors help the bone marrow to make more white blood cells. Anti-nausea medication other medications You will receive medications to prevent nausea and other side effects just before your chemotherapy. You may get prescriptions for other medications to take at home, as below: Infection prevention There is a risk of serious infections during treatment. You may receive medications to prevent infection in the hospital, and may also get prescriptions for medications to take at home for infection prevention, as below: Possible drug interactions o FLAG may interact with other drugs you are taking. Please inform your care providers of all prescription medicine, overthe-counter medications, vitamins, and herbal products that you take. o Talk with your care provider or pharmacist before taking new medications, supplements, or receiving any vaccines. o Grapefruit or grapefruit juice may interact with fludarabine, cytarabine, and filgrastim. Avoid eating or drinking these Page 3 Common Side Effects Common side effects that have been known to happen in patients receiving FLAG are listed in the left side of this table. In some instances, the side effects may be reported less often but are still important to discuss. This table does not list all the known side effects for this therapy, only the ones that are experienced most often. Not every patient experiences every known side effect of a drug; even if you are taking the same drug as another patient, you may experience different side effects. Options to help manage any side effects that do occur are included on the right side of this table. These should be discussed with your care provider. If you experience any side effect you cannot manage or that is not listed here, contact your care provider. Possible Side Effect Management Decreased white blood cells (WBCs) and increased risk for infection Your WBCs should be monitored by a simple blood test. When your WBCs are low, you are at a greater risk of having an in-fection. Take the following precautions to protect yourself from infection. • Wash your hands often, especially before eating and after using the bathroom. • Avoid crowds and people with fevers, flu, or other infection. • Bathe often for good personal hygiene. Contact your care team if you experience any signs or symp-toms of an infection such as: • Fever (temperature more than 100.4°F or 38°C) • Chills • Sore throat • Burning when peeing • Tiredness that is worse than normal • A sore that becomes red, is draining, or does not heal. Check with your care team before taking any medicine for a fever or chills. Continued on the next page Page 4 Decreased platelet count and increased risk of bleeding Your platelets should be monitored by a simple blood test. When they are low, you may bruise or bleed more easily than usual. • Use caution to avoid bruises, cuts, or burns. • Blow your nose gently and do not pick your nose • Brush your teeth gently with a soft toothbrush and maintain good oral hygiene • When shaving use an electric razor instead of razor blades • Use a nail file instead of nail clippers Call your care team if you have bleeding that won’t stop. Examples include: • A bloody nose that bleeds for more than 5 minutes despite pressure • A cut that continues to ooze despite pressure • Gums that bleed a lot when you floss or brush Seek medical help right away if you have any severe headaches, blood in your urine or stool, coughing up blood, or bleeding that you cannot stop or lasts a long time. You may need to take a break or “hold” your medication for medical or dental procedures. Talk to your care team or dentist before any scheduled procedures. Decreased hemoglobin, part of the red blood cells that carry iron and oxygen Your hemoglobin should be checked by a simple blood test. When your hemoglobin is low, you may notice that you get tired or fatigued more easily. • Try to get 7 to 8 hours of sleep per night • Avoid operating heavy machinery if you feel too tired • Find a balance between “work” and “rest” • Stay as active as possible, but know that it is okay to rest as needed, too • You might notice that you are more pale than usual Let your care team know right away if you have: • Shortness of breath • Dizziness • Fast or abnormal heartbeat Page 5 Nausea or vomiting • Take all medications as prescribed to help prevent and lessen symptoms of nausea and vomiting • Eat and drink slowly • Drink 8-10 (8-ounce) glasses of water and/or fluid (soup or broth) each day unless your care team has instructed you to limit your fluid intake • Eat small, frequent meals throughout the day rather than a few large meals • Eat bland foods; avoid spicy, fried, and greasy foods • Avoid intense exercise immediately after eating • Don’t lay down right away after eating • Wear loose fitting clothing for comfort • Avoid strong odors. Consider getting fresh air and try deep breathing. Let your care team know if you have nausea or vomiting. Your care team may prescribe medication to help with the symptoms. Mouth irritation or sores (stomatitis or mucositis) Practice good mouth care. • Rinse your mouth after meals and at bedtime, and more frequently if you develop sores in your mouth • Brush your teeth with a soft toothbrush or cotton swab after meals • Use a mild non-alcohol mouth rinse at least 4 times a day (after eating and at bedtime). One example is a mixture of 1/8 teaspoon of salt and 1/4 teaspoon of baking soda in 8 ounces of warm (not hot) water • Avoid acidic, hot or spicy foods and beverages, and rough foods that might irritate the mouth • If you have sores in your mouth, avoid using tobacco products, alcohol, and mouthwashes that contain alcohol Call your care team if you experience pain or sores in your mouth or throat. Eye changes Cytarabine may cause eye pain, blurred vision, tearing, and light sensitivity. You may receive eye treatments to prevent this side effect from occurring. Page 6 Diarrhea (loose and/ or urgent bowel movements) Monitor how many bowel movements you have each day. • Drink 8-10 (8-ounce) glasses of water or fluid each day unless your care team has asked you to limit your fluid intake. • Eat small, frequent meals throughout the day rather than a few large meals. • Eat bland, low-fiber foods (such as bananas, applesauce, potatoes, chicken, rice, and toast). • Avoid high fiber foods, such as raw vegetables and fruits and whole grains. • Avoid foods that cause gas, such as broccoli and beans. • Avoid foods with lactose, such as yogurt and milk. • Avoid spicy, fried, and greasy foods. Contact your care team if: • The number of bowel movements you have in a day increases by 4 or more • You feel dizzy or lightheaded Talk with your care team if you believe you have diarrhea. They may recommend an over-thecounter medication or prescribe something to help keep it under control. Rare but serious side effects Tell your care provider if you experience any symptoms of these problems: o Central neurotoxicity: Fludarabine and cytarabine can cause changes to your balance, confusion, dizziness, or headache. Your care team will monitor you regularly throughout treatment. o Pulmonary toxicity: Cytarabine may result in serious and fatal lung toxicity. If you start to experience shortness of breath, fatigue, breathlessness, or discomfort/worsening of symptoms while lying on your back, immediately contact your prescriber. o Hepatic toxicity: Cytarabine may be harmful to your liver. Speak to your care team to know when you need to have blood tests done to monitor your liver function. If you get this side effect, your doctor may change your dose or stop treatment for some time. o Tumor lysis syndrome: Fludarabine and cytarabine may cause tumor lysis syndrome when starting treatment. Your care team may do blood tests to check for this side effect. If you experience ANY new, worsening, or uncontrolled side effects, call your care team immediately. Page 7 Handling body fluids and waste Some of the drugs you receive may be present in urine, stool, sweat, or vomit for many days after treatment. Many cancer drugs are toxic, your bodily waste may also be toxic and can be dangerous to come into contact with. Once you have started FLAG, follow the instructions below for at least two days after your treatment. This is to keep you, your loved ones, and the environment as safe as possible. o Pregnant women should avoid touching anything that may be soiled with body fluids from the patient. o Toilet and septic systems • You may use the same toilet, septic tank, and/or sewer that you usually use. If you have a low-flow toilet, close the lid and flush twice to ensure that all waste has been discarded. o If the toilet or toilet seat becomes soiled with urine, stool, or vomit, clean the surface after every use before other people use the toliet. o Wash hands with soap and water after using the toilet for at least 20 seconds. o If you need a bedpan, be sure your caregiver knows to wear gloves to assist with cleanup and to wash the bedpan with soap and water every day. o If you do not have good control of bladder or bowels, use a disposable pad with a plastic back, a diaper, or a sheet to absorb body waste. o Wash any skin that has been exposed to body waste with soap and water. o Linens or clothing that are soiled with body fluids or body waste should be washed separately from other linens and clothing. If you do not have a washer, place the soiled linens in a plastic bag until they can be washed. o Wash hands with soap and water after touching linens or clothing that may be soiled with body fluids. Intimacy, sexual activity, contraception, and fertility This treatment may cause changes that can affect intimacy and sexuality, including desire and body image. Maintaining physical closeness and/or intimacy with loved ones can be continued during treatment. Holding hands, hugging, and kissing can be done safely. It is recommended that you talk to your care team about any restrictions or questions you may have. Some treatments can influence the ability to have children, also known as fertility. If you’re interested in preserving fertility, talk to your care team before treatment. Ask your healthcare provider to determine when it is safe to become pregnant after your treatment. Patients of reproductive ability should not become pregnant or get their partners pregnant while receiving FLAG. Some of the drugs you receive may be present in semen and vaginal secretion for many days after treatment. You should use barrier devices, such as condoms, during sexual activity to limit exposure to body fluids. o Talk to your care team about birth control. Not all options may be right for your treatment or cancer. Effective contraception could include one or more of the following: barrier methods (e.g. condoms), hormone methods (e.g. birth control pills), or surgery. o Tell your care team if you become pregnant or plan to breastfeed. Page 8 Additional resources Prescribing information link: Fludarabine: https://www.accessdata.fda.gov/drugsatfda_docs/label/2009/020038s032lbl.pdf Cytarabine: https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/071868s032lbl.pdf Filgrastim (fil-GRAS-tim): Granix; Neupogen; Nivestym; Zarxio: https://www.accessdata.fda.gov/drugsatfda_ docs/label/2015/103353s5183lbl.pdf • This drug is offered in several different brands. To find out what you’re using, talk to your care team Additional instructions Updated – May 16, 2022 Important notice: The Association of Community Cancer Centers (ACCC), Hematology/Oncology Pharmacy Association (HOPA), National Community Oncology Dispensing Association, Inc. (NCODA), and Oncology Nursing Society (ONS) have collaborated in gathering information for and developing this patient education guide. This guide represents a brief summary of the therapy derived from information provided by the drug manufacturer and other resources. This guide does not cover all existing information related to the possible uses, directions, doses, precautions, warnings, interactions, adverse effects, or risks associated with this therapy and should not substitute for the advice of a qualified healthcare professional. Provision of this guide is for informational purposes only and does not constitute or imply endorsement, recommendation, or favoring of this therapy by ACCC, HOPA, NCODA, or ONS, who assume no liability for and cannot ensure the accuracy of the information presented. The collaborators are not making any representations with respect to the medications whatsoever, and any and all decisions, with respect to such medications, are at the sole risk of the individual receiving therapy. All decisions related to receiving this therapy should be made with the guidance and under the direction of a qualified healthcare professional. Permission: Intravenous Cancer Treatment Education (IVE) sheets are provided as a free educational resource for patients with cancer in need of concise, easy-to-understand information about intravenous cancer therapy. Healthcare providers are permitted to copy and distribute the sheets to patients as well as direct patients to the OCE website for information. However, commercial reproduction or reuse, as well as rebranding or reposting of any type, are strictly prohibited without permission of the copyright holder. Please email permission requests and licensing inquiries to This email address is being protected from spambots. You need JavaScript enabled to view it.. Copyright © 2021 by NCODA. All rights reserved.