Name : …………………………………………………. Date of Birth : ……… M/F MR : …………… Date of Dx. : ………………
INDUCTION CONSOLIDATION
MEDICINES (WEEKS) Dosage
0 1 2 3 4 5 6 7 8 9 10 11 12
Mtx. it
VCR.iv : 1.5 mg/m2
Prednisone po : 60/40 mg/m2 Window
Prednisone 40 mg / m2
( it aplastic occur )
HD - Mtx i.v : 1000 mg/m2 with
Leucovorin rescue 15 mg / m2 / dose
Daunorubicin*. iv. : 30 mg/m2
L - Asp.iv : 7500 IU/m2 SK
6 - MP.po : 50 mg/m2
Blast LCS
Blast PB
BMP
day
Date of therapy month
year
Body Weight ( kg )
Body Height ( cm )
Body Surface Area ( m 2 )
* If not available change to Doxo 20 mg / m2 / dose Peripheral Blast : if >1000 SR change toBlast
HR in CSF at diagnosis
Protokol SR 2013 - Fase Induksi menggunakan Prednison dan pada Fase Maintenance menggunakan Dexametason
Mtx. it
VCR. iv : 1.5 mg / m 2
Dexa.po : 4 mg / m 2
6 - MP.po : 50 mg / m 2
Mtx.po : 20 mg / m 2
day
Date of therapy month
year
Body Weight ( kg )
Body Height ( cm )
Body Surface Area ( m 2 )
VCR. iv : 1.5 mg / m 2
Dexa.po : 4 mg / m 2
6 - MP.po : 50 mg / m 2
Mtx.po : 20 mg / m 2 BMP
day
Date of therapy month
year
Body Weight ( kg )
Body Height ( cm )
Body Surface Area ( m 2 )
Supervisor
----------------------------
RUMAH SAKIT Dr. MOHAMMAD HOESIN PALEMBANG
DEPARTEMEN ILMU KESEHATAN ANAK
Jl. Jend. Sudirman km. 3,5 Palembang 30126 Telp. 0711-354088 Pes 508-511, 0711-372832, 376445 Fax. 0711-372832
( it aplastic occur )
Leucovorin rescue 15 mg /m2/dose
Daunorubicine*.iv : 30 mg / m2
Cyclo. i.v 1000 mg / m2
Citarabin i.v: 75 mg / m2
L - Asp.iv : 7500 u / m2
6 - MP.po : 50 mg / m2
BMP
day
Date of therapy month
year
Body Weight ( kg )
Body Height ( cm )
Body Surface Area ( m 2 )
* If not available change to Doxo 20 mg / m 2 / dose
Supervisor, PRED / DEXA DOSAGE ( mg / m 2 ) PRED / DEXA DOSAGE ( mg / m 2 ) Age Dosages Mtx.it
Days Days < 1 ye 6 mg / x
LEUCOCYTE LEUCOCYTE
1 2 3 4 5 1 2 3 4 5 1 year 8 mg / x
< 20.000 60 / 6 60 / 6 60 / 6 60 / 6 60 / 6 > 50.000 - < 10 / 1 20 / 2 30 / 3 40 / 4 60 / 6 2 year 10 mg / x
………………………….. > 20.000 - < 50.00 20 / 2 30 / 3 40 / 4 50 / 5 60 / 6 > 100.000 5 / 0.5 10 / 1 20 / 2 40 / 4 60 / 6 ≥ 3 y 12 mg / x
DNR dosis 30 mg/m2, bila tidak ada DNR dapat digantikan Doxo 20 mg/m2
Protokol High Risk : menggunakan dexamentason
Fase Konsolidasi : Setelah MTX HD - leucovorin diberikan 2 hari (8 x tiap 6 jam)
RUMAH SAKIT Dr. MOHAMMAD HOESIN PALEMBANG
DEPARTEMEN ILMU KESEHATAN ANAK
Jl. Jend. Sudirman km. 3,5 Palembang 30126 Telp. 0711-354088 Pes 508-511, 0711-372832, 376445 Fax. 0711-372832
Name : ………………………………………… Date of Birth : ………………… M/F MR : …………… Date of Dx. : ………………
Mtx. It
Vcr.iv : 1.5 mg / m 2
Dexa.po : 6 mg / m 2
6 - MP.po : 50 mg / m 2
Mtx.po : 20 mg / m 2
BMP
day
Date of therapy month
year
Body Weight ( kg )
Body Height ( cm )
Body Surface Area ( m 2 )
MEDICINES Dosage MAINTENANCE - II ( Leucocyte > 2,000; Thrombocyte > 50.000 )
(WEEKS) 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110
Vcr.iv : 1.5 mg / m 2
Dexa.po : 6 mg / m 2
6 - MP.po : 50 mg / m 2
Mtx.po : 20 mg / m 2 BMP
day
Date of therapy month
year
Body Weight ( kg ) s
Body Height ( cm )
Body Surface Area ( m 2 )
Supervisor,
…………………………..
Fase Maintenance High Risk : dimulai dengan 6Mp dan MTX po karena minggu ke 17 pasien menerima MTX it pada Fase Intensifikasi