Autologous Transplant Patient Education Guide

Transcription

1 Autologous Tansplant Patient Education Guide Blood & Maow Tansplant Pogam Taussig Cance Institute Copyight The Cleveland Clinic Foundation. All ights eseved.

2 Definitions of Tems Table of Contents Welcome to the Blood & Maow Tansplant Pogam Tansplant Team Phone Numbes Welcome to the Tansplant Pogam Tansplant Oveview Bone Maow and Tansplantation Impotant Cleveland Clinic Phone Numbes Pe-Tansplant/Cental Line Cae Pe-Tansplant Evaluation Requied Tests & Appointments Dono Health Histoy Sceening Questionnaie (Autologous Patients Only) Dental Cleaance (Allogeneic Patients Only) Financial Questions to Ask Common Repoductive Issues You Cental Venous Cathete How to Avoid Poblems With You Cental Venous Cathete Injection Cap Change Cental Venous Cathete Tanspaent Dessing Change Cathete Flushing with Nomal Saline Pefilled Syinges How to Give Youself Subcutaneous Injections When You Need to Know About Neupogen Pleixafo Social Wok Intoduction to Social Wok Pepaing fo You Hospital Stay Packing fo You Hospital Stay Cae-Patne Advance Diectives Resouces/Suppot Goups/Lodging Continued Table of Contents The infomation povided in this guidebook is fo educational use only. This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about you specific medical condition.

3 You Tansplant You Dono s Expeience (Allogeneic Patients Only) The Tansplant Pocess & Sample Calendas Common Inpatient Medicines (Not in Reduced Intensity Binde) You Pepaative Regimen What to Expect Duing You Hospital Stay Staying Active Duing You Hospital Stay Peventing Cental Line-Associated Bloodsteam Infections (CLABSIs) while in the hospital Music Theapy Mouth Cae Schedule How to Cope With Side Effects CMV (Allogeneic Patients Only) Blood Tansfusions Neutopenic Pecautions Thombocytopenic Pecautions Tansplant Medicines Tansplant Medicines Oveview What you Should Know About You Medications & Pesciption Coveage (Allogeneic Patients only) You Tansplant Medicines Follow-Up Cae Afte You BMT Contacting the Team Afte Tansplant Fequent Laboatoy Testing Follow-up Appointments Afte Tansplant Things to Know Befoe Dischage (Not in Reduced Intensity Binde) Taking You Tempeatue Peventing Infections Afte Tansplant Recommended Vaccination Schedule Nutition Afte Tansplant Food Safety Guidelines Resuming Sexual Activity Taking You Blood Pessue Daily Recodkeeping Log Medication Calendas (Allogeneic Patients Only) Gaft-vesus-Host Disease (Allogeneic Patients Only) Gaft-vesus-Host Disease (GvHD): An Oveview Gaft-vesus-Host Disease of the Skin Gaft-vesus-Host Disease of the Eyes Gaft-vesus-Host Disease of the Live Gaft-vesus-Host Disease of the Gastointestinal (GI) Tact Nutition Guidelines fo GvHD Keeping You Healthy Post-Tansplant Cae Guide Copyight The Cleveland Clinic Foundation. All ights eseved. Poduced by Cente fo Consume Health Infomation Rev 10/15/2014

4 Definition of Tems Absolute Neutophil Count (ANC) The total numbe of neutophils in you white blood cell count. (See neutophils. ) Antibody A potein poduced by the white blood cells (leukocytes) to battle foeign substances, such as bacteia, that ente the body. Acute Lymphoblastic Leukemia (ALL) A fast-gowing cance of the lymphocytes, one of the white blood cells. Also called acute lymphocytic leukemia. Appeas most often in childen, but can occu in adults. Acute Myelogenous Leukemia (AML) A cance of the myelocytes, one of the white blood cells. Also called acute nonlymphocytic leukemia. AML occus in all ages and is the moe common acute leukemia in adults. Adjuvant Chemotheapy Dugs used to kill cance cells. They ae given with othe teatments, such as sugey o adiation, to destoy aeas of tumo. Allogeneic Bone Maow Tansplant A type of bone maow tansplant whee the cells a patient eceives ae not thei own. The dono can be a elated family membe o a closely matched unelated dono. Alopecia A patial o complete hai loss, usually a tempoay side effect of the chemotheapy. Anemia A deficiency in the numbe of ed blood cells. (See ed blood cells. ) Antigen A foeign substance, such as bacteia o toxin, that induces a specific immune esponse. Apheesis The pocess by which peipheal blood HPC s (blood stem cells) ae collected. Autologous Tansplant A type of bone maow tansplant duing which the patient eceives his o he own bone maow/stem cells. Blood Count A measuement of the diffeent components that make up the blood. Bone Maow The spongy tissue found in the cavities of the body s bones whee all blood cells ae poduced. Bone Maow Havest The pocedue of collecting stem cells fom the bone maow. Bone Maow Tansplant (BMT) A pocedue duing which bone maow, peipheal stem cells o umbilical cod stem cells ae infused following chemotheapy. (See autologous, allogeneic, and syngeneic, educed intensity and umbilical cod blood tansplants. ) Definition of Tems

5 Blood Stem Cells See Hematopoietic pogenito cells Cental Line o Cental Venous Cathete A small, plastic tube inseted in a lage vein. The cental line used in a stem cell tansplant allows blood samples to be dawn and dugs to be given, as well as the actual infusion of cells. Chemotheapy Teatment with one o moe anti-cance dugs to ty to stop o slow the gowth of cance cells. Chonic Lymphocytic Leukemia (CLL) A cance of the lymphocytes, one of the white blood cells. CLL is moe common in men ove the age of 60. Chonic Myelogenous Leukemia (CML) A cance of the myelocytes, one of the white blood cells. CML can occu at any age but is most often found in people ove the age of 45. Clinical Tials Reseach studies that test new teatments using devices o dugs. Collection Centes National Maow Dono Pogam (NMDP) facilities that collect of peipheal stem cells and bone maow. Colony Stimulating Facto o Gowth Facto The dug given to incease the numbe of stem cells in the blood. Also called Filgastim, Neupogen, G-CSF. Conditioning See pepaative egimen. Confimatoy Typing (CT) A tissue typing test done at the tansplant cente to make sue the dono and patient match. Cod Blood The blood of newbons found in the umbilical cod and placenta that contains lage numbes of blood stem cells. (See umbilical cod blood stem cell.) Cod Blood Bank An oganization that helps to collect and stoe umbilical cod blood fo tansplant. Cytomegalovius (CMV) A hepes vius that can occu in immunocompomised patients. DNA (Deoxyibonucleic Acid) The mateial thoughout the body that caies you cells genetic infomation. DNA-Based HLA Typing Human leukocyte antigen (HLA) is a system of makes found on white blood cells (leukocytes) that the immune system ecognizes. DNA-based HLA typing uses pecise (DNA) methods of testing to detemine and epot specific HLA antigens. This test is pefomed on ecipients and donos to confim an acceptable match exists. Dono A voluntee who has donated stem cells o bone maow fo a patient. Dono Cente An NMDP-accedited oganization with the expeience, staff and facilities to ecuit and manage inteaction with voluntee stem cell donos. Dono Wokup The pocess that a potential dono goes though to make sue he o she is healthy and eady to donate maow o blood stem cells. A wokup includes a detailed infomation session egading the donation pocess, a complete physical exam, and blood tests. Engaftment The pocess duing which tansplanted stem cells begin to gow in the ecipient s bone maow and poduce new white blood cells, ed blood cells, and platelets. Epidual Anesthesia A fom of anesthesia in which medicine is inseted into the oute (epidual) laye of the spinal cod to block any painful sensations fom the point of insetion to the lowe extemities. Eythocytes See ed blood cells. Filgastim See colony stimulating facto. Geneal Anesthesia A fom of anesthesia that causes tempoay patial o complete loss of sensation. Bone maow havests ae most commonly pefomed using geneal anesthesia. Gaft failue A complication afte an allogeneic tansplant in which the dono stem cells do not gow in the ecipient s bone maow and fail to poduce new white blood cells, ed blood cells, and platelets.

6 Gaft Vesus Host Disease (GvHD) A condition whee tansplanted stem cells attack the patient s body. Gaft Vesus Leukemia Effect (also called Gaft Vesus Cance Effect) The phenomenon wheeby the dono cells mount an attack against the ecipient s undelying cance. Gowth Facto o Colony Stimulating Facto See colony stimulating facto. Haplotype -- When the dono is only a half match to the ecipient. These donos can be paents, siblings o childen. Havest See stem cell havest. Hematopoiesis The pocess of foming ed blood cells, white blood cells, and platelets. Hematopoietic Pogenito Cells Bloodfoming stem cells capable of poducing all the components of blood and maow. (abbeviated HPC s) Hemoglobin The pat of the ed blood cell that caies oxygen. Histocompatibility A system that detemines how closely the patient and dono blood stem cells match. HLA_- Human Leukocyte Antigen Poteins on white blood cells that make each peson s tissue unique. The HLA A, B, C, and DR poteins ae impotant in matching patients and donos fo a maow o blood stem cell tansplant. HLA Match When both ecipient and dono have had DNA-based HLA typing pefomed and shae the same human leukocyte antigen esults. HLA typing The identification of a peson s key antigens used fo detemining compatible donos. Hodgkin s Disease A cance found in the lymph tissue. HPC collection The pocess of collecting stem cells fom the ciculating bloodsteam. Human T-Cell Lymphotophic Vius (HTLV) A ae vius tansmitted by cellula components of blood. Two foms of the vius have been identified, HTLV-I and HTLV-II. Immune Compomised A condition in which the patient has a much highe isk of infection due to a weak immune system. Immune System The goup of ogans and cells in the body that fight infection and othe diseases. Infectious Disease Makes Elements in a peson s blood that indicate if a peson has been exposed to cetain viuses. Infomed Consent The pocess by which a peson eceives an explanation of the isks and benefits of a medical teatment o eseach study, agees to paticipate, and indicates in witing that he o she undestands and agees to the infomation povided. A peson can povide infomed consent at age 18. Definition of Tems

7 Infusion The intoduction of medicines, fluids, chemotheapy, o blood poducts into a vein. Sometimes efeed to as an intavenous infusion. Leukemia A goup of cances that involve the white blood cells. Leukemias can be acute (fast gowing) o chonic (slow gowing). Leukocytes See white blood cells. Lymphocytes A type of white blood cell that is pat of the immune system that helps potect the body fom invading oganisms. T-cells ae a kind of lymphocyte that ae involved in gaft vesus host disease. Lymphoma A cance of the lymph tissue. Included in this disease categoy ae Hodgkin s disease and non-hodgkin s lymphoma Malignant Canceous. Maow See bone maow. Maow donation A sugical pocedue by which a peson donates a potion of thei bone maow fo a patient who needs a bone maow tansplant. Metastasis The spead of cance fom one pat of the body to anothe. Mini Bone Maow Tansplant (Non-Myeloablative Allogeneic BMT) A bone maow tansplant duing which lowe doses of chemotheapy and adiation ae used to pepae a patient fo tansplant. It elies on the dono s immune system to kill the disease. Minitansplants equie an HLA matched dono. (Reduced Intensity BMT) Mobilization A pocess involving the movement of stem cells fom the bone maow into the bloodsteam though chemotheapy and/o gowth facto injections. Also called piming. Molecula HLA Typing See DNA-based HLA typing. Monoclonal Antibodies A fom of teatment that only destoys a cetain type of cell that is involved in cance. Multiple myeloma A cance of the plasma cells in the blood. Myelodysplastic Syndome o Disode (Myelodysplasia) A disease of the bone maow in which too few platelets, ed blood cells, and white blood cells ae made. Also called pe-leukemia o smoldeing leukemia. Myelofibosis A disease that causes sca tissue to fom in the bone maow. As a esult of the sca tissue, nomal blood cell poduction is blocked. Nomal blood cell poduction then moves to the spleen, which then becomes enlaged. Anemia esults because blood poduction in the spleen does not wok as well as in the bone maow. Myelopolifeative Disodes A goup of disodes caused by inceased poduction of blood cells by the bone maow. The 4 types of myelopolifeative disodes ae: polycythemia vea, when too many ed blood cells ae fomed; chonic myelomonocytic leukemia, when too many white blood cells ae fomed; pimay thombocythemia, when too many platelets ae fomed; and myelofibosis, a disease that causes sca tissue to fom in the bone maow National Maow Dono Pogam (NMDP) The oganization selected to manage the egisty of voluntee unelated bone maow donos in the United States. Neutophil The type of white blood cell that is the fist line of defense against infection. Non-Hodgkin s Lymphoma A cance that is found in the lymph tissue. Non-Myeloablative Tansplant See mini bone maow tansplant. Peipheal Blood Stem Cells (PBSC) Cells found in the ciculating bloodsteam that have not become specialized. Peipheal Blood Stem Cell Tansplant See bone maow tansplant. Phlebotomy Withdawing blood fom a vein fo testing puposes. Plasma The liquid potion of unclotted blood that helps to eplace blood volume.

8 Platelets Blood cells that act as clotting agents to contol bleeding. Peliminay Seach The pocess by which a patient s HLA type is sent to the NMDP and enteed into the compute, whee it is compaed to the HLA types of all voluntees listed in the egisty at that time. The peliminay seach becomes fomal when specific donos ae equested fo futhe testing on behalf of the patient. Pepaative Regimen The chemotheapy and/o adiation that is given to patients befoe the maow o blood stem cell tansplant. Piming See mobilization. Pognosis The pedicted o likely outcome. Potocol A specifically designed teatment plan. Radiation Theapy Teatment to kill cance cells using high-enegy ays fom X- ays, electon beams, o adioactive isotopes. Recuitment Goup An oganization affiliated with the National Maow Dono Pogam that ecuits donos. Red Blood Cells Cells that cay oxygen to all pats of the body. Also known as eythocytes. Registy A confidential national database of potential voluntee bone maow/stem cell donos established and maintained by the National Maow Dono Pogam. Relapse The etun of the disease afte teatment. Remission Complete o patial disappeaance of cance cells and symptoms afte teatment. Staging Extensive testing done to detemine if a patient is a candidate fo a bone maow tansplant. Stem Cell Tansplant See bone maow tansplant. Syngeneic Bone Maow Tansplant A type of bone maow tansplant whee the dono is an identical twin. T-cells (T-lymphocytes) A type of white blood cells that identifies oganisms that do not belong in the body. The T-cells ae involved in gaft vesus host disease (GvHD). T-cell Depletion Removing T-cells fom the dono s stem cells to significantly educe the isk of developing seious GvHD. Thombocytopenia Low platelet count. Tissue Typing A seies of blood tests that evaluate the compatibility o closeness of tissue between the ogan dono and ecipient. Umbilical Cod Blood Stem Cell A stem cell fom the blood of the umbilical cod and placenta. (See also stem cell and cod blood.) Unelated Bone Maow Tansplant A type of tansplant whee the dono is not elated to the patient. Definition of Tems

9 Voluntee Dono Usually efes to an unelated bone maow dono who is an acceptable HLA match and who is willing to donate bone maow anonymously to a ecipient in need of a bone maow tansplant. Related bone maow donos also may be efeed to as voluntee donos. Notes White blood cells Cells that help fight infection and disease (leukocytes). Wokup See dono wokup. Index #10638 This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Poduced by Cente fo Consume Health Infomation Copyight The Cleveland Clinic Foundation. All ights eseved. Rev

10 Welcome to the Blood & Maow Tansplant Pogam Welcome to the Blood & Maow Tansplant (BMT) Pogam. The BMT Team at Cleveland Clinic s Taussig Cance Institute is hee to help you egain you health. Lean about the tansplantation pocess We have designed an extensive teaching pogam to help you lean about the tansplantation pocess and you individual health needs, as well as you medical cae befoe and afte the tansplant. We know that leaning about the tansplantation pocess and how to cae fo you health might be ovewhelming at fist. But emembe, you can lean a little each day. You'll also have this notebook as a efeence duing you tansplant expeience. We undestand you ae both excited and nevous about you tansplant. These ae nomal eactions. Being pepaed in advance by leaning and undestanding what to expect will help ease you feas of the unknown. Always discuss you questions and expectations with you health cae povides. Be an active patne in you health cae Welcome We believe it is impotant fo you to be an active paticipant in you health cae. You will need to assume much esponsibility in you own cae by doing whateve is necessay to build and maintain you stength fo the tansplant. It is also impotant fo you to ecognize and epot any changes in the way you feel. No one knows how you feel except you. Patient ights Cleveland Clinic suppots the following patient ights: n Reasonable access to cae in a safe envionment, which will not be denied due to ace, ceed, colo, national oigin, sex, age, sexual oientation, disability, o souce of payment n Access to infomation about you diagnosis, condition, and teatment in tems you can undestand so you can paticipate in the decisions egading you cae

11 n Consideate cae that espects you pesonal value and belief systems n Paticipation in the consideation of ethical issues that aise in the povision of you cae n Pesonal pivacy and confidentiality of infomation n Designation of a epesentative decision make in the event you ae incapable of undestanding a poposed teatment o pocedue, o ae unable to communicate you wishes egading cae n Ability to efuse teatment to the extent pemitted by law and to be infomed of the possible consequences of you efusal and the ability to consent o efuse to paticipate in expeimental teatment o eseach n To know the names and pofessional titles of all you caegives (Cleveland Clinic is a teaching institution. Resident doctos, fellows and othe supevised health cae povides in taining might become involved in you cae and teatment.) n To be povided with infomation about you continuing health cae needs and planning fo cae afte you leave the hospital and, as appopiate, afte an appointment with you docto o othe caegive Patient esponsibilities You esponsibilities as a patient at Cleveland Clinic include: n Poviding accuate and complete infomation about all mattes petaining to you health, including medicines and past o pesent medical poblems n Notifying a membe of the health cae team if you do not undestand infomation about you cae and teatment n Repoting changes in you condition o symptoms, including pain, to a membe of the health cae team n Acting in a consideate and coopeative manne, and especting the ights and popety of othes n Following the ules and egulations of the health cae facility, as well as following the instuctions and advice of you health cae team n Keeping scheduled appointments o canceling them in advance if at all possible This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Index #9546 Poduced by the Cente fo Consume Health Infomation Copyight The Cleveland Clinic Foundation. All ights eseved. Rev

12 Blood & Maow Tansplant Pogam Oveview Cleveland Clinic pefomed its fist bone maow tansplant in Since then, the Blood & Maow Tansplant (BMT) Team has pefomed moe than 3,000 tansplants. The Blood & Maow Tansplant Pogam offes state-of-the-at tansplantation in both autologous and allogeneic tansplants. We ae one of the wold s leading authoities on peipheal blood stem cell mobilization and tansplantation of autologous peipheal stem cells. We wee one of the founding membes of the National Maow Dono Pogam in the use of unelated donos fo allogeneic tansplants. The Blood & Maow Tansplant Pogam is accedited by The Foundation fo the Acceditation of Cellula Theapy (FACT), Ameican Association of Blood Banking, the National Maow Dono Pogam, the Ohio Bone Maow Consotium and Southwest Oncology Goup. Cleveland Clinic has designated facilities and suppot sevices available to assist patients and thei families thoughout the entie tansplant pocess. Tansplant patients at Cleveland Clinic eceive the highest-quality medical and nusing cae. Blood & Maow Tansplant Team offes compehensive cae The Blood & Maow Tansplant Team at Cleveland Clinic is specially tained in meeting the needs of tansplant patients. The team is committed to poviding compehensive cae in a compassionate setting. The BMT Team membes include: Tansplant doctos Physician assistants and Nuse Pactitiones Tansplant nuse coodinatos Infectious disease team Phamacologists Tansplant fellows and esidents Administative coodinatos Nuse manage and assistant nuse manage Registeed nuses Nusing assistants Administato Dietitians Social wokes Financial counselos Blood & Maow Tansplant Pogam Oveview Tansplant doctos BMT doctos ae staff doctos with extensive taining and expeience in hematology/oncology and blood o maow tansplant. The tansplant docto on sevice will be caing fo you duing you stay in the hospital and will check you

13 pogess daily. Since Cleveland Clinic is a teaching facility, the tansplant doctos otate caing fo inpatient tansplant ecipients. Theefoe, you tansplant docto might o might not be on sevice while you ae in the hospital, but will continue to be an active membe in the decision-making pocess. You tansplant docto continues to cae fo you health and follows you closely duing you follow-up visits. Physician assistants & nuse pactitiones Physician assistants and nuse pactitiones play an active ole in you teatment. The inpatient BMT unit is staffed with physician assistants who will follow you medical cae, along with the tansplant docto. A physician assistant o Nuse Pactitione and the staff docto will pefom physical exams, eview teatment, and follow laboatoy and X-ay esults on a daily basis. Tansplant coodinatos The tansplant coodinato is a egisteed nuse who helps coodinate all the events leading up to and following you tansplant. He o she teaches you how to pepae fo you tansplant and will find you a suitable blood o maow dono should you equie one. Along with othe membes of the Tansplant Team, you tansplant coodinato teaches you how to take cae of youself afte tansplantation in ode to maintain you health. Afte you ae dischaged fom the hospital, you tansplant coodinato will continue to be diectly involved in all aspects of you cae. Infectious disease team This team of doctos is specially tained in infectious disease and how it elates to the tansplant pocess. Befoe you tansplant, you will have multiple tests to detect any signs of infection. Once you ae admitted to the hospital, the infectious disease doctos will ound evey day with the est of the BMT Team. They will help contol you envionment to potect you against hamful souces of infection. Befoe appoaching you, visitos and othes will be asked to wash thei hands with antimicobial soap o instant hand sanitizing foam located outside and inside each oom. In addition, you tempeatue will be taken evey 4 hous to detect ealy signs of infection. Tansplant fellows Tansplant fellows ae doctos who ae taining to become specialists in hematology and oncology. They wok unde the guidance of you staff tansplant docto and will visit you daily along with you tansplant docto and the est of the BMT Team. Phamacologists Along with you tansplant docto, you phamacologist will make adjustments in you medicine dosage as needed. The phamacologist might assist you nuses and tansplant coodinato in teaching you about you tansplant medicines. Administative coodinatos You administative coodinato will make sue all of you appointments ae scheduled befoe and afte you tansplant. He o she will wok closely with you efeing docto to make sue all necessay medical ecods ae available. The coodinato also stays in close contact with you insuance company fo medical eview and appoval of you teatment plan. Nuse manage and assistant nuse manage The nuse manage and assistant nuse manage ae esponsible fo the oveall daily management while you ae on the BMT Unit (G110) o the Leukemia Unit (G111). The nuse manage and the assistant nuse manage wok with the egisteed nuses and nusing assistants on all nusing units to assue you ae eceiving the best cae. If you have any questions o concens about the condition of you oom o the nusing cae you ae eceiving, you may ask to speak with eithe the nuse manage o assistant nuse manage. Registeed nuses Registeed nuses povide you with individual cae duing you outpatient appointments at the Taussig Cance Institute and 24-hous-a-day while you ae hospitalized. Registeed nuses wok

14 togethe with you docto and the est of the BMT Team to plan you daily cae. In the hospital, egisteed nuses also: Check you pogess at fequent intevals thoughout the day and night Administe you medicines Tell you docto of any changes in you condition Educate you and you family about the medicines you will be taking Teach you how to cae fo you health afte tansplantation Pepae you fo you dischage Nusing assistants Nusing assistants wok with the egisteed nuses to povide you daily cae. They might take you tempeatue, blood pessue, and daily weight. They also assist with you pesonal cae and help make you comfotable duing you hospital stay. Administato The BMT administato ovesees the daily opeations of the Blood & Maow Tansplant Pogam to ensue maximum opeating efficiency while ensuing quality cae of all patients. The administato manages the nusing, engineeing, eseach, technical, laboatoy, financial, social wok, and cleical pesonnel within the BMT Pogam. Dietitians Registeed dietitians (nutition expets) ae available to help you maintain good nutition duing you tansplant ecovey. They wok closely with you and you docto to povide individualized nutitional counseling. They ae available to answe any nutition questions you might have. Social wokes A social woke will be assigned to you and you family and will discuss any concens you might have about you tansplant o you pesonal situation. You social woke will be a pimay souce of suppot duing the tansplant pocess. Social wokes povide education, counseling egading lifestyle changes and coping with teatment demands, efeals to community o national agencies and suppot goups, help with local lodging needs, and any othe assistance you o you family might need. Financial counselos You financial counselo can answe any questions you might have about insuance coveage and benefits elated to you tansplant and cae. They will help obtain insuance appoval fo you tansplant. Tansplant patients will be scheduled to meet with the financial counselo pio to thei tansplant. Some tansplant patients might be eligible fo cetain govenment pogams, depending on thei individual financial situation. Othe BMT tansplant team membes A chaplain is available to povide spiitual guidance o counseling fo all faiths. Thee ae many othe pofessionals such as a music theapist, physical theapists, and espiatoy theapists, laboatoy Blood & Maow Tansplant Pogam Oveview

15 technicians, and suppot staff who wok as membes of the BMT Team to meet you medical and pesonal needs. Special cae fo pediatic patients Pediatic patients eceiving a blood o maow tansplant ae admitted to the Childen's Hospital at Cleveland Clinic. Thee, they ae unde the cae of specialists, nuses, social wokes, child-life wokes, and othe health cae pofessionals who ae tained to meet the unique needs of childen and thei families. The Childen's Hospital povides state-of-the-at cae in a home-like setting. Because the family is an impotant pat of a hospitalized child s ecovey, the hospital ooms ae designed to enable a paent to spend the night in the oom with his o he child. Notes Index #3984 This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Poduced by the Cente fo Consume Health Infomation Copyight The Cleveland Clinic Foundation. All ights eseved. Rev. 05/01/2014

16 Bone Maow and Tansplantation How the bone maow functions Bone maow is the soft, spongy cente of you bone whee blood is poduced. Maow is filled with blood-poducing cells, called hematopoietic pogenito cells (HPCs), which develop into matue white blood cells, ed blood cells, o platelets. White blood cells of vaious kinds make up pat of you immune system fo fighting infections. Red blood cells ae esponsible fo caying oxygen thoughout you body. Platelets clot you blood to pevent bleeding. HPCs ae constantly being poduced by you bone maow, and will develop into the types of cells you body needs. HPCs ae sometimes called stem cells. Types of blood o maow tansplants ed blood cell platelets white blood cells Most people who need to undego a blood o maow tansplant have cance, such as leukemia, lymphoma o multiple myeloma. Thee ae diffeent types of tansplants. The type and seveity of you disease detemine what type of tansplant you will need. An allogeneic tansplant involves eceiving dono bone maow, umbilical cod stem cells o peipheal blood stem cells. This dono is genetically matched and can be elated o unelated to you. Bone Maow and Tansplantation An autologous tansplant involves eceiving you own bone maow o peipheal stem cells. A syngeneic tansplant involves eceiving you identical twin's bone maow o peipheal blood stem cells. Hee is moe infomation about the specific types of blood o maow tansplants:

17 An allogeneic tansplant involves eceiving vey high-doses of chemotheapy and/o adiation theapy, followed by the infusion of you dono's bone maow o peipheal blood stem cells. The high-dose cancefighting teatments ae given to eliminate The infusion of the new maow, cod blood o peipheal stem cells fom the dono eplaces the bone maow destoyed by the chemotheapy and/o adiation theapy. Allogeneic tansplant patients have the isk of developing a complication called gaft-vesushost disease o GvHD. GvHD is a condition whee dono cells fom the gaft attack the patient s (o host s) ogans o tissues The condition can be mild and teated on an outpatient basis, o it can be sevee and equie teatment in the hospital. You might be a potential candidate fo an allogeneic tansplant if you have leukemia, aplastic anemia, myelodysplasia, myelofibosis, high-gade lymphoma o othe types of cances. A Reduced Intensity allogeneic tansplant involves eceiving lowe doses of chemotheapy and adiation theapy followed by the infusion of you dono's bone maow o peipheal blood stem cells. The objective is to suppess you own bone maow by eceiving just enough chemotheapy and adiation theapy to allow you dono cells to engaft and gow within you. The hope is these dono cells will mount an immunologic attack against you undelying cance, geneating a esponse called the gaft-vesusleukemia effect o gaft-vesus-cance effect. You might be a potential candidate fo this type of tansplant if you have a slow-gowing, indolent disode, such as chonic leukemia, multiple myeloma, myelodysplasia, and low-gade lymphoma. An autologous tansplant involves eceiving vey high-dose chemotheapy followed by the infusion of you peviously-collected peipheal blood stem cells o bone maow. The high-dose chemotheapy teatments ae given to eliminate the cance in you body. The infusion of you new maow o peipheal stem cells eplaces the bone maow destoyed by the chemotheapy and/o adiation theapy. You might be a potential candidate fo an autologous tansplant if you have lymphoma, multiple myeloma, Hodgkin's disease, gem cell cance, o cetain types of leukemia. Pe-tansplant evaluation Befoe a blood o maow tansplant can be appoved as a teatment option, you will have a pe-tansplant evaluation. This evaluation includes a complete physical, consultations with membes of the Tansplant Team, and a compehensive seies of tests. A pe-tansplant evaluation povides complete infomation about you oveall health and helps detemine if you ae eligible fo a blood o maow tansplant. Blood o maow tansplantation as a teatment option Afte you tansplant docto has detemined you ae a good candidate fo a tansplant, a date fo the tansplant will be detemined and the pocess of insuance cleaance will begin. Please undestand that insuance eimbusement fo tansplantation is not automatic. If you ae to be admitted to the hospital fo you tansplant, you can expect you stay to be about 3 to 4 weeks, depending on you ecovey. Duing you ecovey, you will lean about you new medicines, how to ecognize signs of complications and infections, and when you can etun to you nomal activities. If an allogeneic tansplant o inpatient educed intensity tansplant has been appoved fo you, you and you designated cae-patne might be equied to stay within a 1-hou dive of

18 Cleveland Clinic s main campus fo appoximately 100 days afte you tansplant. Afte you go home, you can expect to ecove gadually, usually ove 3 to 6 months. If an outpatient educed intensity allogeneic tansplant has been appoved fo you, you will be equied to stay within a one-hou dive of Cleveland Clinic s main campus fo at least 100 days afte you tansplant. At that time, you docto will evaluate you medical condition to detemine whee you can continue you follow-up cae. Follow-up cae afte you tansplant includes appointments with you tansplant o local docto and tests to assess how you ae ecoveing. Notes Bone Maow and Tansplantation

19 Notes This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Index #4752 Poduced by the Cente fo Consume Health Infomation Copyight The Cleveland Clinic Foundation. All ights eseved. Rev.10/15/2014

20 Impotant Cleveland Clinic Phone Numbes Admitting (Patient Registation) Ambassados (Voluntee Sevices) Ameican Cance Society ACS.2345 Apheesis BMT Laboatoy BMT Administation Office Cance Answe Line/R-2 Libay o Cance Infomation Sevice CANCER Cashie Conciege Sevices Cleveland Clinic Infomation o Diections to the Cleveland Clinic Emegency Assistance (Fie, Secuity) Financial Ombudsman Food Sevices, Patient (Menu Hotline) Food Sevices, Retail Geneal Counsel (Legal Affais) Joseph Beth Gift Shop Health Infomation Libay Heaing Impaied Intepete Refeal Cleveland Clinic Home Cae HOME o Impotant Cleveland Clinic Phone Numbes Hope Lodge

21 Hospice of the Cleveland Clinic Infection Contol Intenational Cente Laboatoy (R21) Leukemia & Lymphoma Society Lost and Found Nuse on Call Nutition Hotline Nutition Theapy Appointments Ombudsman Patient Helpline (24 hous a day) Patient Shuttle Bus Poison Contol Cente (Geate Cleveland Aea) Police/Secuity Paye Line Phamacy (Outpatient -Euclid Ave Lobby of Paking #1) Phamacy (Taussig Cance Cente) Reflections Wellness Pogam Social Wok Spiitual Cae Telegam/Telex Sevice Tansplant Housing TV Sevice Vehicle Assistance Index # 9609 This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Poduced by Cente fo Consume Health Infomation Copyight The Cleveland Clinic Foundation. All ights eseved. Rev. 12/12/13

22 Pe-Tansplant Evaluation Requied Tests & Appointments Pe-Tansplant Evaluation You tansplantation pocess began with an initial consult with you tansplant docto. You and you docto have detemined that a tansplant is the ight teatment fo you. The next step in the pocess is you pe-tansplant evaluation. What is a pe-tansplant evaluation? You pe-tansplant evaluation includes a vaiety of medical tests and appointments that will povide complete infomation about you oveall health. These medical tests and appointments help the BMT team identify any potential poblems befoe you tansplant and avoid any potential complications duing and afte you tansplant. These tests ae also equied by you insuance company in ode to appove the medical necessity of you tansplant. About 4-6 weeks befoe you tansplant, you will be scheduled fo you pe-tansplant evaluation. While each patient may not have the same tests, most of the tests listed in this section ae common fo all tansplant patients. The testing equied fo you tansplant is usually done ove a few days as an outpatient, at the Cleveland Clinic. You nuse and administative coodinatos will help aange the testing fo you. If you have an allegy to the contast dye used fo CT scans, o have been told that you need to be pemedicated befoe CT scans, please notify you nuse coodinato. You will need a pesciption sent to you phamacy befoe you scheduled test date. If you have had a PET scan, CT scan, o skeletal suvey done within 6-9 months pio to you pe-tansplant evaluation, please bing a copy of the films o CD along with the epot, to you pe-tansplant evaluation appointments. The adiologist will use them as a compaison when eading you pe-tansplant evaluation scans. If special instuctions ae equied befoe any of these tests, you will eceive witten instuctions that explain how to pepae. Afte the tests ae completed, you tansplant docto will eview the esults with you. Pe-Tansplant Evaluation Requied Tests & Appointments

23 Requied Tests and Appointments You pe-tansplant evaluation will be scheduled at Cleveland Clinic, usually ove a few days. In additon to you equied medical tests, you will also be scheduled to meet with membes of the BMT team. The next few pages will povide infomation about the testing and appointments that you will be scheduled fo as pat of you petansplant evaluation. Meeting with the tansplant team As pat of you evaluation fo tansplant, you will meet with a nuse coodinato, social woke and financial counselo to lean moe about the BMT pocess. Nuse coodinato-- You nuse coodinato will meet with you to eview the calenda of events elated to tansplant, including the chemotheapy, with o without adiation, and infomed consents. This appointment usually lasts about 2 hous. The nuse coodinato will discuss potential side effects of chemotheapy /adiation and what you can expect duing you BMT expeience. Social woke- You social woke will complete a thoough psychosocial assessment, which helps to identify the needs and concens of patients, families, and significant othes. All patients will have an in-peson assessment with the social woke that usually lasts about 1-1/2 hous. You cae-patne(s) should attend this appointment with you. Most insuance companies equie an assessment by a social woke to be completed pio to appoval of you BMT. All patients ae asked to complete the enclosed social woke questionnaie and etun it in the envelope povided. If you ae eceiving a tansplant fom a dono (allogeneic o educed intensity), you and you cae-patne will be equied to stay in the Cleveland Metopolitan aea, within a 1 hou dive of the Cleveland Clinic Main Campus. Most autologous tansplant patients (patients eceiving thei own stem cells), will be equied to stay within 1 hou of Cleveland Clinic Main Campus duing the stem cell collection peiod, which can be up to 3 weeks. In some cases, autologous stem cell patients may also be equied to stay within 1 hou of Cleveland Clinic afte being dischaged. You social woke can help identify local housing options and povide assistance with othe concens that you may have. Radiation oncologist If you equie adiation as pat of you pepaative egimen, you will meet with a adiation oncologist. The adiation oncologist will assess you histoy of pevious adiation exposue to ensue you ae able to eceive adiation fo tansplant. He o she will also explain possible side effects that can be caused by adiation, as well as how adiation is given. Financial counselo All tansplant patients will meet with a financial counselo who can eview insuance coveage fo peand post-tansplant expenses. Dentist All allogeneic tansplant patients equie a dental assessment as pat of you pe-tansplant sceening to ensue that you mouth is fee of potential infection. Autologous tansplant patients may be equied to have a dental assessment. This will be detemined by you insuance company and/o you tansplant physician. Check with you nuse coodinato if you ae unsue. A dental assessment may be scheduled at you pesonal dentist s office o at Cleveland Clinic. If the assessment is done at you local dentist s office, please ask the dentist to fax a lette stating that you mouth is fee fom any souce of potential infection.

24 The lette needs to be faxed to the BMT office at Fax: o hand deliveed pio to you tansplant. (Feel fee to use the handout Instuctions fo You Dentist as a guide.) If dental wok is equied befoe the stat of you pepaative egimen, please notify you nuse coodinato to detemine if peventive antibiotic theapy is needed befoe the dental wok is pefomed. If you would like a dental assessment to be scheduled at Cleveland Clinic, please notify you nuse coodinato and veify that you insuance will cove a dental consult at Cleveland Clinic. Medical insuance does not typically cove dental cleaance. Blood tests You health cae povide o a technician will take a sample of blood fom you am o cental venous cathete (if one is in place). The blood is sent to a lab whee the following tests ae pefomed: Tissue typing (needed fo allogeneic patients only) This was done at o befoe you initial consultation appointment with you BMT docto. Tissue typing is a seies of blood tests that evaluate the compatibility o closeness of tissue between the dono and ecipient. Fom you blood samples, the tissue typing lab can identify and compae infomation about you antigens (the makes in cells that stimulate antibody poduction) so they can match a bone maow o peipheal blood stem cell dono to you. All donos ae caefully sceened to pevent any tansmissible diseases o detect othe medical poblems that might pevent them fom donating bone maow o peipheal blood stem cells. Othe blood tests In the laboatoy, a seies of tests will be pefomed to detect cetain substances in you blood and to evaluate you geneal health. These blood tests might include: Infectious Disease Sceening fo : Hepatitis HIV (human immunodeficiency vius) RPR (syphilis) Toxoplasmosis Vaicella Zoste CMV (cytomegalovius) EBV (Epstein-Ba vius) HSV (Hepes Simplex vius) West Nile Vius HTLV1/11 (Human T-Cell lymphotopic vius) Chagas Blood Wok to Check you Ogan Function Feitin Complete Metabolic Panel Hemoglobin Solubility ABO blood type Bleeding times CBC, diff, platelets Quantitative immunoglobulins Othe Possible Blood Wok Disease-specific labs fo multiple myeloma, including a 24-hou uine Pegnancy test Reseach samples Pe-Tansplant Evaluation Requied Tests & Appointments

25 Heat and lung Tests Because of the pio chemotheapy and/o adiation theapy that you may have eceived, and the chemotheapy and/o adiation that you will eceive fo you tansplant may affect you heat and lungs, you will need heat and lung tests to identify and teat any potential poblems befoe you tansplant pocedue. The heat tests include: Electocadiogam (EKG) An EKG is used to evaluate you heat hythm. Befoe the test, electodes (small, flat, sticky patches) ae placed on you chest. The electodes ae attached to an electocadiogaph monito that chats you heat s electical activity (heat hythm). Echocadiogam An echocadiogam is a gaphic outline of you heat s movement. Duing the test, a wand, o tansduce, is placed on you chest. The tansduce emits ultasound (high-fequency sound wave) vibations so the docto can see the outline of the heat s movement. The echocadiogam povides pictues of the heat s valves and chambes so the pumping action of the heat can be evaluated. Echocadiogam is often combined with Dopple ultasound to evaluate blood flow acoss the heat s valves. The Lung tests include: Chest X-ay A chest X-ay povides a pictue of you heat and lungs. This X-ay povides infomation about the size of you heat and lungs, and might detect the pesence of lung disease o infection. Pulmonay function tests (PFTs, lung tests) Pulmonay function tests measue the capacity and function of you lungs, as well as you blood s ability to cay oxygen. Duing the tests, you will be asked to beathe into a device called a spiomete. Hee ae some guidelines to follow befoe you scheduled pulmonay function tests: Be sue to get plenty of sleep the night befoe. Plan to wea loose clothing duing the test so you can give you geatest beathing effot. Limit you liquids and eat a light meal befoe the test. Dinking o eating too much befoe the test might make you feel bloated and unable to beathe deeply. Radiology Tests Depending on the type of disease you have, you may be scheduled fo adiology tests. You tansplant physician may equest a Compute Tomogaphy scan (CT scan), a Positon emission tomogaphy (PET) scan, o a combination PET/CT scan. Patients with Multiple Myeloma may be equied to have a skeletal suvey. Computed tomogaphy scan (CT Scan) A CT scan, uses X-ays and computes to poduce a detailed image of the body. Depending on the type of scan you need, an oal and/o IV contast mateial might be used so the adiologist can see the extent of you disease. CT scans also might eveal the pesence of othe abnomalities. If you had a CT scan within 6 months befoe you pe-tansplant evaluation, bing the CT scan films o disc, along with a copy of the epot with you. The adiologist will use them as compaison when eading these new scans.

26 Depending on you illness, you docto might ode additional CT scans. Positon emission tomogaphy (PET) scan A PET scan is a unique type of imaging test that helps doctos see how the ogans and tissues inside you body ae actually functioning. The test involves injecting a vey small dose of adioactive chemical, called a adiotace, into a vein. The tace tavels though the body and is absobed by the ogans and tissues being studied. Next, you will be asked to lie down on a flat examination table that is moved into the cente of a PET scanne -- a doughnut-like shaped machine. This machine detects and ecods the enegy given off by the tace substance. The PET scan can measue such vital function as glucose metabolism, which helps doctos identify abnomal fom nomal functioning ogans and tissues. One of the main diffeences between PET scans and othe imaging tests like CT scan o magnetic esonance imaging (MRI) is that the PET scan eveals the cellula level metabolism changes occuing in an ogan o tissue, o the activity of cells. Depending on you illness, you docto may ode a PET scan. Bone maow biopsy-- A bone maow biopsy is a pocedue to collect and examine bone maow-- the spongy tissue inside some of you lage bones. Bone maow biopsy can show whethe you bone maow is healthy and making nomal amounts of blood cells, as well as monito fo abnomal cells. The aea of you back hip bone will be numbed with a local anesthetic o pain elieving medication, befoe the needle is inseted to emove the sample of you bone maow. You might be given oal medicine, pio to the pocedue to help you elax. You should plan to have a dive take you home afte this pocedue since the medication can make you dowsy. Additional Tests Some insuance companies equie additional testing as pat of you petansplant evaluation. These may include: a colonoscopy, mammogam, dental exam, o gynecology exam. You nuse coodinato will let you know if these tests ae equied. Afte you BMT physician eviews you evaluation testing, additional appointments o consulations may be necessay. You nuse and administative coodinato will assist you in scheduling these appointments at Cleveland Clinic. Afte my pe-tansplant evaluation At the end of you pe-tansplant evaluation and afte the test esults ae complete, the BMT docto will decide whethe o not a tansplant is the appopiate teatment fo you. You test esults will also be sent to you insuance company fo the insuance appoval pocess. Usually the insuance company will make a detemination in 7 to 10 days afte eceiving the test esults. Pe-Tansplant Evaluation Requied Tests & Appointments

27 Please undestand that abnomal test esults might equie futhe investigation. Notes The goal of pe-tansplant testing is to ensue that you will be able to undego the tansplant and ecove without inceased isk of complications. Dono pe-tansplant testing Fo allogeneic and mini allogeneic tansplant patients, you blood o maow dono will also have a medical evaluation with many of the same tests. The dono must be cleaed and detemined medically fit to poceed as you dono. Index #9606 This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Copyight The Cleveland Clinic Foundation. All ights eseved. Poduced by the Cente fo Consume Health Infomation Rev. 02/04/2014

28 Dono Health Histoy Sceening Questionnaie When a dono is scheduled fo havest of hematopoietic pogenito cells (HPCs) by eithe apheesis o bone maow havest, he o she will need to complete a dono health histoy sceening questionnaie. Allogeneic tansplant donos will be asked to complete the fom when donating cells intended fo use by anothe patient/ecipient. Autologous tansplant patients donating cells fo thei own futue use will also need to complete the fom. The dono health histoy and sceening questionnaie contains some specific questions and you may wonde why you answes to these questions ae needed. Fedeal law equies that HPC donos answe these questions, which ae simila to the ones asked when donating blood. The answes ae used to ensue the safety of the patient eceiving the cells fo tansplant since infection may be caied in them. The questions gathe infomation in two main aeas: 1. Dono s own health and safety 2. Exposue to infections by vaccinations, sexual contact with othes in a high isk goup o tavel to counties whee paticula infectious diseases ae pevalent. You answes to these questions will emain confidential and will not become pat of you o anothe s medical ecod. Often, a paticula behavio may incease one s isk of infection, but the infection might not be detectable by a blood test fo a longe peiod of time. Review of you answes to these questions allows you physician to assess any isk to you o to othes fom you planned HPC havest. You nuse coodinato will eview the completed questionnaie with you at you scheduled appointment. Please answe evey question and ente any additional infomation needed on the fom to complete you answe. If you have any questions, please discuss them with eithe you nuse coodinato o you physician. You will be infomed of any answe that may incease isk of infection to anothe peson. If you ae an allogeneic tansplant dono, you physician will seek you pemission to shae infomation about the disease that may be tansmitted to the ecipient with you cells. Only the infectious disease and not you specific behavios will be shaed pio to you planned HPC havest and pio to the ecipient beginning the tansplant pocess. Autologous tansplant patients ae teated in a simila fashion to pevent any infection in othes duing HPC collection, pocessing, and stoage. Dono Health Histoy Sceening Questionnaie

29 You tansplant nuse coodinato will ask if any of you answes have changed when thee ae delays in you havest schedule and moe than 30 days have gone by since you initially completed the questionnaie. If moe than 60 days have gone by, then you will be asked to complete a new questionnaie. The collection staff eithe in the apheesis unit o in the opeating oom will also veify that you answes have not changed since the last eview. Fo additional infomation, you may view any of the esouces listed below: n FDA Guidance fo Industy: Eligibility Detemination fo Donos of Human Cells, Tissues, and Cellula and Tissue-based Poducts: GuidanceComplianceRegulatoyInfomation/ Guidances/Tissue/ucm htm n Centes fo Disease Contol and Pevention: Notes This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Index #14675 Heaing Impaied (TTY) Assistance Poduced by Patient Education and Health Infomation Copyight The Cleveland Clinic Foundation. All ights eseved. Rev. 10/10

30 - Pe-Tansplant Sceening: Requied Tests Why do I need to have pe-tansplant evaluation tests? You pe-tansplant evaluation includes a vaiety of medical tests that povide complete infomation about you oveall health. These medical tests help the bone maow tansplant team identify any potential poblems befoe you tansplant and avoid potential complications afte you tansplant. While each patient does not have the same tests, most of the tests included in this handout ae common fo all tansplant patients. The tests equied befoe the tansplant ae usually done on an outpatient basis. You nuse and administative coodinato will help aange these fo you. Please ask you nuse coodinato any questions you have. If special instuctions ae equied befoe any of these tests, you will eceive a witten fom that explains how to pepae. Afte the tests ae completed, you docto will eview the esults with you. These esults ae also equied by you insuance company in ode to appove the medical necessity of you tansplant. Blood tests You health cae povide o a technician will take a sample of blood fom you am o cental venous cathete (if one is in place). The blood is sent to a lab whee the following tests ae pefomed: Tissue typing(needed fo allogeneic patients only) This was done at o befoe you initial consultation appointment with you BMT docto. Tissue typing is a seies of blood tests that evaluate the compatibility o closeness of tissue between the ogan dono and ecipient. Fom you blood samples, the tissue typing lab can identify and compae infomation about you antigens (the makes in cells that stimulate antibody poduction) so they can match a bone maow dono to you. All donos ae caefully sceened to pevent any tansmissible diseases o detect othe medical poblems that might pevent them fom donating bone maow. Pe-Tansplant Sceening: Requied Tests Othe blood tests In the laboatoy, a seies of tests will be pefomed to detect cetain substances in you blood and to evaluate you geneal health. These blood tests might include:

31 Infectious Disease Sceening fo : Hepatitis HIV (human immunodeficiency vius) RPR (syphilis) Toxoplasmosis Vaicella Zoste CMV (cytomegalovius) EBV (Epstein-Ba vius) HSV (Hepes Simplex vius) West Nile Vius HTLV1/11 (Human T-Cell lymphotopic vius) Chagas Blood Wok to Check you Ogan Function Feitin Pegnancy test Complete Metabolic Panel Hemoglobin Solubility ABO blood type Bleeding times CBC, diff, platelets Quantitative immunoglobulins Othe Possible Blood Wok Disease-specific labs fo multiple myeloma Reseach samples Othe tests Chest X-ay A chest X-ay povides a pictue of you heat and lungs. This X-ay povides infomation about the size of you heat and lungs, and might detect the pesence of lung disease o infection. Pulmonay function tests (PFTs, lung tests) Pulmonay function tests measue the capacity and function of you lungs, as well as you blood s ability to cay oxygen. Duing the tests, you will be asked to beathe into a device called a spiomete. Hee ae some guidelines to follow befoe you scheduled pulmonay function tests: Be sue to get plenty of sleep the night befoe. Plan to wea loose clothing duing the test so you can give you geatest beathing effot. Limit you liquids and eat a light meal befoe the test. Dinking o eating too much befoe the test might make you feel bloated and unable to beathe deeply. Computed tomogaphy scan (CT Scan) A CT scan, uses X-ays and computes to poduce a detailed image of the body. Depending on the type of scan you need, an oal and/o IV contast mateial might be used so the adiologist can see the extent of you disease. CT scans also might eveal the pesence of othe abnomalities. If you had a CT scan within 6 months befoe you pe-tansplant evaluation, bing the CT scan films o disc, along with a copy of the epot with you. The adiologist will use them as compaison when eading these new scans. Depending on you illness, you docto might ode additional CT scans. Positon emission tomogaphy (PET) scan A PET scan is a unique type of imaging test that helps doctos see how the ogans and tissues inside you body ae actually functioning. The test involves injecting a vey small dose of adioactive chemical, called a adiotace, into a vein. The tace tavels though the body and is absobed by the ogans and tissues being studied. Next, you will be asked to lie down on a flat examination table that is moved into the cente of a PET scanne -- a doughnut-like shaped machine. This machine detects and ecods the enegy given off by the tace substance. The PET scan can measue such vital function as glucose metabolism, which helps doctos identify abnomal fom nomal functioning ogans and tissues.

32 One of the main diffeences between PET scans and othe imaging tests like CT scan o magnetic esonance imaging (MRI) is that the PET scan eveals the cellula level metabolism changes occuing in an ogan o tissue, o the activity of cells. Depending on you illness, you docto may ode a PET scan. Heat tests Because pio chemotheapy and/o adiation theapy, and the chemotheapy/ adiation theapy you will eceive fo tansplant can affect you heat, you will need heat tests to identify and teat any potential poblems befoe the tansplant pocedue. The heat tests include: Electocadiogam (EKG) An EKG is used to evaluate you heat hythm. Befoe the test, electodes (small, flat, sticky patches) ae placed on you chest. The electodes ae attached to an electocadiogaph monito that chats you heat s electical activity (heat hythm). Echocadiogam An echocadiogam is a gaphic outline of you heat s movement. Duing the test, a wand, o tansduce, is placed on you chest. The tansduce emits ultasound (high-fequency sound wave) vibations so the docto can see the outline of the heat s movement. The echocadiogam povides pictues of the heat s valves and chambes so the pumping action of the heat can be evaluated. Echocadiogam is often combined with Dopple ultasound to evaluate blood flow acoss the heat s valves. Bone maow biopsy A bone maow biopsy is pefomed to evaluate you maow s function and to assess fo disease involvement. A needle is placed in you posteio hip bone to emove a sample of bone maow. The aea will be numbed with a local anesthetic, o painelieving medicine, to make you feel less discomfot duing the pocedue. You might be given oal medicine to help you elax pio to the pocedue. You should plan to have a dive take you home afte this pocedue since the medicine can make you dowsy. Skeletal suvey This is a seies of X-ays of the skull and long bones to assess disease involvement fo patients with multiple myeloma. Othe Tests --may be equied by you insuance company o you physician fo example: colonoscopy, PAP smea, dental exam, o mammogams. Additional tests Afte the pe-tansplant evaluation appointment, the BMT team may decide if you will need any othe tests. Additional tests o consultations will be pefomed at Cleveland Clinic. You nuse and administative coodinato will help you make these aangements. Pe-Tansplant Sceening: Requied Tests

33 Afte my pe-tansplant evaluation At the end of you pe-tansplant evaluation and afte the test esults ae complete, the bone maow tansplant docto will decide whethe o not a bone maow tansplant is the appopiate teatment fo you. You test esults will also be sent to you insuance company fo the insuance appoval pocess. Usually the insuance company will make a detemination in 7 to 10 days afte eceiving the test esults. Notes Please undestand that abnomal test esults might equie futhe investigation. The goal of pe-tansplant testing is to ensue that you will be able to undego the tansplant and ecove without inceased isk of complications. Dono pe-tansplant testing Fo allogeneic and mini allogeneic tansplant patients, you bone maow dono will also have a medical evaluation with many of the same tests. The dono must be cleaed and detemined medically fit to poceed as you dono. This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Index #4487 Heaing Impaied (TTY) Assistance Poduced by the Cente fo Consume Health Infomation Copyight The Cleveland Clinic Foundation. All ights eseved. Rev. 05/11

34 Financial Questions to Ask If you have been appoved fo a bone maow tansplant, you will need to pepae youself financially and claify you insuance coveage while you wait fo you tansplant. The tansplant financial counselo is available to answe you questions and concens. The following questions will help you sot out you insuance coveage and will help you plan fo the expenses of tansplantation. Questions fo you insuance company What is my deductible and out-of-pocket maximum fo medical benefits? What is the maximum on my insuance coveage? What happens if my financial coveage uns out? Do I have a tansplant maximum sepaate fom my lifetime max? How does my plan detemine tansplant appoval? If tansplant coveage is denied, am I able to appeal? What is the pocess? If I have a question egading my Explanation of Benefits (EOB), who should I call? How will a change in my job status affect my insuance? What would the incease be in my deductible? Financial Questions to Ask What pe- and post-tansplant tests ae coveed? Do I need to go to a cetain facility fo these tests to be coveed? Does my plan cove dono seaching expenses? Does my plan cove the expenses incued by my bone maow dono? Ae expenses fo meals, lodging, and tanspotation coveed while I wait fo my tansplant? Ae thee maximums placed on the eimbusement fo these items?

35 Do I epot to you if I have a seconday insuance? What ae my possible out-of -pocket expenses fo pesciptions? At which paticipating phamacies can I fill my pesciptions? Does my insuance povide coveage fo home health sevices? Is thee a maximum on my home health sevice coveage? Is thee a co-pay fo a specialist office visit? Questions fo you tansplant financial counselo What financial coveage is accepted by the hospital (such as Medicae, Medicaid, pivate insuance)? How much will the tansplant cost? How much will I have to pay? Should I notify you if I am an active o etied vetean? Notes Index #10411 This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Heaing Impaied (TTY) Assistance Copyight The Cleveland Clinic Foundation. All ights eseved. Poduced by the Cente fo Consume Health Infomation. Rev. 05/12

36 Common Repoductive Issues Blood & Maow Tansplant pepaative egimens use high-dose chemotheapy and (sometimes) adiation to destoy cance cells. Side effects of this life-saving theapy occu when nomal cells in the body ae also destoyed by the teatment. Cells in the male and female epoductive systems fall into this categoy, and BMT suvivos might suffe tempoay o pemanent damage affecting futue fetility. Little eseach has been done to povide statistics about fetility afte tansplant, but quality of life issues such as fetility/infetility have been identified as majo concens fo cance suvivos. Recovey afte BMT can take months to yeas, so many patients ae not physically o psychologically eady to conside paenthood fo seveal yeas afte tansplant. Howeve, a pe-tansplant discussion of options to peseve fetility might help you plan fo you family's futue. Male fetility issues You might choose to peseve you fetility befoe BMT by having you spem fozen, o banked, fo futue use in eithe atificial insemination o in vito fetilization. If you ae inteested in spem banking, please tell you nuse coodinato, who can schedule an appointment in the Andology Lab. The Andology Lab will pefom an analysis on a fesh semen sample to see if viable spem ae pesent. If you spem poduction is adequate, the Andology Lab will schedule appointments to collect and feeze you spem. This will be done befoe the stat of you BMT pepaative egimen. If you have aleady eceived chemotheapy o adiation theapy, you may o may not still be fetile. Spem may be fozen indefinitely and annual stoage fees ae usually chaged, which might o might not be coveed by medical insuance. If you do not wish to fathe childen afte BMT, the use of contaception is ecommended because we cannot pedict if o when fetility will etun. Seveal options exist if you infetility is polonged o pemanent and you wish to become a paent once you have ecoveed fom BMT. Altenatives include an assessment by a uologic sugeon who specializes in infetility fo possible testicula spem extaction and fo use in specialized in vito fetilization. Othe options include the use of dono banked spem. Common Repoductive Issues Female fetility issues Most female patients expeience tempoay o pemanent menopause, also known as pematue ovaian failue, as a side effect of tansplantation. If you have aleady eceived chemotheapy o adiation theapy, you may o may not still be fetile. If you ae inteested in attempting to peseve you fetility afte tansplant, please tell you

37 nuse coodinato, who can schedule an appointment with a gynecologist who is an infetility expet. This is done befoe the stat of you pepaative egimen. The gynecologist will use lab tests to assess you cuent ovaian eseve, eview you pio chemotheapy dugs and dosages, and discuss options that might be available to you. Baies to conside include cost since insuance companies may not cove these teatments and you age, since fetility deceases as a woman ages. All of the following options should be consideed expeimental with an unknown chance of success in poducing a viable egg o spem. Options to peseve fetility might include: Embyo feezing Matue eggs ae stimulated with homones, emoved, fetilized with spem, and then fozen and stoed. This method can equie seveal weeks to accomplish and might not be feasible fo a cance patient who needs immediate teatment fo active disease. Othe factos to conside include the availability of a patne to donate spem, and the ethical decision of what to do with the fozen embyos that might not be used as planned. Egg feezing Matue eggs ae stimulated, emoved, and fozen unfetilized. This method can equie seveal weeks to accomplish, depending on you menstual cycle, but might be an option fo a woman cuently without a patne to fetilize the eggs. Live biths have been epoted with this method, but it is still consideed expeimental. Testicula tissue feezing-- Outpatient pocedue to emove spembeaing tissue fom the testicle and feeze it fo futue use. This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Ovaian tissue feezing Ovaian tissue is emoved duing an outpatient sugical pocedue and fozen fo futue tansplantation back into you body. This method is consideed expeimental, but the goal is to peseve immatue eggs and the tissue that makes female homones to potentially peseve female fetility, If you do not wish to have childen afte BMT, the use of contaception is ecommended because we cannot pedict if o when fetility will etun. If you infetility is polonged o pemanent and you wish to become a paent once you have ecoveed fom BMT, othe options exist. These include in vito fetilization with dono eggs o adopted embyos, o suogacy. Resouces: Fetile HOPE is a non-pofit oganization that offes fetility esouces fo cance patients. You may visit thei Web site at You BMT social woke is available fo counseling to assist with decision-making. Index #11927 Copyight The Cleveland Clinic Foundation. All ights eseved. Poduced by the Cente fo Consume Health Infomation Rev. 4/25/2014

38 You Cental Venous Cathete A cental venous cathete is a slende, hollow, flexible tube (cathete) that is inseted though a lage vein and into you heat. Hickman and hoizon ae two types of cental venous cathetes. The cathete is made of silicone that is hypoallegenic and well-toleated in the body fo seveal yeas. Why do I need to have a cental venous cathete? You docto has chosen this type of cathete so fluids, nutition solutions, antibiotics, chemotheapy, o blood poducts can be deliveed diectly into you bloodsteam without fequently having to inset a needle into you vein. The cathete can also be used to collect blood samples. Patients having an autologous stem cell tansplant will have a hoizon cathete placed. The hoizon cathete is a stiffe cathete which will allow us to collect you peipheal stem cells fo you tansplant. How is the cathete inseted? The cathete is inseted duing a simple sugical pocedue. You cental venous cathete will be placed in inteventional adiology located in QB100. Duing the sugey, one end of the cathete is placed though a small incision in you Cental venous cathete You Cental Venous Cathete

39 neck (called the insetion site) and is theaded caefully though you vein until it eaches you heat. The othe end of the cathete is theaded though a tunnel beneath you skin whee it exits on you chest though anothe incision called the exit site. Guidelines befoe the cathete placement Insetion site Exit site Do NOT eat any solid food afte midnight the night befoe you pocedue. You may have clea liquids ONLY up to 2 hous pio to you pocedue. Clea liquids consist of anything you can see though, such as apple juice, ginge ale, both, and gelatin. You may take you medicines with a small sip of wate. You must be accompanied by a esponsible adult who can dive you home. You will be at Cleveland Clinic fo about 4 hous fo this pocedue. How will the cathete feel afte it is inseted? You might feel a slight bulge unde you skin whee the Dacon cuff is located. The Dacon cuff suounds the cathete to pevent infection and keep it fom moving out of place. You might also feel mild soeness aound the insetion and exit sites (whee thee will be a a few stitches) immediately following the pocedue. Guidelines fo the fist 24 hous afte the pocedue If you have any questions o poblems within the fist 24 hous afte the cathete placement, contact you nuse coodinato duing business hous o the adiologist. To contact Radiology, call o , ext , Mondays though Fidays, 8 a.m. to 5 p.m. Any othe times, please call Lumens (3) Injection caps (3) Afte the cathete is inseted, you may have stei-stips, sugical glue and/o stitches at the insetion and exit sites. You will lean how to cae fo the cathete and the insetion and exit sites o and ask the opeato to page the adiologist on call. Do not showe fo the fist 5 days afte the cathete is inseted. You can take a sponge bath as long as you keep the dessing and insetion site dy and do not soak above the insetion site. If you have heavy bleeding fom the cathete site, emain sitting upight (unless you feel faint), hold pessue at the site, and have someone take you to the neaest emegency oom o call If you expeience exteme pain, bleeding, o dainage fom the cathete insetion site, feve of F, o shotness of beath, contact you nuse coodinato o adiologist. Keep the dessing clean and dy. If you dessing falls off o becomes loose, cove the cathete site with a steile pad. You can expect some soeness in you neck whee the cathete was inseted. You might notice a black and blue mak on you chest and possibly you neck.

40 You nuse coodinato will meet with you the day afte the cental venous cathete placement to povide you with cathete cae instuctions. How do I cae fo the insetion site? You may have sugical glue o stei-stips ove the insetion site at the base of you neck. The stei-stips will emain in place fo at least 1 week afte the cathete is inseted. Do not pull the stei-stips off. They should fall off afte the incision has healed. Keep the aea dy and clean. The insetion site will heal within a few days afte the pocedue. How do I cae fo the exit site? The aea in you chest whee the cathete exits the skin is called the exit site. Afte you cathete is placed, you will be scheduled fo a teaching appointment with you nuse coodinato to lean how to cae fo you cathete. Thee ae seveal things you will need to do to cae fo you cathete, including: Clean the exit site and apply a clean dessing evey 7 days o soone if dessing gets soiled o wet. Clamp the cathete. Flush each lumen of the cathete with nomal saline evey day. Change the injection caps evey week. Be able to detect potential poblems and lean what to do to pevent o teat them. You will eceive individual instuction sheets on each of the pocedues descibed above so you can pefom the pocedues coectly. You nuse coodinato will eview these instuctions with you. Notes You Cental Venous Cathete

41 Notes Index #4753 This infomation is not intended to eplace the Poduced by the Cente fo Consume Health Infomation medical advice of you docto o health cae Copyight The Cleveland Clinic Foundation. povide. Please consult you health cae All ights eseved. Rev.10/15/14 povide fo advice about a specific medical condition.

42 How to Avoid Poblems With You Cental Venous Cathete Do not expect poblems with the cental venous cathete, but be pepaed if they occu. Read the infomation contained in this handout caefully so you ll know how to teat a poblem o pevent it fom happening. Poblem Signs/Symptoms What to do How to avoid Infection Clotting o cathete blockage Boken scew adapte at the end of the cathete Skin ash o iitation ove the Dacon cuff Feve of F Chills Sweats Swelling o oozing at the exit site Foul odo Pain, wamth, o edness at the exit site o tunnel aea Fatigue; lack of enegy Deceased activity Unable to flush cathete using nomal pessue Cathete cap does not fit secuely Saline leaks out duing flushing pocedue Redness and tendeness at exit site without dainage o feve Call you health cae povide fo instuctions Do not apply exta pessue. Call you health cae povide to assess the blockage. Clamp the cathete Call you health cae povide. The end will need to be eplaced. Call you health cae povide fo instuctions Check you tempeatue daily. Wash you hands befoe any pocedue. Wea a mask duing any pocedue if you have a cold and when changing the bandage. Flush the cathete once a day and afte evey injection using the push pause method. Do not ove-twist the cathete cap when changing. Do not clamp nea the cathete adapte. Do not wea constictive clothing ove the bulge of the cuff. Avoiding Poblems With You Cental Venous Cathete

43 Poblem Signs/Symptoms What to do How to avoid Beak o accidental cut in the cathete Leaking fluid Punctue o split in the cathete Immediately clamp the cathete between the beak and exit site. Call you health cae povide fo instuctions Only clamp the einfoced sleeve of the cathete Rotate the clamping site. Neve use scissos nea the cathete. Do not use foce when flushing the cathete. Ai embolus pesence of ai in the cadiovascula system that could esult in blocked blood flow (This can occu if the cap o IV tubing becomes disconnected. It might occu within hous afte the cathete has been inseted.) Shotness of beath o chest pain. THIS IS AN EMERGENCY Clamp the cathete nea the exit site Call 9- l-1. Lie on you left side while waiting to be seen by a health cae povide Neve leave the cathete cap off without fist clamping the cathete. Additional infomation Thombosis---- blockage in the vein in which the cathete has been placed Difficulty flushing the cathete Swelling in the am shoulde, o neck on the same side of the cathete Facial swelling Enlaged vein on the chest o neck that was not noticeable befoe the cathete was inseted Excessive teaing o unny nose Dizziness Confusion Thoat pain THIS IS AN EMERGENCY Do not put any fluid in the cathete. Call o have someone take you to the emegency oom. Flush the cathete once a day and afte evey pocedue. Dink plenty of fluids to pevent dehydation. You should neve need to use foce to flush the cathete. Notify you docto if you ae to have any dental o sugical pocedues since additional antibiotics might be needed pio to you appointment.

44 Poblem Signs/Symptoms What to do How to Avoid Cathete dislodgement (This occus when the tip of the cathete moves fom its pope location.) Blood back-up Pain o discomfot in the neck o shoulde Swelling in the chest Exposed cuff Leakage of blood whee the cathete cap is impopely connected Do Wash you hands befoe any pocedue. Clean and change the site if the dessing becomes soiled, wet, o loose. Have eveything eady befoe you stat. Flush the cathete at least once in 24 hous, unless IV fluid is being administeed. Use a new syinge to flush each lumen daily. When in doubt about the steility of a piece of equipment, conside it contaminated and use a new, steile piece of equipment. Call you health cae povide fo instuctions (You will need to have an X-ay so you health cae povide can assess the location of the cathete tip.) Do not use the cathete until you ae told it is OK. Clamp the cathete nea the exit site. Flush the cathete with saline solution afe unclamping it Do s and Don ts Don t Exet stess on the end of the cathete. Bend, pull, o kink the cathete. Re-use syinges o IV tubing. Touch the cathete exit site with you finges. Leave the cathete end open to the ai. Use scissos nea the cathete. You cathete should flush easily. Neve foce the saline into the cathete! Fo longe cathetes, loop the cathete and tape it and all of the connections to you chest. Do not pull on the cathete. Do not use foce when flushing. Handle the cathete with cae. Flush the cathete once a day and afte all pocedues CLOSE THE CLAMP befoe emoving the saline syinge afte you flush the cathete. Leave at least 1cc of saline in the syinge when you flush (don t bottom out the plunge) Avoiding Poblems With You Cental Venous Cathete

45 Notes Index #4270 This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Poduced by Cente fo Consume Health Infomation Copyight The Cleveland Clinic Foundation. All ights eseved. Rev. 12/10/2014

46 Injection Cap Change The injection cap needs to be changed once a week. 1. Gathe the following supplies: 70% alcohol Pape towel Liquid antibacteial soap 3 new, steile injection caps 6 alcohol wipes, 2 pe lumen 3 pefilled saline syinges 2. To begin: Moisten a pape towel with alcohol, and wipe the wok suface with it. Wash you hands fo 30 seconds using wam wate and liquid antibacteial soap. Rinse you hands completely, and dy them with a clean pape towel. Tun the wate faucet off using a pape towel. (Don t touch the faucet with you clean hands.) 3. Open all supplies. Caefully open all supplies without touching the inside suface of the kits o wappes. Place supplies on clean suface. 4. Pepae the saline syinges. Examine the 3 pefilled syinges, making sue they contain saline and that they have not expied. Remove the cap on the end of the pefilled syinge. Avoid touching the aea unde the cap. Pull back on the plunge to elease the seal. Note: pushing up on the plunge befoe beaking the seal might educe the amount of saline needed fo flushing. Check the syinge fo ai bubbles. Tap the syinge so the bubbles ise to the top. While holding the syinge at a 90 degee angle, push up on the plunge to emove any ai bubbles. Injection Cap Change 5. Attach saline filled syinge to the MicoCLAVE Connecto Cap by scewing the two pieces togethe and tuning clockwise. Hold vetically so that the cap tip is on top of the syinge then push the syinge plunge so that the saline fills the cap and expels the ai. Place cap back in cap wappe with saline syinge attached. Keep the syinge attached duing the cap exchange to make handling easie.

47 6. Make sue all lumens ae clamped. 7. Clean the injection cap connection whee the cap is connected to the cathete with an alcohol wipe fo 15 seconds, vigoously, and let dy completely (about 15 seconds) 8. Remove the old injection cap and discad. 9. Clean the cathete whee the cap was connected with the second alcohol wipe fo 15 seconds, vigoously, then allow to dy completely (about 15 seconds). 10. Remove the potective cove fom the injection cap. Avoid touching the steile aea unde the potective cove. 11. Scew the new injection cap onto the cathete. 12. Inject the saline into the cathete, using a push-pause method, until all of the saline is out of the syinge. 13. Clamp the cathete. 14. Remove the syinge by twisting the syinge counteclockwise. Notes Index #10140 This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Copyight The Cleveland Clinic Foundation. All ights eseved. Poduced by Cente fo the Consume Health Infomation Rev. 07/30/2014

48 - Cental Venous Cathete Tanspaent Dessing Change Changing the dessing helps to pevent infection and allows fo outine inspection of the exit site. It is necessay to change the dessing evey 7 days, o soone, if it becomes wet, loosened o soiled. 1. Gathe the following supplies (these may be found in a Cental Line Dessing Change Kit o sepaately). Mask 1 ChloaPep One-Step (contains clohexidine gluconate 2% and isopopyl alcohol 70%) Tegadem tanspaent dessing Label If you have a kit, it may contain additional supplies that will not be needed and will not be descibed in these instuctions. You will need to gathe these additional supplies: Liquid antibacteial soap and wateless hand sanitize Clean pape towel 2. To begin: Moisten a pape towel with alcohol and wipe you wok aea with it. Wash you hands fo 30 seconds using wam wate and liquid antibacteial soap. Rinse you hands completely and dy them with a clean pape towel. Tun off the wate faucet using a pape towel. (Don t touch the faucet with you clean hands.) 3. Open Supplies o Cental Line Dessing Change Kit Put mask on now. If a caegive is doing the dessing change, they will put the mask on and you will tun you head away fom the cathete. (o you can both wea a mask.) Tanspaent Dessing Change 4. Remove the old dessing. Stat at the bottom o notched edge of the dessing. Loosen the tanspaent dessing and gently lift and stetch the dessing towad the opposite edge, making sue to stabilize the tubing with a non-dominant finge. Do not use scissos. They can damage the cathete.

49 5. Inspect the exit site. You health cae povide will advise you on the pocess fo emoval of the sutues, which will occu in about 4 weeks. Look caefully at the exit site and the skin aound it. If you notice unusual discoloation, edness, swelling, bleeding, dainage o blisteing, finish changing the dessing and notify you health cae povide. 6. Rewash you hands o use a wateless hand sanitize such, as Puel, to pevent the tansfe of any bacteia fom the old bandage to the new dessing. 9. Wite date of dessing change on the label, emove backing to expose adhesive and place on top of new dessing as a eminde of when new dessing change is due. 10. To extend the likelihood that you tanspaent dessing will last a week, cove it with plastic wap extending ove the shoulde when showeing. Showe facing away fom the wate souce to avoid diect contact with spay. 11. If dessing becomes loose o wet, it will need to be changed. 7. Clean the exit site. Remove one swab fom the ChloaPep package and discad any emaining swabs. Using both sides of the swab, clean the exit site and the skin aound it, extending about 4 inches away fom the exit site. Apply the ChloaPep in an up-and-down and backand-foth motion fo 30 seconds. Avoid ubbing ove you cathete tubing. Instead, use half-cicle motions to clean aound the top and bottom of whee you cathete comes out fom the skin. Allow the ChloaPep to ai dy fo 30 seconds. Do not pat, fan o blow on the aea. 8. Apply the tanspaent dessing. Peel the pinted backing fom the back of the dessing. Cente dessing ove cathete insetion site. Align the slit on the dessing so the cathete tubing lies in between the slit. Smooth edges of dessing unde cathete nea the slit. Once secue, emove the oute pape bode fom the dessing. This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Heaing Impaied (TTY) Assistance The Cleveland Clinic Foundation. All ights eseved. Index #14602 Poduced by the Cente fo Consume Health Infomation Rev. 5/11

50 Cental Venous Cathete ChloaPep Dessing Change Changing the dessing helps to pevent infection and allows fo inspection of the exit site. It is necessay to change the dessing at least daily. 1. Gathe the following supplies fo each dessing change. 70% alcohol and pape towel o Antibacteial wipes Liquid antibacteial soap and wateless hand sanitize 1 ChloaPep One-Step (contains clohexidine gluconate 2% and isopopyl alcohol 70%) Steile 2 x 2 gauze pad Skin pep/potective dessing Pape tape Mask 2. To begin: Moisten a pape towel with alcohol, o use antibacteial wipes and clean you wok suface. Wash you hands fo 30 seconds using wam wate and liquid antibacteial soap. Rinse you hands completely, and dy them with a clean pape towel. Tun off the wate faucet using a pape towel. (Don t touch the faucet with you clean hands.) ChloaPep Dessing Change 3. Open all supplies. Caefully open all supplies without touching the inside suface of the kits o wappes. Place supplies on clean suface. Put you mask on now. If you caegive is doing the dessing change, they will put the mask on and you will tun you head away fom the cathete.

51 4. Remove the old dessing. Stating at the top cones of the dessing, loosen all the edges, and gently lift the dessing down towad the bottom. Do not use scissos. They can damage the cathete. 5. Inspect the exit site. Look caefully at the exit site and the skin aound it. If you notice unusual discoloation, edness, swelling, bleeding, dainage o blisteing, finish changing the dessing and call you health cae povide. 6. Rewash you hands o you can use a wateless hand sanitize such as Puel to pevent the tansfe fom the old bandage to the new bandage. 7. Clean the exit site with ChloaPep Remove one swab fom the package and discad any emaining swabs. Clean the exit site and the skin aound it, extending about 2 inches away fom the exit site. Apply the ChloaPep in an up-anddown and back-and-foth motion fo 30 seconds. Avoid ubbing ove you line. Instead, use half-cicle motions to clean aound the top and bottom of whee you line comes out fom the skin. Allow the ChloaPep to ai dy fo 30 seconds. Do not pat, fan o blow on the aea. 8 Apply the steile dessing. Cove the exit site with the 2x2 gauze pad. Touch only the cones of the dessing, o pinch in the middle of the side of the gauze that will not touch the skin. Apply the skin pep/potective dessing aound the 2x2 gauze pad (hold the gauze pad in place while applying the skin pep/potective dessing). Allow the skin pep to dy. Tape the gauze pad in place, using the pape tape. Notes This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Index #10263 Copyight The Cleveland Clinic Foundation. All ights eseved. Poduced by the Cente fo Consume Health Infomation Rev. 12/10/2013

52 Cathete Flushing With Pefilled Syinges Saline is a neutal salt wate solution used to maintain the patency (ie, quality) of you cathete. It is necessay to flush all lumens (the hollow opening) of you cathete daily. 1. Gathe the following supplies. 70% alcohol Liquid antibacteial soap Pape towels 3 pefilled saline syinges 3 alcohol wipes 2. To begin: Moisten a pape towel with alcohol and wipe the wok suface with it. Wash you hands fo 30 seconds using wam wate and liquid antibacteial soap. Rinse you hands completely, and dy them with a clean pape towel. Tun the wate faucet off using a pape towel. (Don t touch the faucet with you clean hands.) 3. Open all supplies. Caefully open all pefilled syinges and alcohol wipes. Place the supplies on a clean suface. 4. Pepae the saline syinges. Examine the 3 pefilled syinges, making sue they contain saline and that they have not expied. Cathete Flushing With Pefilled Syinges Remove the cap on the end of the pefilled syinge. Avoid touching the aea unde the cap. Pull back on the plunge to elease the seal. Note: pushing up on the plunge befoe beaking the seal might educe the amount of saline needed fo flushing.

53 Check the syinge fo ai bubbles. Tap the syinge so the bubbles ise to the top. While holding the syinge at a 90 degee angle, push up on the plunge to emove any ai bubbles. Use a sepaate syinge fo each lumen of you cental venous cathete Do not put the syinge down. 5. Clean the cathete cap. Wipe the end of the cap with an alcohol wipe, vigoously fo 15 seconds and allow it to dy fo 15 seconds. Do not touch the cap o blow it dy. 6. Inject the saline into the cathete. Gasp cap and fimly push and twist syinge tip into the cap until secue. Unclamp the cathete. Push down slowly on the plunge of the syinge, using a push-pause method, until all of the saline is out of the syinge. Clamp the cathete. Note: The cathete must always be clamped when not in use. Remove the syinge by twisting the syinge in the opposite diection (counte clockwise). Dispose of the syinges. Notes Index #13018 This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Copyight The Cleveland Clinic Foundation. All ights eseved. Poduced by Cente fo Consume Health Infomation Rev. 7/30/2014

54 How to Give Youself Subcutaneous Injections The medicine: has been pescibed fo you. An injection is the best way to get this medicine into you body. This handout will teach you how to give youself a subcutaneous injection. Pepae the wok aea and gathe you supplies 1. Gathe the following supplies: Liquid antimicobial soap Bottle of medicine NOTE: if you medicine equies efigeation, take it out of the efigeato 30 minutes befoe you injection time. cc syinge with wappe emoved Note: You will need moe than 1 syinge if you equie multiple injections. 25-gauge needle Two alcohol wipes (o cotton balls and a bottle of ubbing alcohol) Bandage A subcutaneous injection delives medicine at an angle between 45 and 90 degees into the subcutaneous tissue the tissue between you skin and muscle. One containe fo used equipment (such as a had plastic o metal containe with a scew-on o tightly secued lid o a commecial shaps containe) Skin Subcutaneous tissue Muscle Subcutaneous Self-Injections

55 To begin: 2a. Select a clean, dy wok aea. 2b. Wash you hands fo 30 seconds with antibacteial soap. Rinse you hands completely, and dy them with a clean pape towel. Tun the wate faucet off using a pape towel. Do not tun the faucet off with you hands. Pepae you medicine and syinge 1. Examine you medicine bottle(s), veifying the coect medicine, dosage and expiation date. 2. Remove the plastic cap fom you medicine bottle(s). 3. Wipe off the ubbe pat on the top of the medicine bottle(s) with an alcohol pad o an alcohol-soaked cotton ball. 4. Set you medicine bottle(s) neaby on a flat suface. 5. Remove the wappe fom the 25-gauge needle and scew it onto the syinge. 6. Remove the cap fom the 25-gauge needle and place on a flat suface on its side so it can be used to e-cap you needle if necessay. 7. Daw cc. of ai into the syinge by pulling the plunge back. 8. Inset the needle into the ubbe stoppe of the medicine bottle. 9. Push the plunge down to inject ai into the bottle (this allows the medicine to be dawn moe easily). Leave the needle in the bottle. 10. While holding the plunge down, tun the bottle and syinge upside-down. Be sue the medicine coves the needle. 11. Pull back on the plunge to.cc bubbles ise to the top. While holding the syinge at a 90-degee angle, push up on the plunge to emove the ai bubbles. Recheck the dose and add moe medicine to the syinge if necessay. 13. Remove the needle fom the medicine bottle. Caefully eplace the cap on the needle. Rotate you injection sites Since you will be injecting you medicine on a egula basis, you need to know whee to inject the medicine and how to otate (move) you injection sites. By otating you injection sites, you will make you injections easie, safe, and moe comfotable. If the same injection site is used ove and ove again, you might develop hadened aeas unde the skin that keep the medicine fom being used popely. Follow these guidelines: Move the site of each injection, ensuing that the injection is at least 1 1/2 inches away fom the last injection site. Ask you docto, nuse, o health educato which sites you should use. (See the next page of this handout fo geneal guidelines.) Keep a ecod of which injection sites you have used. Evey time you give youself an injection, ecod the date, time, and site. 12. Check the syinge fo ai bubbles. Ai bubbles in the syinge can educe the amount of medicine in the syinge. To emove ai bubbles, tap the syinge so the ai

56 Injection sites FRONT abdomen abdomen injection otation sites font and side of thigh BACK uppe and oute am injection otation sites injection otation sites font and side of thigh uppe and oute am injection otation sites Subcutaneous Self-Injections buttocks buttocks injection otation sites injection otation sites side of thigh side of thigh

57 IMPORTANT NOTE: We ecommend that you use only the font sites fo subcutaneous self injection. Any of the sites may be used if someone else is giving you the injection. Select and clean the injection site 1. Choose an injection site. Do not inject nea joints, goin aea, navel, middle of abdomen, and sca tissue. A pictue of the injection sites that can be used is included in this section. These sites ae away fom neves, joints, and lage blood vessels. 2. Clean the injection site (about 2 inches of you skin) in a cicula motion with an alcohol wipe. Leave the alcohol wipe neaby. Allow alcohol to dy completely, do not fan o blow to dy. Inject the medicine 1. Using the hand you wite with, hold the syinge like a pen o pencil, with the needle end down. 2. Remove the needle cap. 3. With you othe hand, pinch about 2 to 3 inches on eithe side of the cleaned skin. 4. Inset the needle with a quick motion into the pinched skin at a 45- to 90-degee angle The needle should be all the way into you skin. 5. Slowly push the plunge of the syinge until all of the medicine is pushed out of the syinge. This step should take less than 10 seconds. If the medication is stinging as it goes in, slow down the push. 6. Count to 3 and then pull the needle out. 7. You might o might not bleed at the injection site. If you notice bleeding, apply pessue with the alcohol wipe. Cove the injection site with a bandage if necessay. 8. Do not ub the injection site. Dispose of the needle 1. Do not cap the needle. 2. Dop the entie syinge and needle into you containe fo used shaps equipment. Notes _ Index #4611 This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Copyight The Cleveland Clinic Foundation. All ights eseved. Poduced by the Cente fo Consume Health Infomation Rev. 07/30/2014

58 Neupogen What ae some othe names fo this medicine? Neupogen is also called a ganulocyte colony stimulating facto (G-CSF), o filgastim. What does it do? Neupogen inceases the poduction and activity of diffeent types of cells, such as white blood cells (specifically neutophils) and stem cells, found in you blood and immune system. With the inceased numbe of stem cells in you bloodsteam, we ae able to collect them fo use in you autologous tansplant o fo you dono s cells in you allogeneic tansplant. The stem cells ae collected in a pocess called apheesis o stem cell collection duing which a cell sepaation machine is used. Apheesis involves taking blood fom you cental venous cathete, sepaating out the stem cells though the apheesis machine, and then etuning the emaining blood components back to you. White blood cells fight infections. When you white blood cells ae low, you have a highe isk fo infection. Neupogen is also given to help you white blood cells ecove fom chemotheapy and educe the isk of infection. You blood counts will be monitoed on a egula basis duing you Neupogen theapy. How is it given? Neupogen is given by injection unde the skin (subcutaneously) using a needle Neupogen You Neupogen dose is mcg. You will need to take one injection of mcg and one injection of mcg to equal you total dose of mcg. You will need to give youself the injection(s) at the same time evey day.

59 and syinge, o though a vein (intavenously). While you ae an outpatient you Neupogen will be given by an injection unde the skin. What ae some side effects I might expeience? Mild to modeate bone pain Flu-like symptoms including muscle and joint aches, feve and chills, fatigue, weakness, and headaches Have a feve of F (38 C) o highe Have a skin ash. Sevee Abdominal pain. Have shotness of beath. Expeience unusual sweating. Have any othe unusual symptoms. Have any questions o concens. Nausea Diahea Loss of appetite Please note: The side effects listed ae the most common. All possible side effects ae not included. Always contact you docto if you have questions about you pesonal situation. What ae some pecautions o ecommendations I should know when taking this medicine? Do not take aspiin o poducts containing aspiin unless you docto pescibes them. These medicines ae often efeed to as blood thinning pills. If you ae expeiencing pain, please contact you docto o nuse coodinato. When should I call my docto? Call you docto if you: Index #9607 This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Copyight The Cleveland Clinic Foundation. All ights eseved. Poduced by the Cente fo Consume Health Infomation Rev. 10/15/2014

60 - Pleixafo Band name: Mozobil Class of dugs: Hematopoietic Pogenito Cell Mobilize Why is it pescibed? Pleixafo is given to you in conjunction with filgastim (Neupogen ) to stimulate the bone maow to poduce moe hematopoietic pogenito cells (HPCs). The combination of these medications allows the HPCs to flow fom the maow spaces into you peipheal ciculation whee they can be havested duing apheesis fo use in a futue tansplant. Apheesis involves taking blood fom you cental venous cathete, sepaating out the HPCs though the apheesis machine, and then etuning the emaining blood components back to you. The HPCs will be fozen until they ae needed afte you high-dose chemotheapy. Pleixafo is used in patients with lymphoma and multiple myloma. How is it taken? Pleixafo is given by injection unde the skin (subcutaneously) using a needle and syinge. It will be given appoximately 15 hous befoe stating apheesis. Pleixafo Pleixafo will be given to you in R10, the Chemotheapy Outpatient Depatment at Taussig Cance Institute. You will be monitoed fo possible side effects fo 30 minutes afte the injection is given. It is impotant that you ae pompt fo this appointment. You may etun fo additional doses of Pleixafo until the desied amount of HPC s ae collected. You may need to eceive up to thee doses of Pleixafo. Ae thee special instuctions that I should follow while using this dug? Befoe you physician pescibes this medicine, tell you health cae povide if you have eve had any unusual o allegic eactions to any medication. Also tell you health cae povide if you ae allegic to any othe substances such as cetain foods, pesevatives, o dyes. If you ae allegic to some medicines o foods, Pleixafo might not be the ight medicine fo you.

61 What ae the common side effects of this dug? Fatigue, headache, dizziness Joint pain Insomnia Decease in platelet count - You labs will be checked daily when you stem cells ae being collected. Facial tingling - this will esolve on its own without teatment within an hou o so. Redness, swelling o itching at injection site which is usually elieved with Benadyl. Diahea, flatulence (gas). Immodium may be suggested to you by you BMT physician. Nausea/vomiting - you BMT team may discuss antinausea medications fo you to use. When should I call my health cae povide? Call you health cae povide if you: Have a tempeatue of o highe Have a skin eaction Have moe than five liquid stools (diahea) pe day Have signs of dehydation including weakness, dizziness when standing fom a sitting position, deceased uine output, and confusion Have dizziness, chest pain, o shotness of beath Have any sign of an allegic eaction Have numbness o tingling that continues o wosens afte you injection Have sevee abdominal pain (especially in left uppe aea) Expeience pesistent o sevee side effects Develop new symptoms afte stating this medication Have any othe symptoms that cause concen Have any questions o concens Index #14387 This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Heaing Impaied (TTY) Assistance Copyight The Cleveland Clinic Foundation. All ights eseved. Poduced by the Cente fo Consume Health Infomation Rev. 07/11

62 Intoduction to Social Wok You will be assigned a Bone Maow Tansplant (BMT) social woke who will complete a thoough psychosocial assessment to help identify you needs and concens, as well as those of you family membes and significant othes. Evey patient eceiving a bone maow tansplant has a scheduled in-peson assessment with a BMT social woke. Many insuance companies equie this assessment as pat of you pe-tansplant evaluation. What type of taining does a social woke have? BMT social wokes have a Mastes in Social Wok (MSW) degee, which povides theoetical knowledge, clinical expetise, and pactical expeience with patients and families. In addition, BMT social wokes eceive specialized taining in cance cae. The lettes LISW (Licensed Independent Social Wokes) afte a social woke s name indicates the social woke has eceived a highe level of specialized taining. This infomation was adapted in pat fom the Association of Oncology Social Wok (AOSW) Standads of Pactice and the National Association of Social Woke (NASW) publication, The Powe of Social Wok ( Intoduction to Social Wok Index #10417 This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Poduced by the Cente fo Consume Health Infomation. Copyight The Cleveland Clinic Foundation. All ights eseved. Rev.04/13

63 Notes

64 Pepaing Fo You Hospital Stay Staying in Cleveland If you ae fom out of town, you and you loved ones might need tempoay housing. You condition will detemine you length of stay in the Cleveland Metopolitan aea. Allogeneic tansplant patients must stay less than a 1-hou dive fo a minimum of 100 days afte tansplant. Autologous tansplant patients might have to stay less than a 1-hou dive duing the pe-tansplant phase of teatment. Occasionally, thee might be a need to stay locally afte dischage fom the inpatient unit. Please check with you nuse coodinato. Some insuance companies povide a tavel and lodging benefit that will pay fo such expenses. If you insuance company does not offe this benefit, you might choose to stay in a hotel o tempoay apatment at you own expense, o ask you social woke to place you on the waiting list fo Hope Lodge Please see the enclosed visito tavel guide fo help in selecting local lodging options. You will need to make aangements and obtain cuent ates. You may also contact the Ameican Expess Tavel office though Cleveland Clinic. They can be eached at o by at amexclinictavel@aexp.com. Hospital tou To aange a tou of the inpatient Bone Maow Tansplant Unit (G110) please contact you social woke. Visitos Having family and close fiends visit can be vey helpful. It is a good idea to think ahead about having you family and fiends take tuns visiting so you ae not ovewhelmed with company. You might want to ask othes to call ahead befoe coming to see if you feel up to a visit. Pepaing Fo You Hospital Stay It is impotant that visitos wash thei hands befoe enteing the G110 unit and you oom. Visitos should not come if they have an infectious illness such as the flu o common cold.

65 Visiting hous The Bone Maow Tansplant Unit (G110) does not enfoce stict visiting hous. Howeve, the staff equests that the numbe of visitos at one time be limited. Ovenight visitation Having one adult family membe stay in the hospital oom ovenight is possible. Childen Childen of any age ae allowed to visit you duing you inpatient stay. Childen of immediate family membes (own childen, siblings o gandchilden) ae pemitted to visit in patient ooms. No child unde 18 may be left unsupevised o spend the night. Childen ae not allowed in the communal ooms inside the unit. You social woke can povide counseling to assist with any emotional concens you childen might expeience. What will my addess be at Cleveland Clinic? You addess duing you stay at Cleveland Clinic will be: You Name Cleveland Clinic G Euclid Ave. Cleveland, Ohio Index #5025 This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Poduced by the Cente fo Consume Health Infomation Copyight The Cleveland Clinic Foundation. All ights eseved. Rev.04/13 Patient Lounge The Patient Lounge aea has comfotable seating, a television and DVD playe, and a compute with Intenet access. An execise oom is available fo you use on the unit. A nutition oom is available fo you use with small lockes to stoe non-efigeated food items. You oom Telephone A telephone with an individual phone numbe is povided in all ooms. A daily fee fo the telephone will appea on you home telephone account 30 days afte you ae dischaged. Please talk to you social woke if this will be a financial buden fo you. Please feel fee to notify Admitting if you do not want the phone sevice. Please note: You will not know you telephone numbe until you have checked into you oom. Television A television and DVD playe ae povided in evey oom on G110. Limited cable, as well as seveal Cleveland Clinic channels, ae fee of chage.

66 Packing fo You Hospital Stay Clothing Bing loose, comfotable clothing. The tempeatue on the floo may vay, so it's best to bing clothes that can be layeed. You may want to bing a obe if you wea one. Pack sneakes o comfotable walking shoes. Fo patients eceiving Total Body Iadiation, you will need to wea the same shoes fo teatments as you woe when you wee measued fo the adiation theapy. Slippes ae fine, but also bing had-soled, closed-toe shoes fo walking. A family membe o fiend may do you laundy on the unit in the washe/dye. Pack a soft, comfotable cap to keep you head wam when hai loss occus. Accessoies Pack eye glasses o contacts if you have coected vision. Pesonal Hygiene Poducts Face washes, soaps, body washes, lotions, deodoants and makeup ae all pemitted. Please continue using you usual bands; it is not a good idea to expeiment with new poducts duing you hospital stay. Miscellaneous Bing pictues of family, fiends, pets o any othe comfoting scenes. Allogeneic BMT patients should bing a blood pessue monitoing device and an digital themomete to have on hand when dischage planning is eviewed. Feel fee to bing you own pillow and a blanket/comfote to make you moe comfotable, but launde them fist. Radios, CD playes, MP3 playes, and video game sets ae pemitted. Intenet access is available fo computes and wieless intenet is available. Pack magazines, puzzles, wod seaches, books, DVDs, o anything else that may help pass the time. Cell phone use is pemitted. Calling cads ae helpful fo long distance calls if you do not have a cell phone. Packing Fo You Hospital Stay Items to Leave at Home Valuable jewely; eaings and ings ae not ecommended. Cedit cads, checks o lage amounts of cash Nail polish and atificial nails should be emoved. Pets and pet visitation ae not allowed.

67 Things to bing: This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Index #13963 Poduced by Cente fo Consume Health Infomation Copyight The Cleveland Clinic Foundation. All ights eseved. Rev. 04/13

68 - Cae-Patne What is a cae-patne? A cae-patne is a suppotive peson who helps a bone maow tansplant (BMT) patient though the BMT pocess, shaing in the expeience. You cae-patne might be you spouse, significant othe, a family membe, o tusted fiend. Patients who have a consistent cae-patne duing thei hospitalization have been found to have bette outcomes. Although the medical caegives in the hospital unit will meet you physical needs fo cae, a cae-patne helps keep you as a patient focused on you goals and gounded in a meaningful elationship beyond the sometimes all-consuming illness expeience. Cae-patne equiements While all bone maow tansplant patients benefit fom having a cae-patne with them duing an inpatient hospital stay, cae-patne equiements vay in the outpatient setting, based on you type of tansplant. Allogeneic and mini-allogeneic tansplantation All patients having an allogeneic BMT must have a cae-patne stay with them 24-hous a day when they ae dischaged fom the hospital. Fo mini-allogeneic outpatient patients, you cae-patne must be with you when you stat you daily outpatient teatment. Patients and cae-patnes must stay less than a 1-hou dive of the Cleveland Clinic main campus. You cae-patne should be suppotive, as well as willing to povide hands-on cae such as caing fo you cental venous cathete, assisting with intavenous medicines, and assisting with you nutitional needs. Cae-Patne Autologous Tansplantation At cetain time fames duing you teatment, you may have to stay within a 1-hou dive of Cleveland Clinic. If you ae being chemotheapy pimed, having a cae-patne is highly ecommended duing the outpatient phase of you teatment, pio to you hospital admission. Afte you ae dischaged fom the inpatient hospital unit, you typically ae able to etun diectly home, but you might equie some tempoay assistance at home. Helpful Hints fo Cae-Patnes Cae-patnes play a citical ole in the tansplant pocess. Caing fo a tansplant patient not only challenges you physical needs but you emotional needs as well.

69 Hee ae some tips to help you pepae fo this ole: Ask the Tansplant Team questions Lean as much as you can about you loved one s teatment, medicines, and possible side effects to help you undestand what is happening. Plan a netwok of suppot befoe the tansplant Having a few people lined up that you can ely on will be vey helpful. Delegate 1 o 2 people to communicate medical pogess to othes so you don t have to update eveyone daily. Be pepaed fo changes in you loved one s behavio Medicines, discomfot, and stess can cause you loved one to become depessed o angy. These changes ae tempoay. Take cae of youself Be ealistic about you own needs. Get enough sleep, eat popely, and take some time fo youself. You can t offe much help if you ae exhausted o ovewhelmed. Maintain a balance Ty to maintain a balance between helping you loved one accomplish a task and actually doing the task fo him o he. Allow you loved one enough time to complete activities on his o he own. Ask othe family membes and fiends fo help Often, they want to help but don t want to intefee. While family and fiends might not be able to help out at the hospital, let them help with daily eands o choes at home. You family and fiends will appeciate the oppotunity to lend a helping hand. Have someone you can talk to You ae thee fo you loved one to listen and to offe suppot, but you also need a suppot peson. Talk openly and honestly with a fiend o family membe. Conside joining a suppot goup o talking to a social woke This might help you addess specific concens you might have about caing fo you loved one. Undestanding you ae not alone and thee ae othes in simila situations will help you cope. Talk to you loved one about making health cae decisions Although it s not easy to discuss these topics, you should be infomed of you loved one s wishes egading a Living Will and Duable Powe of Attoney fo Health Cae. Set attainable goals fo you and you loved one Do not attempt to do eveything. By setting attainable goals, you ae setting eveyone up fo success athe than disappointment. Index #10413 This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Heaing Impaied (TTY) Assistance Poduced by Cente fo Consume Health Infomation Copyight The Cleveland Clinic Foundation. All ights eseved. Rev. 01/11

70 - Advance Diectives What ae advance diectives? Advance diectives ae legal documents pepaed and signed in advance to let you docto and family membes know you wishes concening medical teatment at the end of life, including a Living Will o Duable Powe of Attoney fo Health Cae. Ask you Social Woke fo additional infomation. The Living Will A Living Will is a document that allows you to state what kind of medical cae you desie to eceive o what life-suppot pocedues you would like to have withheld if you become teminally ill and unable to make you wishes known, o if you become pemanently unconscious. Duable Powe of Attoney fo Health Cae When you complete a Duable Powe of Attoney fo Health Cae (o whateve simila document is available in you state), you ae naming a peson to act as you attoneyin-fact to make health cae decisions fo you if you become unable to make them fo youself. You may cancel a Duable Powe of Attoney at any time and in any manne. Howeve, to avoid confusion, you should notify the elevant people, including you pesonal docto and anyone given legal esponsibility to act on you behalf. Advance Diectives

71 Notes Index #10415 This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Heaing Impaied (TTY) Assistance Poduced by Cente fo Consume Health Education Copyight The Cleveland Clinic Foundation. All ights eseved. Rev. 01/11

72 Blood & Maow Tansplant Resouces Getting in touch with community sevices might be helpful to you and you family. These oganizations and pogams epesent just some of the esouces available to you. Individual counseling with a social woke is also available and might be useful in helping you cope with the demands of teatment. Please contact you social woke if you need moe assistance. Cance & Disease Specific Oganizations BMT infonet (Blood and Maow Tansplant Infomation Netwok) BMT Infonet povides paents, suvivos and thei loved ones with emotional suppot and high quality, easy to undestand infomation about bone maow, peipheal blood stem cell and cod blood tansplants. nbmtlink (National Bone Maow Tansplant Link) The mission of the National Bone Maow Tansplant Link is to help patients, caegives, and families cope with the social and emotional challenges of bone maow/stem cell tansplant fom diagnosis though suvivoship by poviding vital infomation and pesonalized suppot sevices. The Multiple Myeloma Reseach Foundation Povides infomation about multiple myeloma. Funds myeloma specific eseach. Aplastic Anemia & MDS Intenational Foundation, Inc. A patient advocate and suppot oganization poviding hope, knowledge, and suppot to patients and families. Offes the expetise of medical expets, scientific eseaches, doctos, nuses, counselos, infomation specialists, govenment agencies, political advocates, and phamaceutical companies. Resouces/Suppot Goups/Lodging

73 LiveStong Foundation We empowe the cance community to addess the unmet needs of cance suvivos. To do so we encouage collaboation, knowledge-shaing and patneship. Then, we develop evidence-based solutions to addess both the common and unique poblems suvivos ae facing aound the wold. Cancecae CanceCae is a national nonpofit, 501(c)(3) oganization that povides fee, pofessional suppot sevices to anyone affected by cance: people with cance, caegives, childen, loved ones, and the beeaved. CanceCae pogams-- including counseling and suppot goups, education, financial assistance and pactical help--ae povided by pofessional oncology social wokes and ae completely fee of chage. National Maow Dono Pogam (NMDP) Also known as Be the Match Registy This pogam facilitates maow and blood stem cell tansplants fo patients who do not have a matched dono in thei family. It is a netwok of national and foeign donation centes, collection centes, tansplant centes, and minoity ecuitment goups. ExploeBMT ExploeBMT, a website sponsoed by Be the Match, is a geat place to stat when you ae looking fo infomation and suppot about blood and maow tansplantation. You can use ExploeBMT, an easy-to-seach web potal, to bowse esouces and sevices fom many espected oganizations. You can then connect to the esouces that you need most thoughout you tansplant jouney, fom diagnosis though suvivoship. Lymphoma Reseach Foundation The Lymphoma Reseach Foundation (LRF) is the nation s lagest lymphoma-focused voluntay health oganization devoted exclusively to funding lymphoma eseach and poviding patients and health cae pofessionals with citical infomation on the disease. LRF s mission is to eadicate lymphoma and seve those touched by this disease. Online & Telephone Communication Resouces The Status.com This Web site keeps family and fiends updated on the patient's condition. Family and fiends can wite messages to patients. It equies a secued passwod to potect patient confidentiality. Lotsa Helping Hands A simple, immediate way fo fiends, family, colleagues, and neighbos to assist loved ones in need. It's an easy-to-use, pivate goup calenda, specifically designed fo oganizing helpes, whee eveyone can pitch in with meal delivey, ides, and othe tasks necessay fo life to un smoothly duing a cisis. Caingbidge A Web site designed to help patients keep in touch with loved ones duing teatment. Patients ceate thei own web page fee of chage. News about the patient's pogess can be posted to keep loved ones infomed.

74 Fetility Fetile HOPE A national LIVESTRONG initiative dedicated to poviding epoductive infomation, suppot, and hope to cance patients and suvivos whose medical teatments pesent the isk of infetility. Childen & Family Kidskonnected.og Kids Konnected povides complimentay counseling, summe camps, beeavement wokshops and cance educational tools fo childen and teens with a paent with cance, o who have lost a paent to cance. Kids Konnected was founded on the pemise that when a paent gets cance, the entie family is affected, especially the childen. Bea Essentials This pogam povides age-appopiate suppot and tools to help childen and paents cope with a paent's diagnosis and teatment of cance. Addesses the needs of childen ages 4 to 12. Young Adult Ulman Cance Fund fo Young Adults Povides suppot pogams, education and esouces, fee of chage, to benefit young adults, thei families and fiends who ae affected by cance and to pomote awaeness and pevention of cance. Also has a national college scholaship pogam. Planet Cance This is a community of young adults with cance who shae insights, exploe feas, and appoach cance with a sense of humo. Stupid Cance Helps to decease isolation of adolescents and young adults with cance by poviding infomation on esouces, suppot oganizations, scholaships and financial aid, online foums and chat ooms, excusions, camps and eteats, young adult blogosphee, coping liteatue, advocacy tools, and moe! Financial/Insuance Social Secuity Administation If a peson is likely to be unable to wok fo 12 months while undegoing teatment, applying fo Social Secuity Disability is an option. Ohio Depatment of Insuance Cance and Caees A esouce fo woking women with cance. Resouces/Suppot Goups/Lodging

75 Centes fo Medicae & Medicaid Sevices (CMS) q Medicae MEDICARE ( ) Povides helpful infomation about Medicae, Medicae health plans, pesciption dug plans, and consume ights and potections. qmedicaid Ohio Medicaid Consume Hotline can diect you to you local Office of Job & Family Sevices A State and Fedeally funded health cae coveage plan poviding assistance to cetain low-income and medically vulneable people. Ohioans eligible fo Medicaid ae entitled to all medically necessay sevices. Medicae Rights Cente The lagest independent souce of health cae infomation and assistance in the United States fo people with Medicae. Sevices include enollment pojects, telephone hotline sevices, education depatment, public policy effots, and media communications. Medication Assistance Needy Meds This site lists phamaceutical manufactues who povide dugs fee of chage to patients with limited financial esouces. Rx Assist This povides infomation about public and pivate phamaceutical patient assistance pogams, including dug discount cads. Rx fo Ohio A Web site designed to help low-income, uninsued Ohio esidents get fee o discounted band-name medicines. Complementay and Altenative Medicine Health Jouneys: The Guided Imagey Resouce Cente National Cente fo Complementay and Altenative Medicine (NCCAM) The Cente fo Integative Medicine at the Cleveland Clinic HEAL (4325) Pactitiones that addess lifestyle, emotional, spiitual as well as physical needs. Povides educational pogams fo patients and staff. Woks towads impoving quality of life by integating pactices that addess the needs of the whole peson. Fund-Raising Oganizations National Foundation fo Tansplants 1102 Bookfield - Suite 200 Memphis, TN o Help Hope Live Suite 230, 3475 West Cheste Pike Newtown Squae, PA o BMT Suppot Goups Suppot goups povide a vey useful shaing expeience. They offe an envionment whee you can lean new ways of dealing with you illness. You might want to shae appoaches you have discoveed with othes. You will also gain stength in knowing you ae not facing hadships alone. q Post-Tansplant Pepaation Goup This inpatient education goup meets on the fist Wednesday of the month in the G110 lounge. This goup is facilitated by a social

76 q woke and nuse coodinato fom the Pogam and povides necessay infomation to pepae patients and caegives fo cae afte tansplant. Contact Jane Dabney, LISW-S, at o ext Living with Blood o Maow Tansplant The Leukemia & Lymphoma Society sponsos this quately goup fo adults who have undegone a tansplant. Paticipants lean the latest infomation and have an oppotunity to discuss the unique issues faced by those who have had a tansplant. Family membes ae welcome. Contact Linda McLellan, LISW-S, at o , ext , o the Leukemia & Lymphoma Society at Lodging Infomation Fo lodging suggestions, please see the Visitos Tavel Guide to Univesity Cicle and Downtown Cleveland located in the font pocket of this notebook. Hope Lodge OhioACS@cance.og The Ameican Cance Society s Hope Lodge is a unique option fo adults who need tempoay, no-cost accommodations while eceiving outpatient cance teatment and who live a distance fom Cleveland. The Hope Lodge is located about 1 mile away fom Cleveland Clinic. Oncology patients and thei adult cae-patnes can stay hee while eceiving teatment in Cleveland. Patients must have a cae-patne stay with them at Hope Lodge. You social woke can place you on the waiting list fo this facility. If you do plan to stay at Hope Lodge, it is ecommended that you make back-up lodging aangements because thee is a waiting list, and oom availability will not be known until just befoe you teatment begins. Cleveland Clinic also offes a discounted ate fo tansplant patients at Cleveland Clinic s Guest House Hotel. The cost fo this option is $60 pe night plus tax. The esevation line is o Fo additional lodging infomation, visit Cleveland Clinic s Web site at click on Patients and Visitos and then Paking, Lodging & Tanspotation. Index #3985 This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Poduced by the Cente fo Consume Health Infomation Copyight The Cleveland Clinic Foundation. All ights eseved. Rev. 07/15/2014 Resouces/Suppot Goups/Lodging

77 Notes

78 The Autologous Peipheal Blood Stem Cell Tansplant Pocess Anothe tem you will hea fo a peipheal blood stem cell is Hematopoietic Pogenito Cell, apheesis (HPC, apheesis). You docto has detemined that an autologous tansplant is the best teatment fo you. An autologous tansplant means you will eceive you own bone maow o peipheal blood stem cells back afte eceiving high-dose chemotheapy. This pocess involves collecting some of you bone maow o peipheal blood stem cells fom you bloodsteam (a pocess called havesting), peseving, and stoing them in fozen fom. You bone maow o peipheal blood stem cells will be collected and stoed befoe you ae admitted to the hospital fo you blood o maow tansplant. Afte you complete you high-dose chemotheapy egimen in the hospital, you stem cells will be thawed and e-infused to eplace the cells that wee destoyed by the high-dose chemotheapy. Stating the tansplant pocess You will be assigned a nuse coodinato who will contact you to discuss the tansplant pocess and answe you questions. You nuse coodinato will schedule you pe-tansplant tests (a pocess called evaluation) and will set a tentative calenda fo you tansplant, which outlines you impotant tests and appointments. You will eceive a copy of this calenda in the mail. Remembe, this calenda is tentative and is likely to change. You nuse coodinato may need a lette fom you dentist stating you mouth is healthy and fee fom infection. You will be notified if you insuance equies this lette fo tansplant appoval o if you tanslant physician feels that a dental assessment is necessay. Appoval At the end of you pe-tansplant evaluation and afte the test esults ae complete, you BMT docto will eview the esults and decide whethe o not a tansplant is the appopiate teatment fo you. Next, you pe-tansplant esults ae submitted to you insuance company fo appoval. The appoval pocess takes 7 to 10 woking days. Autologous Peipheal Blood Stem Cell Tansplant

79 Getting stated Afte the evaluation pocess has been completed and you insuance company has appoved you tansplant, you will begin the teatment pocess. Fist, a cental venous cathete will be placed duing an outpatient sugical pocedue in the Radiology Depatment. This type of cathete is efeed to as a hoizon cathete. All tansplant patients must have a cental venous cathete. The cathete is used to daw blood and to infuse you chemotheapy, collect you peipheal blood stem cells, and povide othe IV medicines. You can lean moe about the cathete in the section entitled Pe-Tansplant/Cental Line Cae. You nuse will ode you cathete supplies and teach you how to cae fo it. You cental line cathete is usually emoved pio to you hospital dischage at you docto s discetion. Pepaing fo stem cell collection Befoe you stem cells can be collected, they need to be moved out of you bone maow and into you bloodsteam. This pocess is called mobilization. Thee ae thee methods of mobilization, descibed below. You docto will decide which method is best fo you. Depending on the method you physician chooses, you will have 1-3 weeks of daily out-patient appointments. Neupogen piming Neupogen is a colonystimulating facto that helps incease the numbe of stem cells in you bloodsteam. Neupogen is given as a subcutaneous injection (into the fat unde you skin). If Neupogen is you method of piming, you will begin the injections fou days pio to you fist stem cell collection. The stem cell collection pocess will then continue until the tageted numbe of cells is collected, usually five days. Pleixafo (Mozobil ) and Neupogen piming--pleixafo given with Neupogen helps incease the numbe of stem cells in the blood steam. Pleixafo is given in ou outpatient clinic(r10) at 5 pm the night befoe apheesis collection begins. Pleixafo is a subcutaneous (into the fat unde you skin)injection. You will also have Neupogen injections that will begin fou days befoe you fist stem cell collection. Chemotheapy and Neupogen piming This method involves collecting stem cells afte you eceive chemotheapy and Neupogen. The numbe of stem cells ciculating in you blood duing ecovey fom chemotheapy might be up to 25 times highe than nomal. The specific type of chemotheapy you will eceive depends on the type of disease you have. It is typically given ove seveal hous duing an outpatient appointment. Foty eight hous afte you eceive the chemotheapy infusion, you will begin daily injections of Neupogen until enough stem cells ae collected. You blood counts will become vey low the week afte the chemotheapy infusion; you will have daily appointments fo about a week in the Taussig Cance Institute outpatient clinic to monito you condition. Duing these appointments, you will eceive a 1-hou infusion of an antibiotic called Vancomycin to pevent infection. You blood will be dawn daily to evaluate you blood counts. Blood poducts will be given to eplace what is needed. If you show clinical signs of dehydation, you will eceive fluids intavenously (IV). While you ae being teated in the outpatient clinic, you will be equied to eside within a 1-hou dive of Cleveland Clinic. The social woke can help you with any lodging issues. Also efe to the Lodging Infomation in the Social Wok section. If you develop a feve of degees F at any time duing you outpatient follow-up, you will be admitted to Cleveland Clinic whee you will emain until you white blood cell count ecoves. As soon as you white blood cell count ecoves, the stem cell collection pocess will begin. Stem cell collection is usually done about 12 to 20 days afte you eceive the chemotheapy infusion.

80 Stem cell collection pocess Stem cells ae collected in a pocess called apheesis o stem cell collection. Apheesis is an outpatient pocedue. If you live within diving distance, you can commute each day. This pocedue does not equie you to stay in the Cleveland aea. Duing apheesis one lumen of you cental venous cathete is hooked up to a cell sepaation machine. You blood is filteed though the machine and emoves the stem cells needed fo you tansplant. The est of you blood is einfused though anothe lumen of you cental venous cathete. Each stem cell collection is stoed in a sepaate bag and kept fozen until it is etuned to you bloodsteam. The apheesis collection lasts about 4 hous and will take place on 5 sepaate days, o until enough stem cells have been collected. A minimum numbe of stem cells must be collected befoe you can be admitted to the hospital fo you tansplant. You will be scheduled to aive at M12 at 7:30 AM daily to stat you apheesis collection. How will I feel duing the apheesis pocess? Apheesis is a painless pocedue. Changes in blood volume occasionally cause some people to feel dizzy o lightheaded. Also, you might feel cold, expeience a tingling sensation aound you lips o finges, o might even feel camps in you legs. Tell you apheesis nuse if you expeience any of these symptoms, and he o she she will be able to help elieve you discomfot. Hospital admission and meeting with the Tansplant Team When enough stem cells have been collected, the next step is you admission to Cleveland Clinic fo you peipheal stem cell tansplant. This is usually the week following stem cell collection. Please follow you calenda instuctions that will diect you to to Desk J1-1, the Admissions Desk. Once you ae admitted to G110 o G111 (both ae specialized oncology nusing units), you and you family will have time to tou the nusing floo, if you haven't done so aleady. You will have the oppotunity to ask nuses, physician assistants, and doctos any questions you might have. You might also meet othe membes of you tansplant team, including the social woke, nutitionist, chaplain, nusing assistants, and unit secetaies. Please be awae that you usually do not see you nuse coodinato when you ae admitted to the hospital. He o she has left you cae in the expet hands of the inpatient BMT Team and is awaiting notification that you ae pepaing fo dischage. Pepaative egimen The fist step of you peipheal stem cell tansplant is the pepaative egimen, also called maow ablation. You pepaative egimen consists of highdose chemotheapy, which is used to destoy you own bone maow and tumo cells. Autologous Peipheal Blood Stem Cell Tansplant

81 Pepaative egimens ae disease-specific. The medicines you eceive will be based on the type of disease you have and its stage. The chemotheapy medicines you might eceive duing you pepaative egimen include high-doses of cyclophosphamide (Cytoxan ), busulfan (Busulfex, Mylean ), etoposide (VP-16, Etopophos ), o melphalan. Othe chemotheapy dugs may be used depending on you disease. The days you will be eceiving you pepaative egimen ae called countdown days (day -3, -2, -1). The days following you stem cell infusion ae efeed to as +1, +2, +3. Infusion: Day 0 The day you eceive the e-infusion of you stem cells is efeed to as Day 0. You will eceive an anti-anxiety/anti-nausea medicine (Ativan ), an antihistamine medicine (Benadyl ) and Tylenol about 30 minutes befoe you stem cells ae e-infused. You stem cells ae caefully thawed in the laboatoy and bought to you oom. The stem cells look simila to a bag of blood. You nuse will e-infuse each bag of stem cells though you cental venous cathete. Each patient will have a diffeent quantity of stem cells, but it is usually between 3 and 12 ounces. The einfusion is simila to eceiving a blood tansfusion and lasts about 1 hou fo each bag of stem cells to be infused. Duing you infusion, you blood pessue, pulse, and beathing ate (espiations) will be monitoed closely. How will I feel duing the infusion? Patients may expeience a bad taste in thei mouth, stomach camping, nausea, vomiting, feve, chills, o a galic-like odo. The pesevative, DMSO, which is placed in with you stem cells befoe they ae fozen, causes most of the side effects. The side effects usually don't last longe than the infusion. The odo can last fo one o two days. You also might notice that you uine might be ed afte you stem cell infusion. This is caused by the beakdown of ed blood cells that wee in the stem cell bag. You uine should tun back to its nomal colo within 6 hous. You Tansplant Team will monito you uine output. Afte you infusion Afte you infusion, you will be monitoed closely. You stem cells make thei way to you bone maow immediately afte being infused. You cuent blood counts will be affected by the high dose chemotheapy you eceived, and theefoe will continue to decease in the days following you stem cell infusion. It takes at least 7 to 10 days fo the new stem cells to matue and be eleased into the bloodsteam. This is called engaftment. This time of neutopenia (fom the time you blood counts fall to the time when they ecove) is vey citical. Special pecautions, called neutopenic and thombocytopenic pecautions, will be used to potect you fom infections and bleeding. You will be monitoed many times thoughout the day and be assessed fo any changes in you condition. You will eceive intavenous antibiotics, antifungal and antivial medicines to potect you fom infections. You will eceive blood and platelet tansfusions when you counts fall too low. Blood tests ae taken daily to monito you kidney and live function. Othe tests, such as a chest x-ay o CT scan, will be done if the Tansplant Team feels these tests ae needed. It is impotant to stay active duing this time. A daily walk in the hall o on the teadmill is definitely encouaged. Blood counts You nuse can tell you you blood counts on a daily basis. Thee will be a calenda in you oom so you can keep tack of you daily blood counts and see the pogess. Usually aound 12 days afte you stem cell infusion, you blood counts will be high enough fo you to be safely

82 dischaged. You also must meet cetain dischage citeia befoe you ae eleased, i.e., have no feves, and be able to dink an adequate amount of fluid. Going home You tansplant nuse coodinato will meet with you on the day of you dischage o the day pio to dischage to eview you dischage instuctions and will help aange appointments needed once you leave the hospital. Please make aangements fo you family to pick you up by noon on the day of you hospital dischage. Unde most cicumstances, when you ae dischaged you will be able to etun home. You will need to get you blood counts checked following you dischage, and have weekly labs locally fo the fist month. You will need to see you tansplant docto within 2-4 days following dischage. You will also need to see you local docto within two weeks of dischage so he o she can evaluate you. Pulmonay function tests and a chest X-ay might be monitoed locally at cetain intevals by you BMT docto. You tansplant nuse coodinato will speak with you by phone at least weekly fo the fist month and then peiodically fo the next yea. Post-dischage evaluation You will need to etun to Cleveland Clinic about 1 month afte you dischage fo a post-tansplant evaluation with you Cleveland Clinic tansplant docto. This post-dischage evaluation will include pulmonay function tests, chest X-ay, and blood wok. This post-tansplant evaluation is essential to evaluate any side effects you might still be expeiencing. Afte you 1 month follow-up appointment, you local oncologist may esume managing you follow-up cae, testing, etc. Notes Autologous Peipheal Blood Stem Cell Tansplant

83 Notes Index #10251 This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Poduced by the Cente fo Consume Health Infomation Copyight The Cleveland Clinic Foundation. All ights eseved. Rev. 02/06/2014

84 Sample Calenda fo Chemo-Pimed Autologous Tansplant Sunday Monday Tuesday Wednesday Thusday Fiday Satuday Oct. 27 Oct. 28 Appointment With you tansplant Docto R20 Oct. 29 Hoizon Cathete teaching with you BMT nuse Desk R32 Oct. 30 Oct. 31 Neupogen Injection Nov. 1 Neupogen Injection Nov. 2 Neupogen injection Hoizon Cathete Placement Desk HB6 Chemo Infusion Desk R10 Please follow all instuctions Desk R10 IV Antibiotic (ATB) Desk R10 IV Antibiotic (ATB) Nov. 3 Neupogen injection Nov. 4 Neupogen injection Nov. 5 Neupogen injection Nov. 6 Neupogen injection Nov. 7 Neupogen injection Nov. 8 Neupogen injection Nov. 9 Neupogen injection Lab/Teat Desk R10 IV ATB Bloodwok Lab/Teat Desk R10 IV ATB Bloodwok Lab/Teat Desk R10 IV ATB Bloodwok Lab/Teat Desk R10 IV ATB Bloodwok Lab/Teat Desk R10 IV ATB Bloodwok Lab/Teat Desk R10 IV ATB Bloodwok Nov. 10 Neupogen injection Nov. 11 Neupogen injection Stem Cell Collection 7:30 am Nov. 12 Neupogen injection Stem Cell Collection 7:30 am Nov. 13 Neupogen injection Stem Cell Collection 7:30 am Nov. 14 Neupogen injection Stem Cell Collection 7:30 am Nov. 15 7:30 am Stem Cell Collection Nov. 16 Nov. 17 Nov. 18 Nov. 19 Nov. 20 Busulfan Nov. 21 Busulfan Nov. 22 Busulfan Nov. 23 Etoposide Admit Desk J1-1 Busulfan Nov. 24 Etoposide Nov. 25 Cytoxan -9 Nov. 26 Cytoxan -8 Nov. 27 Day of Rest -7 Nov. 28 Stem Cell Infusion -6 Nov Nov Dec. 1-3 Dec. 2-2 Dec.3-1 Dec. 4 0 Dec Dec Dec Dec 8 Dec 9 Dec 11 Dec 12 Dec 13 Dec 14 Dec Rev. 7/2012

85 NOTES:

86 Sample Calenda fo Neupogen + Pleixafo Pimed Autologous Tansplant Sunday Monday Tuesday Wednesday Thusday Fiday Satuday Oct. 6 Oct. 7 Appointment with you tansplant docto Desk R20 Oct. 13 Neupogen injection Oct. 14 Neupogen injection Repot to R10 at 4:30 PM fo pleixafo injection Oct. 8 Oct. 9 Oct. 10 Hoizon placement in Radiology Oct. 15 Repot fo Stem Cell Collection 7:30am Desk M12 Neupogen inj Repot to R10 at 4:30 pm fo pleixafo inj Oct. 20 Oct. 21 Oct. 22 Repot to J1-1 at 1 pm fo BMT admin Hydation Oct. 16 Repot fo Stem Cell mobilization 7:30-am Desk M12 Neupogen inj Repot to R10 at 4:30 pm fo pleixafo inj Oct. 23 Melphalan (please follow all instuctions) Oct. 17 Repot fo Stem Cell Collection 7:30am- Desk M12 Neupogen inj Oct. 24 Day of Rest Oct. 11 Hoizon teaching with you BMT nuse Desk R32 Neupogen injection Oct. 18 Repot fo Stem Cell Collection 7:30 am- Desk M12 Oct. 25 Stem Cell Infusion Oct. 12 Neupogen injection Oct. 19 Oct. 26 Oct. 27 Oct Oct Oct Oct Nov Nov Nov. 3 Nov. 4 Nov. 5 Nov. 6 Nov. 7 Nov. 8 Nov Nov. 10 Nov. 11 Nov. 12 Nov. 13 Nov. 14 Nov. 15 Nov

87 NOTES:

88 Common Inpatient Medicines fo Autologous Tansplant Patients Medications will be administeed to you while you ae an inpatient. You may efe to this list as you nuse administes new medicines while you ae in the hospital. Please don't hesitate to ask you nuse questions about you medicine if you do not undestand. Always notify you nuse of any unusual o new symptoms. ACYCLOVIR is used to pevent o teat infections caused by cetain viuses. This medicine is stated on admission and given evey 12 hous, o twice a day fo 6-12 months following you auto stem cell tansplant. Possible side effects include dizziness, headache, nausea, vomiting, muscle o joint pain. Allopuinol is used to contol uic acid levels. Uic acid is found inside cells, both nomal and canceous. When chemotheapy is given, it kills the cance cells, and the contents ae eleased into the bloodsteam. If uic acid levels get too high, it can cause kidney poblems. This dug is given once a day, and the most common side effect seen is the development of a skin ash. ATENOLOL, CLONIDINE, NORVASC, VASOTEC, AND Metopolol ae used to contol high blood pessue (hypetension). Possible side effects include dizziness, insomnia, low blood pessue, inging in the eas, headache, dy mouth, and dowsiness. ATIVAN, APREPITANT, COMPAZINE, ZOFRAN, and Decadon ae commonly used to pevent o teat nausea and vomiting elated to chemotheapy. These medicines ae stated on admission. Possible side effects include dizziness, dowsiness, confusion, incease in heat ate, decease in blood pessue, dy mouth, and blued vision. CIPRO is used to pevent o teat bacteial infections. This medicine is stated on admission and is usually given evey 12 hous, o twice a day. Possible side effects include nausea, vomiting, abdominal pain, diahea, ash, headache, and feve. DILANTIN is used to pevent seizues. If busulfan is pat of you pepaative egimen, you will eceive Dilantin to educe the isk of seizues associated with busulfan. DILAUDID, MORPHINE, OXYCODONE ae used to contol pain elated to mouth and thoat soes, abdominal pain, and headaches. Possible side effects include dowsiness, confusion, dizziness, headache, incease o decease in heat ate, inging in eas, blued vision, nausea, vomiting, uinay etention, ash, and camps. Common Inpatient Medicines fo Autologous Tansplant Patients

89 ELECTROLYTES (CALCIUM, MAGNESIUM, PHOSPHORUS, POTASSIUM) ae chemical substances in you body that ae involved in metabolic activities and ae essential to the nomal function of all cells. Cetain medicine, diahea, and nutitional status deplete you body of its nomal levels of electolytes. You will be given electolytes in ode to eplace what has been lost. GENTAMYCIN, VANCOMYCIN, AND ZOSYN ae common antibiotics used to pevent o teat seious bacteial infections. These medicines ae usually stated when you white blood cell count is low o with you fist feve. Possible side effects include nausea, vomiting, ash, diahea, heaing loss, and decease in kidney function. G-CSF, NEUPOGEN ae used to stimulate the gowth of white blood cells (neutophils). These ae given daily beginning 5 days afte you stem cell infusion. Possible side effects include feve, low platelet count, nausea, vomiting, and bone pain. IMODIUM, LOMOTIL ae used to pevent and teat diahea. Chemotheapy and cetain medicines can cause an incease in diahea. If you have (significant) diahea, a stool sample will be sent to check fo bacteia called Clostidium difficile (C-diff). If the bacteia is not pesent, these medicines will be stated and given afte each loose stool. Possible side effects include dizziness, dowsiness, lightheadedness, headache, nausea, vomiting, and dy mouth. LASIX is used to elease excess fluid in the body. You Tansplant Team will assess you weight, fluid etention, and blood pessue, as well as the amount of fluid you take in and put out evey day to detemine whethe you need this medicine. Possible side effects include headache; dizziness; decease in blood pessue; decease in potassium, magnesium and calcium levels; ash; and decease in kidney function. MYCOSTATIN, NYSTATIN ae used to help pevent mouth soes and fungal infections in patients eceiving chemotheapy and antibiotics. These medicines can be taken in liquid fom, which you swish aound in you mouth and swallow, o by placing a toche (simila to a lozenge) in you mouth and letting it dissolve. To incease the effectiveness of this medicine, you should not eat o dink anything fo 15 minutes afte taking it. NEXIUM, PEPCID, PRILOSEC, and Pevacid educe acid poduction theeby educing heatbun and nausea. Possible side effects include headache, dizziness, and constipation Temazepam (Restoil) used to help you sleep, if needed. This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Index #11071 Poduced by the Cente fo Consume Health Infomation Copyight The Cleveland Clinic Foundation. All ights eseved. Rev. 10/15/2014

90 What to Expect Duing You Hospital Stay Ou goal is to povide you with the best possible cae in an atmosphee that is pleasant, educational, and suppotive. If thee is anything we can do to impove you hospital stay, please do not hesitate to ask. Daily outine You hospital outine stats the day you aive. Chest X-ay Weight and vital signs You will be weighed once o twice a day. You tempeatue, heat ate, beathing, and blood pessue will be monitoed at least evey 4 hous aound the clock. Blood daws Evey moning at 4 a.m., you nuse will take a blood sample fom you tiple lumen cathete. This sample will be evaluated in the lab. Taking the blood sample at this time ensues you lab test esults will be completed in time fo you moning visits with the Tansplant Team. It might also be necessay to daw blood samples at vaious othe times of the day. All tansplant patients will have a chest X-ay when medically indicated. Fo example, a chest X-ay might be pefomed if you have a feve to ule out possible infection. Medicines Duing you hospital stay, you will be equied to take medicines seveal times a day. You nuse will be esponsible fo giving you you medicine at the pescibed times. Please bing a list of you cuent medicines when you ae admitted. You do not need to bing in medications fom home. Hygiene Keeping youself clean is vey impotant to help pevent infection. You ae encouaged to bathe evey day. Soap and lotion canbe povided. Howeve, feel fee to bing you own soap and lotion. What to Expect Duing You Hospital Stay

91 Mouth cae Mouth cae is a vey impotant daily outine. Keeping you mouth clean helps pevent mouth soes and infection. The day you ae admitted to the hospital, you nuse will eview mouth cae instuctions (potocol). Mouth cae supplies will be povided. Bing you own vey soft/soft bistle toothbush and fluoide toothpaste. Tansplant Team ounds Evey day you Tansplant Team will assess and monito you health. Keep in mind that the tansplant docto who sees you daily duing you hospital stay might be diffeent than you pimay tansplant docto. They will communicate about you cae and pogess. Notes Index #10435 This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Poduced by the Cente fo Consume Health Infomation. Copyight The Cleveland Clinic Foundation. All ights eseved. Rev. 10/15/2014

92 Health Infomation Fo Patients and the Community Peventing Cental Line-Associated Bloodsteam Infections (CLABSIs) While in the Hospital What is a cental line? A cental line o cental venous cathete is a slende, hollow, flexible tube (cathete) that is inseted though a lage vein usually in the neck, chest, am, o goin. Hickman and Hoizon ae two types of cental venous cathetes. The cathete is made of silicone that is hypoallegenic and well-toleated in the body fo seveal yeas. Why do I need to have a cental line? You docto has chosen this type of cathete so fluids, nutition solutions, antibiotics, chemotheapy, o blood poducts can be deliveed diectly into you bloodsteam, and to collect blood samples, if needed. What is a CLABSI? A bloodsteam infection can occu when bacteia o othe gems tavel down a cental line and ente the blood this is called a cental-line associated bloodsteam infection (CLABSI). If you develop a CLABSI, you may become ill with feves and chills o the skin aound the cathete may become soe and ed. Why is a CLABSI dangeous? These infections can cause high feves, a dangeous dop in blood pessue and can be life-theatening. Can a CLABSI be teated? These infections ae seious, but often can be successfully teated with antibiotics. The cathete might need to be emoved if you develop an infection.

93 What ae some of the things we ae doing to pevent CLABSIs? The doctos and nuses will: n Clean thei hands with soap and wate o an alcohol-based hand ub befoe and afte caing fo you. n Clean the cathete o tubing with alcohol fo at least 15 seconds befoe putting anything into it o taking blood out. n Caefully handle medications and fluids that ae given though the cathete. n Discuss the plan of cae fo you cathete. The cathete will be emoved as soon as it is no longe needed. n Change the dessing and the caps on the end of the cathete once a week. The dessing will also be changed if it becomes dity, wet o loose. n Wea a mask and steile gloves when changing the dessing. What ae some things you can do to pevent CLABSIs? n Tell you nuse o docto if the dessing becomes dity, wet o loose. n Remind all caegives to clean thei hands with soap and wate o an alcohol-based hand ub befoe and afte caing fo you. Some sinks and hand ub dispenses ae located outside of patient ooms; it is okay to ask you caegives if they washed thei hands befoe enteing you oom. n Do not let family and fiends who visit touch the cathete o tubing. n Make sue family and fiends clean thei hands with soap and wate o an alcohol-based hand ub befoe and afte visiting you. n Wash you hands with soap and wate o an alcohol-based hand ub befoe eating and especially afte you have gone to the bathoom. Refeences: Wold Health Oganization (WHO) guidelines on hand hygiene in health cae, 2009; Pyek, K.M. (2014) Patient empowement in infection pevention and hand hygiene. Infection Contol Today: Special Repot (3), 1-26.; O Gady, N.P. (2011) Centes fo Disease Contol and Pevention (CDC) Guidelines fo the pevention of intavascula cathete elated infections. U.S. Depatment of Health and Human Sevices, This infomation is not intended to eplace the medical advice of you health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Index #15532 Copyight The Cleveland Clinic Foundation. All ights eseved.

94 - Mouth Cae Schedule Some teatment potocols estict the use of cetain mouth inses. You inpatient team will eview you specific egimen. An example is listed below: Mouth Cae Schedule 9:00 a.m. 1:00 p.m. 6:00 p.m. 9:00 p.m. Cleanse you mouth with a soft toothbush and flouide toothpaste. Then inse you mouth with a 10 cc salt and soda solution, swish fo 30 seconds and spit. Follow with 5 cc Nystatin swish and swallow. Cleanse you mouth with a soft toothbush and flouide toothpaste. Then inse you mouth with a 10 cc salt and soda solution, swish fo 30 seconds and spit. Follow with 5 cc Nystatin swish and swallow. Rinse you mouth with a 10 cc salt and soda solution, swish fo 30 seconds and spit. Follow with 5 cc Nystatin swish and swallow. Cleanse you mouth with a soft toothbush and flouide toothpaste. Then inse you mouth with a 10 cc salt and soda solution, swish fo 30 seconds and spit. Follow with 5 cc Nystatin swish and swallow. Mouth Cae Schedule *If you expeience mouth discomfot, you will be given a bottle of BMX solution to keep at you bedside. Use 10 cc to swish and swallow evey 4 hous as needed to soothe you mouth and thoat. ( BMX = Benadyl + Maalox + Lidocaine)

95 Notes This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Index #10714 Heaing Impaied (TTY) Assistance Poduced by the Cente fo Consume Health Infomation. Copyight The Cleveland Clinic Foundation. All ights eseved. Rev.02/11

96 Staying Active Duing You Hospital Stay Duing you hospital stay, it is extemely impotant to stay active. The moe active you ae, the stonge you body will be, and the moe pepaed you will be to etun home. Execise has numeous benefits, such as stengthening muscles and bones, impoving balance, and educing stess. Activity will also help educe you isk of developing pneumonia. Below is a list of things that you can do each day to make sue you ae staying active. Walk in the hallways 4-6 times a day Sit in a chai fo all you meals Walk to the bathoom to pefom you daily gooming activities Use the execise oom on a egula basis Read, play games, wok on the compute, and visit with family and fiends A physical o occupational theapist may be consulted to show you diffeent execises and ways to stay active duing you hospital stay. Staying Active Duing You Hospital Stay

97 Notes This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Index #14676 Poduced by the Cente fo Consume Health Infomation. Copyight The Cleveland Clinic Foundation. All ights eseved. Rev. 03/28/2014

98 Music Theapy What is music theapy? Music theapy, conducted by a boad-cetified music theapist, uses music and music inteventions within a theapeutic elationship to pomote physiological, psychological, emotional, and social well-being of the individual duing the teatment of an illness. How can music theapy benefit me? Music theapy may help with physical discomfot by deceasing you feelings of pain, nausea, agitation o estlessness. Music theapy may addess emotional distess, such as symptoms of depession, anxiety, o feelings of isolation. Music theapy may help to fulfill a need fo social suppot by poviding oppotunities fo self-expession, comfot, distaction, and by poviding additional suppot to you and you family membes. What happens in a music theapy session? The music theapist completes a bief assessment, elated to you music pefeences and expeiences, as well as symptom scales (i.e. pain, nausea), then woks with you to develop goals fo the session. Music theapy inteventions ae based on the goals of the session. Following the session, goals will be e-assessed and plans fo futue sessions may be made. The most commonly used music theapy inteventions include: Music Listening (usually live), Active Music Engagement (instument playing, singing, humming, etc.), Music- Assisted Relaxation Execises (beathing, pogessive muscle, music and imagey), and Songwiting. Howeve, othe music theapy inteventions may be implemented, depending on the goals of the music theapy session and the inteests of the patient and/o family. Music Theapy Whee does a music theapy session take place? Music theapy sessions take place in you oom; you can lie in bed o sit in a chai whateve is most comfotable fo you. What else do I need to know? You do not need to have pio musical skills to benefit fom music theapy. If you play an instument egulaly, you ae encouaged to bing it with you while you ae hospitalized. You ae also encouaged to bing some of you favoite ecoded music. You family membes ae welcome to paticipate in music theapy sessions with you at you discetion.

99 How do I equest music theapy sevices? Any staff membe, patient, o family membe can make a music theapy efeal. You can ask any staff membe to call o page the music theapist to equest music theapy sevices. We have a dedicated music theapist fo ou BMT Pogam because we want to povide the best sevices available. Notes This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Index #14674 Poduced by the Cente fo Consume Health Infomation. Copyight The Cleveland Clinic Foundation. All ights eseved. Rev. 03/28/2014

100 How to Cope With Side Effects Thee ae side effects associated with adiation theapy and high-dose chemotheapy. Some of the most common side effects and ways to elieve them ae descibed in this handout. Evey peson s eaction to teatment is unique, and some of these side effects might not affect you, o you might have a side effect not listed hee. No one can pedict which side effects will affect you o how sevee they might be. Please discuss any concens about you side effects with you health cae team. Following you pepaative egimen, thee might be days when you feel vey sick. Please make sue to tell you nuse, physician assistant, o docto how you ae feeling so he o she can intevene ealy to ty to make you feel bette. Only you know how you feel. Chemotheapy and adiation destoy cance cells. They also destoy nomal cells in the pocess. These include cells of the potective lining of the mouth and the gastointestinal tact. This can cause soes in the mouth and/o thoat that ae painful. The pain can be mild to sevee. The gastointestinal tact can become iitated, which causes nausea, vomiting, and diahea. These conditions ae not pemanent, and you might eceive medicines to help elieve you symptoms. As you blood counts begin to ecove afte you infusion of stem cells, you mouth and thoat will begin to heal, and the nausea and vomiting will also impove. Cetain side effects can happen months o yeas afte you tansplant. They can be caused by adiation o chemotheapy, and some can be pemanent, such as steility. Seconday malignancies have been epoted in some patients eceiving adiation and cetain types of chemotheapy. Ask you docto fo you specific isk. The isk vaies depending on you age, menopausal status fo women, pevious histoy of adiation, type and doses of chemotheapy, type of tansplant, and disease. How to Cope With Side Effects

101 Discomfot Dehydation Pesistent vomiting and diahea cause the body to lose lage amounts of wate and nutients. If you ae vomiting o having diahea moe than 3 times a day and you ae not dinking enough fluids, you could become dehydated. Dehydation is the loss of wate fom body tissues, and it distubs the balance of essential substances in you body. Dehydation can cause seious complications if it is not teated. Recommendations When you ae in the hospital. you will eceive intavenous fluids. When you ae an outpatient, please tell you health cae povide if you ae vomiting pesistently o have pesistent diahea and expeience any of these signs of dehydation: Dak uine Small amount of uine Rapid heat ate Headaches Flushed o dy skin Coated tongue Iitability and confusion Dizziness with position changes Skin Rash A skin ash o othe iitation might occu because of chemotheapy, an allegic eaction to a medicine, o fom an infection. Allogeneic tansplant might also expeience skin ashes fom gaft vesus host disease. (See section on GvHD fo moe infomation.) A skin biopsy, duing which a small sample of skin is emoved and examined unde a micoscope, might be equied to diagnose you skin ash. Most skin ashes impove but equie time fo healing. Gently cleanse the affected aea using lukewam wate and mild soap. Do not ub you skin. Pat you skin dy with a soft towel. Do not scatch o ub the affected aea. Do not apply any ointment, ceam, lotion, o powde to the affected aea unless it has been pescibed. Do not apply cosmetics, shaving lotions, pefumes, o deodoants on the affected aea. Use only an electic azo if you need to shave within the affected aea. Do not wea tight-fitting clothing o clothes made fom hash fabics such as wool o coduoy. These fabics can iitate the skin. Instead, choose clothes made fom natual fibes such as cotton. Do not apply medical tape o bandages to the affected aea unless you ae told to do so by you health cae povide. Do not expose the affected aea to exteme heat o cold. Avoid using an electic heating pad, hot wate bottle, o ice pack. Do not expose the affected aea to diect sunlight. Sun exposue might intensify you skin eaction and lead to sevee sunbun. Wea a lage-bimmed hat o potective clothing to minimize sun exposue. Choose a sunblock/sunsceen of SPF 30 o highe. Continue to potect youself fom the sun even afte you couse of teatment has been completed.

102 Discomfot Recommendations Hai loss Hai follicles ae vey sensitive to adiation and chemotheapy. Both of these teatments cause hai loss. Hai loss might be tempoay o pemanent. If you hai loss is tempoay, it might stat to e-gow about 3 to 6 months afte you tansplant. You might notice that when you hai begins to e-gow, the textue o colo is diffeent than befoe. Fatigue Eveyone has a diffeent level of enegy, so BMT will affect each patient diffeently. Many patients might equie a full yea to ecove physically (cont.) This side effect can be vey upsetting. Talk to you nuse o social woke about weaing scaves, hats, o a wig. Ask about The Look Good, Feel Bette pogam, which is sponsoed jointly by the Ameican Cance Society; the Cosmetic, Toilety and Fagance Association; the National Cosmetology Association; and the Cleveland Clinic Cance Cente. All paticipating patients eceive a complimentay gift bag of skin cae and cosmetic poducts. Avoid fequent shampooing. Use a mild shampoo (such as baby shampoo) without any pefumes. Wash you scalp with wam wate. Avoid ubbing and do not scatch. Pat dy with a soft towel. Avoid excessively combing o bushing you hai. Avoid using hai spay, oils, o ceams. Avoid using heat souces on you hai (including hai dyes, olles, o culing ions). Do not pem o colo you hai. Ask you health cae povide when you can go back to coloing o peming you hai. Potect you head fom the sun, cold, and wind by weaing a head coveing (such as a cap, tuban, scaf, o hat made of cotton o a cotton blend). Evaluate you level of enegy. Think of you pesonal enegy stoes as a bank. Deposits and withdawals have to be made ove the couse of the day o the week to balance enegy consevation, estoation, and expenditue. Keep a diay fo 1 week to identify the time of day when you ae eithe most fatigued o have the most enegy. Note what you think might be contibuting factos. How to Cope With Side Effects

103 Discomfot Recommendations Fatigue (cont.) and psychologically fom thei tansplant. Even afte that, life might not etun to the nomal you had expeienced befoe you tansplant. You might find that you need to pemanently change you lifestyle to pevent fatigue, avoid infections, and cope with the long-tem effects of teatment. Duing you ecovey, you will feel fatigued and weak. You will also have a deceased appetite. It will take some time to egain you stength and ability to paticipate in daily activities. Each peson's ecovey vaies. You might find that it takes seveal weeks to many months to esume you daily activities. The time following you tansplant is a time of cell ecovey and gowth of you new maow and e-gowth of cells in you mouth, stomach, intestines, hai, and muscles. This gowth equies caloies and enegy, and might explain why you feel moe tied than you anticipated. Be alet to you pesonal waning signs of fatigue. Fatigue waning signs might include tied eyes, tied legs, whole-body tiedness, stiff shouldes, deceased enegy o a lack of enegy, inability to concentate, weakness o malaise, boedom o lack of motivation, sleepiness, inceased iitability, nevousness, anxiety, o impatience. Plan ahead, oganize and pioitize you daily activities. Change stoage of items to educe tips o eaching. Decide which activities ae impotant to you, and delegate othe tasks/activities when needed. Combine activities and simplify details. Schedule est. Balance peiods of est and wok. Rest befoe you become fatigued. Fequent, shot ests ae beneficial. Pace youself. A modeate pace is bette than ushing though activities. Execise daily. Walking is an excellent way fo you to egain you stength and stamina. Eat a well balanced, nutitious diet. Manage stess. Managing stess can play an impotant ole in combatting fatigue. Adjust you expectations and ask othes fo suppot and help. Talk to you health cae povides. Although fatigue is a common, and often expected, side effect of cance and its teatments, mention you concens to you health cae povides. Thee ae times when fatigue might indicate an undelying medical poblem. Othe times, thee might be medical inteventions to assist in contolling some of the causes of fatigue. Finally, thee might be suggestions that ae moe specific to you situation that would help in combatting you fatigue. Be sue to let you docto o nuse know if you have: Inceased shotness of beath with minimal exetion Uncontolled pain Inability to contol side effects fom teatments (such as nausea, vomiting, diahea, o loss of appetite) Uncontollable anxiety o nevousness Ongoing depession

104 Discomfot Recommendations Insomnia (difficulty sleeping) Many patients have touble sleeping duing thei hospital stay. You might expeience insomnia because of discomfot fom nausea, mouth soes, o othe poblems. Changes in you daily outine o stess fom you pesonal concens might also be factos. Sexual side effects Chemotheapy and adiation theapy can affect you ability to have childen (fetility) in the futue. Factos that impact sexual desie such as homonal changes, excessive fatigue, cance pain o teatment, o changes in a peson s selfimage also might affect a peson s ability to have childen afte cance teatment. (cont.) If necessay, you might be given a pesciption medicine to help you fall asleep. Pactice elaxation techniques such as mental imagey, deep beathing, eading, o listening to calming music. Make sue you ae comfotable. Aange you pillows so you can maintain a comfotable position. Avoid napping too much duing the day. At the same time, emembe to balance activity with est. If you feel nevous o anxious, talk to you spouse, patne, o a tusted fiend. Get you toubles off you mind. You social woke can meet with you fo individualized counseling and is available to meet with you on the BMT unit. Discuss you concens about fetility and you desie to have childen afte teatment with you docto befoe you begin cance teatment. Concens about being biologically able to have childen might be distessing, so it might help to seek counseling with you BMT social woke. It might help to talk about fetility loss and its impact on you and you patne o futue patne. Even though infetility (the inability to have childen) might occu afte cance teatment, it is still possible to get pegnant, so both men and women should use bith contol afte teatment. If you do wish to stat a family afte cance teatment, talk to you health cae povide about the timing of a pegnancy afte teatment. How to Cope With Side Effects

105 Discomfot Sexual side effects (cont.) Some women stop having thei menstual cycles afte a blood o maow tansplant and might benefit fom homone eplacement theapy to elieve menopausal symptoms. Talk to you docto about this teatment option. Some men might expeience a deceased o absent spem count afte cance teatment. Recommendations Some ways to incease you chances of having childen afte cance teatment include: spem banking and cyopesevation (feezing spem samples so it can late be used to fetilize a woman s egg); assisted epoduction techniques such as in vito fetilization (a pocedue in which thousands of spem ae placed in a laboatoy dish with an egg); and intacytoplasmic spem injection (a pocedue in which spem is injected diectly into an egg). Reseaches ae also looking at new methods of teatment that spae the epoductive system, including homonal suppession of the epoductive ogans, new sugical techniques, and tissue tansfe. Fo moe infomation, please efe to the booklet, Sexuality and Cance povided by the Ameican Cance Society. Also talk to you social woke who can efe you to seveal agencies o suppot goups fo moe infomation. Index #10257 This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Poduced by the Cente fo Consume Health Infomation. Copyight The Cleveland Clinic Foundation. All ights eseved. Rev

106 Blood Tansfusions What is a blood tansfusion? A blood tansfusion is the delivey of whole blood o blood components to eplace blood lost though tauma, sugey, o disease. All patients eceiving a blood o maow tansplant will eceive blood poducts duing thei hospital stay. Blood tansfusions at Cleveland Clinic About 1 of evey 3 patients hospitalized at Cleveland Clinic will eceive a blood tansfusion duing his o he stay. Moe than 7,500 Cleveland Clinic patients eceive a total of about 120,000 units of blood annually. Expeience has shown that tansfusion is a vey safe pocedue. The possibility of a blood tansfusion concens some patients who woy about contacting AIDS o anothe infectious disease fom the blood. If you equie a tansfusion duing you hospitalization, be assued that the entie tansfusion pocess will be expetly pefomed to potect you safety and health. Components of blood poducts Donated whole blood is typically divided into 4 diffeent components, including: 1. Red blood cells the pimay caie of oxygen Blood Tansfusions 2. Platelets substances that help fom clots to contol bleeding 3. Plasma eplaces blood volume and clotting factos 4. Clotting factos substances in the blood that help it thicken (clot) You might eceive one o all of these diffeent components duing you hospital stay.

107 What ae the benefits of blood tansfusions? Red blood cells ae usually tansfused to a patient to pevent anemia. Anemia is a deficiency of hemoglobin, the pimay caie of oxygen in ed blood cells. A substantial loss of hemoglobin in the body can cause injuy to vital ogans such as the bain and heat. Platelets, plasma and clotting factos ae tansfused to pevent bleeding. If a patient lacks platelets o clotting factos, pofuse (sevee) bleeding could occu duing sugey o teatment, causing a loss of ed blood cells (which could esult in anemia). Platelets ae seveely depleted in people with leukemia, aplastic anemia, and othe blood disodes. These disodes, as well as thei teatment, educe a patient s ability to manufactue platelets. Sevee bleeding might esult fom a lack of platelets, making platelet tansfusions necessay. How safe is the blood supply? Cleveland blood donos have one of the lowest ates in the county of diseases that can be tansmitted though blood. In addition, about 80% of the blood comes fom people who have donated blood in the past. This is impotant because these people have established a ecod of safety with us. Evey unit of blood used fo tansfusion at Cleveland Clinic has been donated by a healthy individual, and each unit has passed 8 diffeent tests fo infectious diseases, such as hepatitis (a vial infection of the live) and AIDS, which attacks the immune system. Donated blood that tests positive fo an infectious disease is discaded, and the dono is neve pemitted to donate blood again. Despite the best effots of moden technology, howeve, thee emains a bief peiod of time duing which a healthy but potentially infectious dono might test negative. This is called the window peiod. Cuently, sceening tests used by Cleveland Clinic and othe institutions will detect an infection afte a window peiod of seveal days. The isk of eceiving an infection such as HIV (the vius that causes AIDS) though a tansfusion is less than 1 in 500,000. In othe wods, fewe than 1 in 500,000 tansfusions will tansmit the HIV vius fom a dono to a ecipient; simila to the isk of being stuck by lightning (1 in 600,000 pe yea). Evey unit of blood is caefully tested in the laboatoy fo compatibility with the patient s own blood befoe it is appoved fo use. The label on evey unit is checked and double-checked at the patient s bedside befoe it is given. Whee will the blood I eceive come fom? Most of the blood used at Cleveland Clinic comes fom the Ameican Red Coss. Donos ae voluntees who cae enough about someone else s medical needs to give a pint of thei own blood. Evey dono is sceened in detail befoe each donation. Donos ae asked questions about thei medical histoy and thei lifestyles (sexual histoy) befoe blood is collected. This infomation is used to identify people who might be at high isk fo a disease that could be tansmitted (spead) though thei donated blood. Should I povide my own donos? This is not advisable fo most people. Patients who want to choose thei own donos (called diected donos) usually believe this will make blood tansfusion safe. It will not. Often, the fiends o elatives a patient chooses ae fist-time donos. Unlike the majoity of Red Coss donos, thei blood has no poven tack ecod of safety. Most people who lean the facts about the safety of blood tansfusion choose to let thei doctos select the blood that will be used. Such selections ae always based on the best scientific infomation available. Howeve, if a diected donation pogam is impotant to you, discuss it with an Ameican Red Coss epesentative by calling Diected donos must meet the same stict standads that community blood donos meet. Blood fom diected donos must pass tests fo hepatitis, AIDS, and syphilis, as well as othe blood-bone viuses. Each unit must be shown to match the intended ecipient s blood type

108 befoe it will be issued. Pocessing these tests can take 3 full woking days afte the pint is dawn, so aangements should be made well in advance to avoid unnecessay delays. Any diected units emaining afte the intended patient is dischaged will be eleased fo geneal use. Fiends and family membes can be encouaged to donate blood poducts at an Ameican Red Coss donation cente. What ae the costs of blood tansfusions? The costs fo a nomal blood tansfusion include the fees fo the collection and stoage of the blood unit plus fees fo the compatibility test. Blood fom diected donos is moe expensive because of fees fom pocessing costs. Blood collected fom donos who ae out of town might include additional shipping fees. What can I expect duing the tansfusion? Fist, a nuse will check you blood pessue, tempeatue, and pulse. An intavenous line will be stated with saline (salt) solution. While this is being completed, the blood o blood poducts will be etieved fom the Blood Bank. Red blood cells ae kept unde 50 degees Fahenheit to pevent contamination, so you might feel a cold sensation duing a ed blood cell tansfusion. A nuse will peiodically check you blood pessue, pulse, and tempeatue thoughout the pocedue. How long will the tansfusion take? Blood typing and matching to you own blood will take appoximately 2 hous. Red blood cell tansfusions geneally take about 3 to 4 hous. You blood tansfusion might be slightly shote o longe. Platelet tansfusions take appoximately 1 hou, which includes a half-hou obsevation peiod afte the platelets have been infused. How will I feel afte the tansfusion? Most patients who eceive a blood tansfusion feel bette within a few days. Once the tansfusion has been completed you may etun to you nomal activities. Benefits fom the ed blood cell tansfusion might not be noticed immediately. Will I notice any eactions? Reactions fom tansfusions happen vey aely. A eaction can occu duing, immediately afte, o even seveal hous o days following the tansfusion. You nuse will watch fo eactions duing the tansfusion. If a eaction occus, the tansfusion will be stopped, and pemedicines might be equied fo futue tansfusions. Tell you health cae povide immediately if you have any of the following symptoms duing o afte you tansfusion: Feve of degees F (38 degees C) o highe Shiveing o chills Headache Blood Tansfusions

109 Nausea and/o vomiting Chest pain Back pain Shotness of beath Itching o hives Reddish uine Yellowing of the skin (jaundice) Notes _ This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Index #10254 Poduced by the Cente fo Consume Health Infomation. Copyight The Cleveland Clinic Foundation. All ights eseved. Rev

110 Neutopenic Pecautions Fo Autologous BMT Patients 1. Good hand washing fo all who ente the oom. 2. Single oom isolation with lamina ai flow. 3. Wea mask when outside G110 o G111 inpatient units. 4. No aspiin o non-steoids, as they might mask feves. 5. Weekly dessing change of Hoizon cathete. 6. Minimize visitos and sceen fo infection, uppe espiatoy infection, diahea, etc. 7. No tampons. 8. No suppositoies o enemas. 9. No cotton swabs (Q-Tips ). 10. Wea glasses instead of contact lenses. 11. No pieced eaings. 12. No intimate contact (sexual intecouse). 13. Except fo handwashing, only the patient is to use the bathoom. 14. Only the patient is to occupy the bed. 15. Avoid contact with new animals. If you have pets at home, do not clean up afte them. Neutopenic Pecautions Fo Autologous Patients

111 Notes _ Index #10259 This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Poduced by the Cente fo Consume Health Infomation. Copyight The Cleveland Clinic Foundation. All ights eseved. Rev

112 - Thombocytopenic Pecautions Fo Autologous and Allogeneic Patients 1. Minimize venipunctues and invasive pocedues 2. No aspiin o non-steoids, as they might incease you isk of bleeding 3. No flossing o toothpicks 4. No staight azos, fingenail o toe clippes (use a file) 5. No suppositoies o enemas 6. No tampons 7. No nose blowing 8. No cotton swabs (Q-Tips ) 9. No intimate contact (sexual intecouse) until you platelet count is geate than 50 Thombocytopenic Pecautions

113 Notes This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Index # Heaing Impaied (TTY) Assistance Poduced by the Cente fo Consume Health Infomation. Copyight The Cleveland Clinic Foundation. All ights eseved. Rev.02/11

114 - Busulfan BRAND NAME: Mylean, Busulfex What does it do? Busulfan stops the gowth of cance cells by attaching to the DNA molecule that gives the cell the ability to epoduce. Theefoe, the cell can no longe epoduce. Busulfan belongs to a goup of medicines known as alkylating agents. How is it given? Busulfan is given as an intavenous solution though you cental venous cathete. Busulfan is given evey 6 hous aound the clock fo a specific numbe of doses. (Please efe to the sepaate infomation sheet about chemotheapy pecautions unde the Medication tab in this binde.) What ae some common side effects I might expeience? Please note: The side effects listed ae the most common. All possible side effects ae not included. Always contact you docto if you have any questions about you pesonal situation. Deceased blood counts Busulfan Nausea and vomiting Nausea might incease as moe doses of busulfan ae taken. Anti-nausea medicines can be given befoe each dose. Loss of appetite Rash, itching Mucositis The lining of you mouth and thoat, as well as you gums (called the oal mucosa), might become inflamed o soe duing teatments. You might have a dy mouth with thick, sticky saliva; discomfot when chewing o swallowing; o soes in you mouth. Esophagitis The lining of you esophagus (food pipe) might become inflamed and soe duing teatments. You might feel a buning sensation in you thoat o chest, o you might feel as if you have a lump in you thoat. You might also feel pain when swallowing.

115 Seizues The isk of developing this side effect is minimal. Howeve, to futhe educe the isk of developing seizues, you will be given an anti-seizue medicine called Dilantin once a day while you ae taking busulfan. Diahea Loss of fetility Discoloation of the skin and nails Scaing of the lung tissue (called pulmonay fibosis) To monito this side effect, you will have a pulmonay function test 1 month afte you ae dischaged fom the hospital. (This is ae.) Hai loss Inceased isk of infection What do I need to know when I go home? Nausea and vomiting might continue fo a length of time afte you ae dischaged. Call you docto if you have a pesistent, dy, hacking cough. Notes Index #10421 This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Heaing Impaied (TTY) Assistance Poduced by the Cente fo Consume Health Infomation Copyight The Cleveland Clinic Foundation. All ights eseved. Rev. 02/11

116 - Caboplatin BRAND NAME: Paaplatin What ae some othe names fo this medicine? Caboplatin might also be called C.B.D.C. What does it do? Caboplatin stops cance cells fom foming by intefeing with DNA and RNA, the genetic mateial in cells. Caboplatin belongs to a goup of medicines known as "alkylating agents." How is it given? Caboplatin is an intavenous solution given though you cental venous cathete continuously fo 3 to 4 days, depending on you specific pepaative egimen. (Please efe to the sepaate infomation sheet about chemotheapy pecautions unde the Medication tab in this binde.) What ae some side effects I might expeience? Deceased blood counts Caboplatin Nausea and vomiting Loss of appetite Metallic taste o change in taste peception Hai loss on scalp and othe aeas of the body Deceased levels of electolytes (potassium, magnesium, and calcium) Numbness and tingling o mild loss of muscle stength in ams and legs (called peipheal neuopathy) Heaing loss ae Renal toxicity (kidneys affected by the medicine) uncommon

117 Weakness, fatigue (feeling vey tied) Diahea Mouth soes Risk of infection Skin iitation Loss of fetility Please note: The side effects listed hee ae the most common. All possible side effects ae not included. Always contact you docto I you have questions about you pesonal situation. Notes Index #4794 This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Heaing Impaied (TTY) Assistance Poduced by the Cente fo Consume Health Infomation. Copyight The Cleveland Clinic Foundation. All ights eseved. Rev. 02/11

118 - Camustine BRAND NAME: BiCNU What ae some othe names fo this medicine? Camustine is commonly called BCNU. What does camustine do? Camustine inhibits cell division. This medicine belongs to a goup of agents known as alkylating agents. How is camustine given? Camustine is usually given as an infusion into a vein (intavenous, IV) ove 2 hous. This medicine also comes in wafe fom that can be used fo patients with bain tumos. The amount of camustine is based on you specific pepaative egimen. (Please efe to the sepaate infomation sheet about chemotheapy pecautions unde the Medication tab in this binde.) What ae some common side effects of this dug? Nausea and vomiting Note: You will be given an antinausea medicine befoe eceiving camustine. Camustine Facial flushing Low blood counts This might put you at inceased isk fo infection and/o bleeding until you blood counts ecove. Inceases in live function tests These usually etun to nomal once teatment is stopped. Dizziness Low blood pessue This has been seen with high doses of camustine. Pulmonay toxicity This has been seen with high doses of camustine. Scaing of the lung tissue (pulmonay fibosis)may occu. To monito this side effect, you will have a pulmonay function test one month afte you ae dischaged fom the hospital

119 Tempoay edness o bluing of the eyes Pain and/o buning at injection site Please note: The side effects listed ae the most common. All possible side effects ae not included. Always contact you docto if you have questions about you pesonal situation. Notes This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Index #11032 Heaing Impaied (TTY) Assistance Poduced by the Cente fo Consume Health Infomation. Copyight The Cleveland Clinic Foundation. All ights eseved. Rev. 02/11

120 - Cyclophosphamide BRAND NAMES: Cytoxan and Neosa What ae some othe names fo this medicine? Cyclophosphamide might also be called CTX. What does it do? Cyclophosphamide destoys tumo cells and makes them unable to epoduce. It is known as an alkylating agent. How is it given? Cyclophosphamide is an intavenous solution given though you cental venous cathete fo fou hous at a time, two days in a ow, depending on you pepaative egimen. It can also be used with Neupogen to mobilize stem cells fo autologous stem cell tansplants. This is called a piming agent. (Please efe to the sepaate infomation sheet about chemotheapy pecautions unde the Medication tab in this binde.) What ae some side effects I might expeience? Deceased blood counts This usually occus in about 7 days and lasts about 21 days. Nausea and vomiting (NOTE: You will be given an antinausea medicine befoe eceiving cyclophosphamide.) Cyclophosphamide Loss of appetite Mucositis The lining of you mouth and thoat, as well as you gums (called the oal mucosa), might become inflamed o soe duing teatments. You might have a dy mouth with thick, sticky saliva; discomfot when chewing o swallowing; o soes in you mouth. Esophagitis The lining of you esophagus(food pipe) might become inflamed and soe duing teatments. You might feel a buning sensation in you thoat o chest, o you might feel as if you have a lump in you thoat.you might also feel pain when swallowing.

121 Buning, painful feeling when uinating Facial flushing Blood in the uine (hemohagic cystitis) To help pevent this side effect, you might eceive an intavenous medicine called mesna (band name Mesnex ). Additional peventive measues include exta IV fluid and close monitoing of uinay output. Dinking lots of fluids (2 to 3 quats evey 24 hous) and emptying you bladde fequently will also help pevent this effect. Change of taste Hai loss on scalp and othe aeas of the body Heat damage (cadiotoxicity) To help pevent this side effect fom developing, you will have an electocadiogam (EKG) to monito the electical activity of you heat befoe each dose of cyclophosphamide. If necessay, the dosage of the medicine will be adjusted. Dizziness o nasal stuffiness o jaw pain while you ae eceiving the medicine Sensitivity to the sun Avoid diect sunlight and wea sunsceen with an SPF of 30 o geate. Steility in males and females Diahea Discoloation of skin o nails Please note: The side effects listed ae the most common. All possible side effects ae not included. Always contact you docto if you have questions about you pesonal situation. What do I need to know when I go home? Tell any new doctos o othe health cae povides, including dentists, that you eceived this medicine in the past. Notes Index #4813 This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Heaing Impaied (TTY) Assistance Poduced by the Cente fo Consume Health Infomation Copyight The Cleveland Clinic Foundation. All ights eseved. Rev. 02/11

122 - Etoposide (VP-16) BRAND NAMES: VePesid, Etopophos, Toposa What ae some othe names fo this medicine? Etoposide is commonly called VP-16. What does it do? Etoposide inhibits cell division. It belongs to a goup of agents known as plant alkaloids, meaning it is deived fom a plant souce. Why is it given? Etoposide can be given as pat of the pepaative egimen fo autologous and allogeneic tansplants. It is also sometimes used as a piming agent fo autologous tansplant patients pio to stem cell collection, to help make moe stem cells. How is it given? If given as pat of a pepaative egimen, Etoposide is an intavenous solution given though you cental venous cathete continuously fo 18 to 36 hous at a time (depending on you body weight), o fo 2 hous at a time, twice a day fo 3 days in a ow. The amount of etoposide you eceive will depend on you specific pepaative egimen. If given as a piming agent, Etoposide is infused ove 4 hous in the outpatient clinic. (Please efe to the sepaate infomation sheet about chemotheapy pecautions unde the Medication tab in this binde.) Etoposide (VP-16) What ae some common side effects I might expeience? Deceased blood counts Nausea and vomiting You will be given anti-nausea medicines as needed to teat this side effect. Loss of appetite Low blood pessue. You will be monitoed closely fo this effect. Headaches

123 Mucositis The lining of you mouth and thoat, as well as you gums (called the oal mucosa), might become inflamed o soe duing teatments. You might have a dy mouth with thick, sticky saliva; discomfot when chewing o swallowing; o soes in you mouth. Esophagitis The lining of you esophagus (food pipe) might become inflamed and soe duing teatments. You might feel a buning sensation in you thoat o chest, o you might feel as if you have a lump in you thoat. You might also feel pain when swallowing. Loss of hai on scalp and othe aeas of the body. Skin changes simila to a sevee sunbun. You skin might become dake, extemely dy, and peel. Peipheal neuopathy: numbness, tingling and loss of muscle stength in the ams and legs. This geneally impoves ove many months post-tansplant. Loss of fetility. Diahea Metallic taste duing infusion Sucking on had candy o chewing gum might help alleviate this effect. Please note: The side effects listed ae the most common. All possible side effects ae not included. Always contact you docto if you have any questions about you pesonal situation. What do I need to know when I go home? If you expeience a skin eaction, you skin colo will etun to nomal ove time. Lotion is ecommended to teat dy skin. Sunsceen is also ecommended, as you skin might be moe sensitive to the sun. This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Notes Index #4975 Heaing Impaied (TTY) Assistance Poduced by the Cente fo Consume Health Infomation. Copyight The Cleveland Clinic Foundation. All ights eseved. Rev. 02/11

124 - Ifosfamide BRAND NAME: IFEX What ae some othe names fo this medicine? Ifosfamide might also be called isophosphamide. What does it do? Ifosfamide intefees with the gowth of cance cells to destoy them. Ifosfamide belongs to a goup of medicines known as alkylating agents. How is it given? Ifosfamide is an intavenous solution given though you cental venous cathete fo 2 hous at a time, 4 days in a ow. (Please efe to the sepaate infomation sheet about chemotheapy pecautions unde the Medication tab in this binde.) What ae some common side effects I might expeience? Deceased blood counts Nausea and vomiting You will be given antinausea medicine to pevent this side effect. Ifosfamide Loss of appetite Inflammation and bleeding of the bladde To pevent this side effect, you might eceive an intavenous medicine called mesna. You will also eceive moe intavenous fluids, and you will be asked to uinate fequently. Confusion Loss of hai on scalp and othe aeas of the body Change in sense of taste Loss of fetility Please note: The side effects listed ae the most common. All possible side effects ae not included. Always contact you docto if you have any questions about you pesonal situation.

125 Notes This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Index #4855 Heaing Impaied (TTY) Assistance Poduced by the Cente fo Consume Health Infomation. Copyight The Cleveland Clinic Foundation. All ights eseved. Rev. 02/11

126 - Melphalan Band Name: Alkean What ae some othe names fo this medicine? Melphalan is also called L-PAM, L-sacolysin, phenylalanine mustad. What does melphalan do? Melphalan inhibits cell division. It belongs to a class of medicines known as alkylating agents. How is melphalan given? Melphalan can be given in pill fom o as an infusion into a vein (intavenous, IV). The amount of melphalan that is given is based on you specific pepaative egimen. (Please efe to the sepaate infomation sheet about chemotheapy pecautions unde the Medication tab in this binde.) What ae some common side effects of this dug? Low blood counts Melphalan Nausea and vomiting Mouth soes Diahea Loss of fetility Hai loss Kidney toxicity You will be monitoed closely fo this side effect. Heat iegulaities You will be monitoed closely fo this side effect. Allegic eactions You will be monitoed closely fo this side effect. Please note: The side effects listed ae the most common. All possible side effects ae not included. Always contact you docto if you have questions about you pesonal situation.

127 Notes This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Index #11033 Heaing Impaied (TTY) Assistance Poduced bythe Cente fo Consume Health Infomation. Copyight The Cleveland Clinic Foundation. All ights eseved. Rev. 02/11

128 Tansplant Medicines Oveview The most impotant step in maintaining you health afte you tansplant is to take you medicines exactly as pescibed. These dugs help pevent ejection and infection. You might need to take some of these medicines fo the est of you life. What should I know about taking my medicines? Befoe you docto pescibes any medicine, he o she will ask you: q q q If you ae allegic to any medicines If you ae cuently taking any othe medicines (including ove-thecounte medicines, vitamins and hebal supplements) If you have poblems taking any medicines The type of medicines, the dosage, and side effects might be diffeent fo each patient. You BMT Team will teach you about you medicines and give you infomation sheets descibing each dug and how to take it. You should always know: q q The name of the dugs pescibed and thei action (Please note: all medicines have two names the geneic o chemical name and the band name.) The dosages, how to take them, and the time of day to take them Tansplant Medicines Oveview q The side effects and how you can teat o pevent them You family membes ae encouaged to lean about you medicines. Whee will I get my pesciptions? Autologous Patients will eceive witten pesciptions at the time of dischage that can be filled at you pefeed phamacy. We also offe bedside delivey of you medicines befoe you leave the hospital. You will be asked duing you stay if you would like to use this sevice.

129 Allogeneic If appoved by you pesciption plan, most pesciptions ae povided by the Taussig Cance Cente Phamacy. These pesciptions usually include a 1-month supply with efills. When you ae notified that you pesciptions ae eady, please send a family membe, along with you pesciption cad, to pick up you medicines. Befoe you go home, you, you cae-patne, and you nuse must veify the medicine dosages. Please eview the infomation on you pesciption labels. This includes the medicine name, dose, instuctions on how to take, and emaining efills. You can also use the bedside delivey sevice. Pesciption efills When you initial supply of medicine is unning low, you may call you nuse coodinato with you pefeed phamacy s phone numbe and you pesciption numbe so the efill can be called in. Do not wait until you ae completely out of medicine befoe filling you pesciptions. If thee ae no emaining efills, notify you nuse coodinato at least 1 week befoe the medicine will un out. Mail-ode pogams Many pesciption benefits plans offe a mail-ode pogam. These ae povided to decease you pesciption co-pay. It is necessay to plan ahead, since initial pesciptions can take up to 3 weeks to eceive. Notify you nuse coodinato if you plan to use this benefit. Will the dugs I m taking cause any side effects? Some of the dugs pescibed fo you might cause unwanted side effects such as weight gain, acne, o excess hai gowth. Despite these side effects, neve change the dose o stop taking you medicines without fist checking with you docto. Many of the side effects can be contolled. You docto might adjust you dosage o offe othe suggestions fo managing the side effects. Keep all appointments with you docto so you esponse to the dug can be monitoed. of each dug and how to manage them. Call you health cae povide if you become sick and vomit soon afte taking you medicine. If you vomit within 30 minutes of taking the medicine, epeat the dose. If you ae unable to keep down the second dose, call you health cae povide. Also call if you have any othe symptoms that ae pesistent o sevee. Does it eally matte if I miss a dose? Yes. It is vey impotant to always follow the instuctions fo you medicines evey day to pevent ejection o infection. What if I foget to take my medicines at the scheduled time? If you miss a dose of you medicine at the scheduled time, don t panic. Take it as soon as you emembe. (Howeve, if it is almost time fo you next dose, skip the missed dose and etun to you egula medicine schedule.) As you begin to feel well, it might be easy to foget to take you medicines, but always emembe that you body neve stops equiing the tansplant medicines. By taking you medicines consistently and following-up with you docto outinely, you ae assuming the most impotant job afte you tansplant. Dose changes You docto will peiodically change the dose of you medicines. The dose might be changed because you ae having uncomfotable side effects o because blood test esults indicate that a diffeent dose is needed. You will eceive a medicine dosage ecod to wite down you medicines and dosages. Evey time you docto tells you to change the dose of you medicine, coss out the pevious dose and wite in the new dose. (Use ink, not pencil, and do not ease pevious infomation so you have a ecod of you ealie doses). Remembe, neve change the dose of you medicine unless you docto has told you to do it. The individual dug infomation sheets contained in this notebook descibe the common side effects

130 Othe medicines Neve take othe medicines without fist talking to you docto, including ove-thecounte dugs (those you can buy without a pesciption). Some ove-the-counte dugs including aspiin, ibupofen (Advil, Nupin ), napoxen (Aleve ), vitamins, cold medicine, antihistamines, antacids, hebs, laxatives, and sleeping pills might decease the effectiveness of you tansplant medicines and can cause unwanted side effects. Will any new medicines be available? Exciting developments in dug eseach ae ceating new immunosuppessive medicines. Cleveland Clinic s Bone Maow Tansplant Pogam paticipates in new dug studies on a continuous basis. You might be asked to paticipate in one of these pogams afte you tansplant. All pogams ae stictly voluntay and have no influence on you tansplant status. Geneal medicine guidelines Note: these ae geneal guidelines. Be sue to ask you docto o phamacist fo guidelines specific to you medicine. q q Keep a list of you medicines and thei dosages with you. Take you medicines exactly as pescibed, at the same time(s) evey day. Do not stop taking o change you medicines o the dosages unless you fist talk with you docto. Even if you feel good, continue to take you medicines. q q q q q Stopping some medicines suddenly might make you condition wose. Have a outine fo taking you medicines. Conside getting a pill box that is maked with the days of the week. Fill the pill box at the beginning of each week to make it easie fo you to emembe. If you ae taking Neoal o cyclospoine, keep these medicines in thei oiginal packaging. Keep a medicine calenda and note evey time you take a dose. You pesciption label tells you how much to take at each dose, but you docto might change you dosage peiodically, depending on you esponse to the medicine. On you medicine calenda, you can list any changes in you medicine dosages as pescibed by you docto. If you docto has discontinued a medicine, place the discontinued medicine in a sepaate aea away fom you cuent medicines. You docto might e-pescibe this medicine at a late date. Wash you hands befoe pepaing o taking medicines. Take you time. Double check the name and dosage of all you medicines befoe using them. q Regulaly fill you pesciptions and ask you phamacist any questions you have about efilling you pesciption. Know you phamacy phone numbe, pesciption numbe, medicine name, and dose so you can Tansplant Medicines Oveview

131 easily call fo efills. Ty to fill all you pesciptions at the same phamacy so the phamacist can monito fo inteactions, and povide pope dosing and efills. If you efill medicine does not look ight, ask you phamacist to veify that you have eceived the coect pesciption. q q q q q q Do not decease you medicine dosage to save money. You must take the full amount to get the full benefits. Talk with you docto about ways you can educe the costs of you medicines. If you have pesciption coveage, make sue you know the tems of you policy. Remind you docto about the type of insuance coveage you have. Do not stop taking a medicine. Talk to you docto if you have concens about a medicine and how it is woking. Keep medicines stoed in sealed containes. Stoe accoding to the instuctions given with the pesciption. Check liquid medicines often. If they have changed colo o fomed cystals, thow them away and get new ones. When taveling, keep you medicines with you so you can take them as scheduled. On longe tips, take an exta week s supply of medicines and copies of you pesciptions in case you need to get a efill. Questions to Ask About You Medicines Be sue you know the answes to these questions befoe you stat taking any new medicine: q q q q q q q q q q q q What is the name of the medicine? Why do I need to take it? How often should I take it? What time of day should I take it? Should I take it on an empty stomach o with meals? Whee should I stoe the medicine? What should I do if I foget to take a dose? How long should I expect to take the medicine? How will I know it is woking? What side effects should I expect? Will the medicine intefee with diving, woking, o othe activities? Does the medicine inteact with any foods, alcohol, o othe medicines (including ovethe-counte medicines)? q q Always keep medicines out of the each of childen. Neve give you medicine to othes. Index #10422 This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Poduced by the Cente fo Consume Health Infomation. Copyight The Cleveland Clinic Foundation. All ights eseved. Rev. 04/13

132 - Nystatin Common band name: Mycostatin Why is nystatin pescibed? Nystatin is used to pevent o teat fungus infections. These infections ae caused by a fungus calledcandida. Candida can affect many pats of the body, including the mouth, thoat, esophagus, and stomach. Tansplant patients might develop infections because thei immune systems ae suppessed by eithe chemotheapy o by the immunosuppessant medicines they must take to pevent gaft vesus host disease (fo allogeneic patients). How is nystatin taken? Nystatin is geneally taken in a liquid fom. Thee is also a toche (lozenge) fom available. It is usually taken 4 times a day afte meals and at bedtime. The dose of this medicine will be diffeent fo each patient. You pesciption label tells you how much to take at each dose and how often to take the medicine. Follow these instuctions caefully, and ask you phamacist o docto to explain anything you do not undestand. Nystatin What special instuctions should I follow while using this dug? If you wea dentues, emove them befoe using this medicine. Make sue to wash the dentues caefully to pevent you mouth fom getting the infection again. Shake this medicine well befoe using. Swish nystatin aound in you mouth and hold it thee ae long as possible (seveal minutes) befoe swallowing. If you ae using toches, it is impotant to hold the toche in you mouth until it has completely dissolved. Do not eat o dink anything fo at least 15 minutes afte using this medicine. If you ae having difficulty swallowing fo any eason, please tell you docto.

133 What should I do if I foget to take a dose? If you foget to take a dose, take it as soon as you emembe. Howeve, if it is almost time fo you next dose, skip the missed dose and continue you egula dosing schedule. Do not take a double dose. What stoage conditions ae necessay fo this dug? Stoe the liquid and the toches at oom tempeatue. DO NOT stoe the toches o liquid in diect sunlight o in the bathoom, nea the kitchen sink, o in othe damp places. Heat and moistue might cause them to beak down. Keep this medicine in a tightly sealed containe. Keep this and othe medicines out of the each of childen. What ae the common side effects of this dug? Nystatin might cause any of the following side effects: Diahea If you have diahea, dink moe fluids to eplace the fluid lost in you stool and to pevent dehydation. You can become dehydated quickly. Signs of dehydation might include weakness, dizziness when standing fom a sitting position, deceased uine output, and confusion. Tell you nuse coodinato if you ae having moe than 5 liquid stools daily. Nausea and/o vomiting Tell you nuse coodinato if you symptoms pesist. Stomach pain Rash This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. When should I call my health cae povide? Call you health cae povide if you: Have a skin eaction Have moe than 5 liquid stools (diahea) pe day Have signs of dehydation, including weakness, dizziness when standing fom a sitting position, deceased uine output, and confusion Expeience pesistent o sevee side effects Develop new symptoms afte stating this medicine Have any othe symptoms that cause concen Have any questions o concens Notes _ Index #5654 Heaing Impaied (TTY) Assistance Poduced by the Cente fo Consume Health Infomation Copyight The Cleveland Clinic Foundation. All ights eseved. Rev. 02/11

134 Steoids Geneic names: Pednisone, methylpednisolone, Dexamethasone Common band names: Deltasone, Meticoten, Oasone, Pednicen-M, Pednisone Intensol, Solu-Cotef, Solu-Medol, Steaped DS Why is this dug pescibed? Classified as coticosteoids o steoid homones, pednisone and methylpednisolone ae simila to the steoid homone you body poduces natually. Steoids might be given along with othe immunosuppessive medicines to pevent o teat gaft-vesus-host-disease (GvHD). How ae steoids taken? Pednisone is available in many geneic bands and in seveal dosages. Geneally, you will be pescibed the pill fom of pednisone. Methylpednisolone is given by infusion (IV) in the hospital. These dugs wok best when thee is a constant amount of it in the bloodsteam. Steoids must be taken fo the entie duation of teatment in ode to achieve the best esults. It is impotant you take this medicine egulaly as pescibed. Do not stop taking you steoids. Steoids The dose of these dugs will be diffeent fo each patient. You pesciption label tells you how much to take at each dose and how often to take it. Follow these instuctions caefully and ask you phamacist o docto to explain anything you do not undestand. Once pescibed pednisone/methylpednisolone, you docto will gadually decease the dosage ove a peiod of time. This is called a tape schedule. Tape schedules ae individualized to meet each peson s special needs. Neve change the dose of you pednisone/methylpednisolone without the advice of you docto. What special instuctions should I follow while using this dug? Take pednisone ealy in the day to pevent insomnia (difficulty sleeping). Take this medicine with food. You must take all of the pescibed amount of pednisone/methylpednisolone to maintain enough immunosuppession to pevent/teat GvHD. Follow you dosage schedule caefully.

135 Fo pednisone Be sue you always have enough medicine on hand. Check you supply befoe holidays o othe occasions when you might be unable to fill you pesciption. Keep all appointments with you docto and the laboatoy so you esponse to the dug can be monitoed. Do not have any immunizations o vaccinations without you docto s appoval. Do not dink alcohol while taking this medicine. Alcohol can intefee with the effectiveness of this medicine and cause seious side effects. Do not take any new medicines (pesciption o non-pesciption) without telling you health cae povide fist. Seveal dugs might intefee with the effectiveness of pednisone. Take pecautions to avoid infection while taking this medicine. What should I do if I foget to take a dose? DON T FORGET TO TAKE THIS MEDICINE. You body gets used to having this medicine in you system. If you foget to take a dose, take it immediately. If you have fogotten moe than one dose, contact the Tansplant Cente fo instuctions. What stoage conditions ae necessay fo this dug? Stoe this medicine at oom tempeatue. DO NOT stoe this medicine in diect heat o light. DO NOT stoe this medicine in the bathoom, nea the kitchen sink, o in othe damp places. Heat o moistue might cause it to beak down. Keep this medicine in a tightly sealed containe. Keep this and othe medicines out of the each of childen. What ae the side effects of this dug? Even though the side effects of pednisone/ methylpednisolone could be seious, emembe that this dug is necessay to pevent/teat GvHD. We will take pecautions to detect these side effects and teat them befoe they become hamful. Pednisone/methylpednisolone might cause doseelated side effects, which will subside as you dosage is educed. If any of the following symptoms occus, epot them to you health cae povide. Incease in blood pessue Inceased swelling of the face (chipmunk cheeks), hands, o ankles due to sodium (salt) etention Dowage s hump (cuve in the back of the neck) Inceased appetite This might esult in weight gain. These medicines alte bain chemicals that can incease hunge and fluid etention. Steoid-induced diabetes This might esult fom high doses of these medicines, which may o may not equie teatment. If you cuently have diabetes, you medicines may need to be adjusted to contol you blood glucose. Vision changes, cataacts, o glaucoma Skin changes including acne, easy buising, thinning of the skin, stetch maks, and inceased sensitivity to the sun Excess hai gowth on the face, back, ams, and legs Mouth soes Stomach iitation o ulces Mood swings and depession Joint pain and muscle weakness Inceased isk of infection Inceased isk of developing osteopoosis Insomnia (difficulty sleeping o falling asleep) Please see the guidelines on the next page fo infomation on what you can do to help teat these symptoms.

136 What can I do to educe the side effects of steoid medicines? To educe toublesome side effects, you dosage might be deceased as soon as it is safe. In the meantime, thee ae some daily pactices that can help you pevent o decease the side effects of steoids. Possible Side Effect High blood pessue Inceased appetite What You Should Do This can be caused by inceased fluid etention. Take you medicine as pescibed, and educe the amount of salt and fluid you use. Also, measue you blood pessue and ecod it evey day. Ask you health cae povide what you blood pessue ange should be. Eat well-balanced, nutitious meals, and visit a dietitian egulaly to discuss excess weight gain and ways you can maintain a healthy lifestyle. Steoid-induced diabetes Vision changes, cataacts, glaucoma Acne If you fomely contolled you pe-existing diabetes without medicine, you might now need to take insulin o pills to contol diabetes. Visit an ophthalmologist yealy. Check with you BMT Team befoe getting a new pesciption fo glasses. Pactice good hygiene. Wash you face with an antibacteial soap to contol acne and educe the isk of infection. Avoid soaps with lanolin o cold ceam, which tend to clog poes. Acne might be contolled with medicines such as benzoyl peoxide (Cleaasil ). Acne subsides when you dosage is loweed. Steoids Easy buising Inceased sensitivity to the sun Inceased swelling of the face, hands, o ankles Mouth soes Avoid accidental bumps and cuts by taking exta safety pecautions befoe beginning any task. Avoid the sun wheneve possible. When outdoos, wea a sunblock with an SPF of at least 30. Repot any skin changes to you docto. Swelling is caused by fluid etention. Swelling will subside in 3 to 4 months if weight is maintained. Monito you weight and discuss any concens with you BMT Team. Pactice good oal hygiene to pevent mouth soes and oal infections. Repot any soes to you health cae povide. Visit you dentist evey 6 months, and notify you tansplant docto befoe any dental pocedues.

137 Possible Side Effect Stomach iitation, ulces Mood swings Inceased isk of infection Joint pain, inceased isk of osteopoosis Insomnia Excess hai gowth What You Should Do Take you medicine afte meals (with a full stomach) and use antacids (as diected) between meals. Repot any stomach poblems to you health cae povide. Ty elaxation techniques. You social woke can ecommend mateials that can help. Avoid anyone who might have an infection, and epot any signs o symptoms of infection to you docto o nuse. Steoids might mask a feve so it is impotant to epot any signs of infection to you BMT Team. Avoid gaining excess weight and include low-impact execises in you daily schedule to avoid a possible need fo joint eplacement. Talk to you health cae povide about taking steoids in the moning. Avoid napping too much duing the day and balance activity with est. To emove unwanted hai, use safe bleaching techniques o ceams. Please contact you BMT Coodinato befoe using. When should I call my health cae povide? Call you health cae povide ight away if you have any of these waning signs of infection: Feve of o F Sweats o chills Skin ash Pain, tendeness, edness, o swelling Wound o cut that won t heal Red, wam, o daining soe Soe thoat, scatchy thoat, o pain when swallowing Sinus dainage, nasal congestion, headaches, o tendeness along uppe cheekbones Nausea, vomiting, o diahea Flu-like symptoms (chills, aches, headache, o fatigue), o geneally feeling lousy Touble uinating: pain o buning, constant uge, o fequent uination Bloody, cloudy, o foul-smelling uine, o black, tay stools Iegula heatbeat o shotness of beath Sudden confusion Dizziness, light-headedness, o feeling faint Also contact you health cae povide if you have any othe symptoms that cause concen o if you have any questions. Pesistent dy o moist cough that lasts moe than 2 days White patches in you mouth o on you tongue This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Index #10344 Poduced by the Cente fo Consume Health Infomation Copyight The Cleveland Clinic Foundation. All ights eseved. Rev

138 Magnesium Common geneic and band names: Magnesium is available as many diffeent foms. Common names include: Magnesium L-lactate - Mag-Tab SR Magnesium Oxide - Mag-Ox 400 Magnesium Gluconate - Magonate, Magtate, Mag -G Magnesium Chloide - Chloomag, Mag Delay, Slow-Mag Why is magnesium pescibed? Magnesium is a necessay mineal used by you body to pomote pope gowth and good health. Magnesium supplements ae often pescibed to BMT patients when the magnesium levels in the blood ae lowe than nomal. Cetain medications that ae necessay fo BMT can cause low magnesium levels. How is magnesium taken? Magnesium is most commonly taken in the fom of tablets and capsules. In the hospital, magnesium can also be given intavenously. The dose of the medication is diffeent fo evey patient. It is most commonly given two o thee times pe day. The pesciption label tells you how much to take at each dose. Follow these instuctions caefully and ask you docto o phamacist to explain anything you do not undestand. Do not stop taking the medicine without consulting you docto. Ask you phamacist any questions you have about efilling you pesciption. Magnesium What special instuctions should I follow while using this dug? Magnesium can affect the absoption of cetain antibiotics such as cipofloxacin (Cipo ), levofloxacin (Levaquin ), and moxifloxacin (Avelox ). It is impotant to take these antibiotics at least 2 hous befoe o 6 hous afte magnesium. Magnesium should be taken with food to educe stomach upset. Cetain magnesium tablets and capsules can not be split, cushed, chewed, o opened. Check with you phamacist o docto if you ae having difficulty swallowing the tablets o capsules whole.

139 Be sue you always have enough medicine on hand. Check you supply befoe holidays o othe occasions when you might be unable to fill you pesciption. Keep all appointments with you docto and the laboatoy so you esponse to the dug can be monitoed. What should I do if I foget to take a dose? If you foget to take a dose, take it as soon as you emembe. If it almost time fo you next dose, skip the missed dose and continue you egula dosing schedule. Do not take a double dose. How should I stoe this medicine? Stoe magnesium tablets o capsules at oom tempeatue, away fom diect sunlight. What ae some possible side effects of this medicine? Diahea Upset stomach When should I call my health cae povide? Call you health cae povide if you: Have moe than 5 liquid stools (diahea) pe day. Have signs of dehydation including weakness, dizziness when standing fom a sitting position, deceased uine output, and confusion. Have any othe symptoms that cause concen. Keep magnesium out of the each of childen. Do not use this medication afte expiation on packaging. Index #14680 This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Poduced by Patient Education and Health Infomation Copyight The Cleveland Clinic Foundation. All ights eseved. Rev. 04/13

140 - Acyclovi Band name: Zoviax Class of dugs: Antivial Why is acyclovi pescibed? Acyclovi is used to pevent infections caused by viuses, especially the hepes vius. Hepes vius infections can affect the skin, bain, genitals (sex ogans), lips, and mouth ( cold soes o ulces). Although acyclovi will not cue hepes, it will help elieve the pain and discomfot faste, and will help the soes (if any) heal faste. Acyclovi is also used to suppess the vius that causes chickenpox and shingles. Allogeneic tansplant patients might develop these viuses due to the lage amount of immunosuppessive dugs they must take to pevent gaft-vesus-host disease (GvHD). Autologous tansplant patients emain on acyclovi pophylaxis fo 6 to 12 months following tansplant. They ae given a pesciption fo a 6-12-month supply when they ae dischaged fom the hospital. Acyclovi How is acyclovi taken? Acyclovi is geneally taken in the fom of tablets, capsules, o suspension liquid (with small paticles in it). It can be given intavenously in the hospital, if necessay. In ode to suppess the infection, acyclovi is geneally taken twice a day. It might be pescibed to take moe fequently if you develop an active vial infection. You pesciption label tells you how much to take at each dose and how often to take it. Follow these instuctions caefully and ask you phamacist o docto to explain anything you do not undestand. It is impotant that you take this medicine egulaly as pescibed. Do not stop taking it without talking to you docto.

141 What special instuctions should I follow while using this dug? Take acyclovi fo the entie time it is pescibed fo you. Take this medicine with o without food. Take it with food if it upsets you stomach. Be sue you always have enough medicine on hand. Check you supply befoe holidays o othe occasions when you might be unable to fill you pesciption. Shake the liquid well befoe use. Measue the coect amount using a specially maked measuing spoon. What should I do if I foget to take a dose? If you foget to take a dose, take it as soon as you emembe. Howeve, if it is almost time fo you next dose, skip the missed dose and continue you egula dosing schedule. Do not take a double dose. What stoage conditions ae necessay fo this dug? Stoe capsules, tablets, and liquid at oom tempeatue. DO NOT stoe this medicine in diect sunlight o in the bathoom, nea the kitchen sink, o in othe damp places. Heat o moistue might cause it to beak down. What ae the common side effects of this dug? Acyclovi might esult in any of the following side effects: Tiedness Lightheadedness Headache Nausea o vomiting Diahea Abdominal pain Skin eactions When should I call my health cae povide? Call you health cae povide ight away if you: Develop a skin eaction Expeience pesistent o sevee side effects Develop new symptoms afte stating this medicine Have any othe symptoms that cause concen Have any questions o concens Keep this medicine in a tightly sealed containe. Keep this and othe medicines out of the each of childen. Index #10242 This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Heaing Impaied (TTY) Assistance Copyight The Cleveland Clinic Foundation. All ights eseved. Poduced by the Cente fo Consume Health Infomaion Rev. 04/11

142 Antacids Common geneic and band names: These medicines can be divided into 3 goups. All ae used to pevent ulces and educe the acid in you stomach. 1. Antacids Maalox, Mylanta, Tums 2. Acid blockes ( Poton pump inhibitos ) Omepazole (Pilosec ), lansopazole (Pevacid ), esomepazole (Nexium ), pantopazole (Potonix ), abepazole (AcipHex ) dexlanspazole (Dexilant ) 3. Acid blockes ( H2 antagonists ) Famotidine (Pepcid ), cimetidine (Tagamet ), nizatidine (Axid ), anitidine (Zantac ) Why ae antacids pescibed? Antacids ae used to teat and pevent the ecuence of ulces and othe conditions whee the stomach poduces too much acid. Antacids wok by deceasing the amount of acid poduced in the stomach. Histamine (H2) ecepto blockes ae a type of commonly pescibed antacid that pevents the elease of acid into the stomach. If you ae taking steoids such as pedisone, dexamethasone, o methylpednisolone you docto may pescibe a daily antacid o H2 blocke to pevent indigestion. How and when should antacids be used? Many insuance companies cove only selected acid blockes. Discuss this with you BMT Team to ensue that the pope substitution is made, if necessay. Antacids Pilosec, Pevacid, and Nexium come as delayed-elease capsules and should be taken on an empty stomach at bedtime (at least 2 hous afte meals). Pepcid is available as an intavenous solution (deliveed into you vein in the hospital only), tablets, chewable tablets, and suspension liquid (with small paticles in it). Shake the liquid fom befoe each use. Measue the liquid fom with a specially maked measuing spoon to measue each dose accuately. Pepcid can be taken with food. If you have difficulty swallowing capsules, you can open Pevacid o Nexium capsules and spinkle the contents on food o in a dink. Howeve, do not chew o cush the contents inside the capsule. Do not open o chew Pilosec capsules. Swallow them whole with a full glass of wate. Antacids ae usually taken once a day

143 at bedtime o twice a day in the moning and at bedtime. You pesciption label tells you how much to take at each dose. Follow these instuctions caefully, and ask you docto o phamacist to explain anything you do not undestand. Do not stop taking the medicine without consulting you docto. Ask you phamacist any questions you have about efilling you pesciption. What special instuctions should I follow while using this dug? Keep all appointments with you docto so you esponse to the dug can be monitoed. Pepcid might cause dizziness. Do not dive, opeate machiney, o paticipate in any potentially dangeous activity until you know how the medicine affects you. Do not smoke. Cigaette smoking can decease the effectiveness of antacids. Ask you docto fo advice on how to quit smoking. If you ae also taking itaconazole (spoanox),take you antacid medicine at least 2 hous afte taking the itaconazole dose o as diected. When should I call my health cae povide? Call you health cae povide ight away if you: Develop a skin ash o skin iitation Have any othe symptoms that cause concen What should I do If I foget to take a dose? Take the missed dose as soon as you emembe. If you miss 2 o moe doses of antacids in a ow, contact you health cae povide fo advice. What stoage conditions ae necessay fo this dug? Keep antacids in a tightly sealed containe. Stoe tablets at oom tempeatue, away fom diect sunlight. Stoe liquid antacids in the efigeato, but do not allow it to feeze. Discad liquid that is olde than 30 days. Keep antacids out of the each of childen. Cabonated beveages might cause futhe stomach iitation. You might want to avoid cabonated beveages while taking antacids. If you ae also taking cipofloxin, take you cipofloxin two hous befoe o six hous afte you antacid. What ae the common side effects? What can I do about them? Although side effects ae not common when antacids ae taken popely, they can occu. Some side effects might include: Headache This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Index #10424 Dizziness Diahea o constipation Call you health cae povide if these symptoms ae pesistent o sevee. Poduced by the Cente fo Consume Health Infomation Copyight The Cleveland Clinic Foundation. All ights eseved. Rev

144 Cipofloxacin Band name: Cipo How is cipofloxacin pescibed? Cipofloxacin is mainly used to pevent o teat bacteial infections called gam-negative oganisms. These infections include uinay tact infections; acute sinusitis; lowe espiatoy, skin, bone, and joint infections. Allogeneic tansplant patients might develop infections because thei immune systems ae suppessed by eithe chemotheapy o by the immunosuppessive medicines they must take to pevent gaft vesus host disease. Autologous patients who eceive chemotheapy to assist in the mobilization of thei stem cells fo collection will be on cipofloxacin when thei blood counts ae low. How is cipofloxacin taken? Cipofloxacin is geneally taken in the fom of tablets in 250 mg, 500 mg and 750 mg doses. In the hospital, this medicine can be given intavenously. A liquid fom is available if you have difficulty swallowing tablets. It is usually taken twice a day. This medicine woks best when thee is a constant amount of it in the bloodsteam. Cipofloxacin must be taken fo the entie duation of teatment in ode to achieve the best esults. It is impotant that you take this medicine egulaly as pescibed. Do not stop taking it without talking to you docto fist. Cipofloxacin The dose of this medicine will be diffeent fo each patient. The pesciption label tells you how much to take at each dose and how often to take it. Follow these instuctions caefully, and ask you phamacist o docto to explain anything you do not undestand. What special instuctions should I follow while using this dug? Take this medicine with a full glass of wate. Limit caffeine while taking this medicine. Its use might cause nevousness, shakiness, and fast heatbeat.

145 BEFORE you docto pescibes this medicine, tell him o he if you have eve had any unusual o allegic eactions to quinolone medicines such as Levaquin, Tequin, and Avelox. If you ae taking medicines called anticoagulants, such as wafain (Coumadin ), to pevent blood clots, it is impotant to tell you docto. Cipofloxacin can incease the effect of the anticoagulant, so it might be necessay to have blood tests moe fequently. Because of absoption, it is impotant to take you dose of cipofloxacin at least 2 hous befoe o 6 hous afte daiy poducts o taking antacid, calcium, magnesium, zinc, o ion. Keep taking cipofloxacin fo the full time of you teatment. Be sue you always have enough medicine on hand. Check you supply befoe holidays o othe occasions when you might be unable to fill you pesciption. This medicine might make you skin moe sensitive to sunlight. Use a sunsceen when you ae outdoos. Avoid sunlamps and tanning beds, and wea potective clothing. What should I do if I foget to take a dose? If you foget to take a dose, take it as soon as you emembe. Howeve, if it is almost time fo you next dose, skip the missed dose and continue you egula dosing schedule. Do not take a double dose. What stoage conditions ae necessay fo this dug? Stoe the tablets at oom tempeatue. The liquid can be stoed at oom tempeatue o in the efigeato. DO NOT stoe the tablets in diect sunlight o in the bathoom, nea the kitchen sink, o in othe damp places. Heat o moistue might cause them to beak down. Keep this medicine in a tightly sealed containe. Keep this and othe medicines out of the each of childen. What ae the common side effects of this dug? Cipofloxacin might cause any of the following side effects: Headache Restlessness Diahea If you have diahea, dink moe fluids to eplace fluid lost in you stool and to pevent dehydation. You can become dehydated quickly. Signs of dehydation might include weakness, dizziness when standing fom a sitting position, deceased uine output, and confusion. If any of these symptoms occu, tell you nuse coodinato. Also notify you nuse coodinato if you have moe than 5 liquid stools daily. Nausea and/o vomiting - Tell you nuse coodinato if you symptoms pesist. Skin ash Tell you nuse coodinato as soon as you notice a ash. If it is sevee, and you also have beathing poblems, call This might be a sign of an allegic eaction. When should I call my health cae povide? Call you health cae povide ight away if you: Have tightness in the chest o touble beathing Have vaginal itching

146 Have a fuy o white coating on you tongue. Have a skin ash o itching Have moe than 5 liquid stools (diahea) pe day Have signs of dehydation including weakness, dizziness when standing fom a sitting position, deceased uine output, and confusion Expeience pesistent o sevee side effects Develop new symptoms afte stating this medicine Have any othe symptoms that cause concen Have any questions o concens Notes Cipofloxacin

147 Notes This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Index #10992 Poduced by the Cente fo Consume Health Infomation Copyight The Cleveland Clinic Foundation. All ights eseved. Rev. 04/13

148 Contacting the Team Afte Tansplant You have just completed an intense peiod in the hospital fo blood o maow cell tansplantation. You ae pobably excited about being able to leave the hospital because thee's no place like home. You might also feel uneasy about leaving the constant suppot and supevision you've had duing you hospitalization. Please emembe two things: 1. The Tansplant Team would not dischage you unless you wee eady to leave the hospital. 2. Suppot does not stop hee. Doctos, nuses, social wokes, dietitians, financial counselos, and othes ae available to help you. Ou goal is to keep you out of the hospital and fee of complications. Please ask questions You ae the best judge of how you feel. This simple ule is essential afte you ae dischaged: When in doubt, check it out. We ae hee to help you. You questions ae ou concen. Please see the list of phone numbes on the back of this page. You and you suppot goup of family and fiends ae the most impotant membes of the Tansplant Team. Follow-up appointments You will be monitoed closely in the outpatient setting. You will eceive detailed instuctions fo you follow-up appointments, which ae designed to meet you specific needs. Feel fee to ask questions The BMT Team wants to seve you and cae fo you unique health needs in the best possible way. Membes of the BMT Team ae always available. Please feel fee to talk to the Team membes about any medical o pesonal questions and concens. In ode to avoid any miscommunications, we will not espond to electonic media communication such as Facebook. Please call o discuss diectly with you BMT Team Contacting the Team Afte Tansplant

149 If you have questions at any time, please call you nuse coodinato: Lisa Caaway, R.N o ext Page: , ask fo page #81453 Kelly Cheni, R.N o ext Page: , ask fo page #22539 Chistina Feao, R.N o ext Page: , ask fo page #24729 Babaa Gedeon, R.N o ext Page: , ask fo page # Gina Geen, R.N o ext Page: , ask fo page #25619 Jamie Stan, R.N o ext Page: , ask fo page #23199 Afte Hous o on Weekends: Call and ask fo the Hematology/Oncology fellow on call. Note: since you will be diecting you questions o concens to you BMT nuse coodinato o the fellow on call, please do not call the G110 o any othe nusing unit. If you ae unable to each the Hematology/Oncology fellow, please page you nuse coodinato. In an Emegency: Call o go to the neaest Emegency Depatment. If time allows, bing a list of you cuent medicines and the name and phone numbe of you BMT docto o nuse coodinato. Index #10432 This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Poduced by the Cente fo Consume Health Infomation Copyight The Cleveland Clinic Foundation. All ights eseved. Rev. 08/20/2014

150 Nutition Afte Blood & Maow Tansplant Good nutition is a vey impotant pat of you ecovey. It helps you body esist infection and epai tissue damage caused by chemotheapy and/o adiation theapy. Losing inteest in food afte a long illness is to be expected. Some of the side effects you might have expeienced while in the hospital may continue even afte you go home. These side effects may include nausea, vomiting, loss of appetite, taste changes, and a soe o dy mouth. With these symptoms, it may be difficult fo you to imagine eating high-caloie, nutient-ich meals. Nutition supplements When you ae unable to eat a well-balanced diet, we ecommend you ty ove-the-counte nutition supplements to meet you nutitional needs, unless othewise instucted. Howeve, it is impotant to check the labels fo the specific vitamin, mineal o nutient levels. They can vay fom diffeent manufactues. Examples of nutition supplements ae Ensue, Boost, Resouce, Canation Instant Beakfast, Boost bas and Boost puddings. If you have diabetes, Glucena and Boost Glucose Contol ae options. Seveal discount stoes and dug stoes have nutitional supplements packaged unde thei pivate label. Please check with the dietian to detemine if the paticula poduct will meet you needs. Multivitamins We ecommend you take a daily multivitamin, afte you ae dischaged. You can take childen s chewable multivitamins twice a day if bette toleated. Excess doses of some vitamins and mineals might be unsafe at this time. Fo instance, it is impotant to choose vitamins that do not contain ion o hebs. Also, due to you numeous ed blood cell tansfusions, additional ion supplementation is unnecessay. You body does not eliminate ion. If you have questions egading you pefeed multivitamin, bing you labeled vitamin bottle to you appointment fo you docto s appoval. Follow food safety guidelines when choosing any of the following foods: Calcium and Phosphous Some of you medicines might deplete calcium, which is impotant fo maintaining bone stength. When the staff eviews you medications and labs, they will infom you if this is likely to be a poblem. Phosphous is a mineal that helps to stengthen bones. Some tansplant patients often need additional phosphous. Unless you ae following a special diet, we ecommended you eat a diet high in calcium and phosphous. Nutition Afte Blood & Maow Tansplant

151 Daiy poducts high in calcium and phosphous include: Ceame (pasteuized) Milk (skim, low-fat, whole) Natual cheese, pocessed cheese (pe-packaged) Cottage cheese, icotta cheese Yogut (egula, fozen o Geek) Pudding, custad Eggnog Rice milk, calcium fotified Ice ceam o ice milk Ceam soup Buttemilk Evapoated milk Powdeed milk Soy Milk Non-daiy poducts high in calcium include: Calcium-eniched fuit juice Roasted almonds Died peas and beans (cooked thooughly)* Tofu (calcium eniched, cooked thooughly) Geens (kale,collad, mustad, tunip*) Canned salmon with soft bones Bok choy Calcium fotified ceeal Sadines Spinach * a good souce of phosphous Additional foods with significant amounts of phosphous: Biscuit Beef o veal -lean only Ceeal - ban Cheese-Ameican, chedda, mozzaella, Swiss, Povolone Chicken -white meat Cheese - icotta Cheese - cottage Died beans and peas Fish - Pollock, walleye, swodfish, cod, halibut, salmon, tuna Ganola Milks Milkshake Nuts, most vaieties Oatmeal Peanut/nut buttes Pok loin Potato/baked with skin Pudding/custad Seeds - sunflowe o pumpkin Soybeans Soy milk Totillas Tuna, canned in wate Tukey Veggie o soy patty Waffle o pancake Yogut You docto might ecommend calcium supplements such as Tums, Oscal +D, o Caltate. Calcium supplements with vitamin D ae essential fo those who equie long-tem steoid theapy, such as pednisone. Steoids cause bone loss, called osteopoosis. Taking these supplements, as well as execising, can help minimize bone loss and pevent factues. An appointment with a heumatologist may be advised to monito you bone density.

152 Potassium and magnesium Antibiotics, diahea, and vomiting can cause electolyte (mineal) imbalances. Even afte you hospital dischage, it is common to equie potassium and magnesium supplementation, which can be given by pill o intavenous infusion. Potassium is an electolyte (mineal) that maintains nomal fluid balance, suppots cell integity, facilitates the making of potein, assists in the tansmission of neve impulses, and the contaction of the heat and othe muscles. Fuit Souces of potassium include: Vegetables high in potassium include: Apicots Avocados Bananas Dates, figs Honeydew/cantaloupe Kiwi Nectaines Oanges Oange Juice Peaches Punes Pune juice Raisins Atichokes Avocado Bamboo shoots Beets Bussel Spouts Chad Chick peas Died Beans Escaole Kohlabi Pasnips Pumpkin Rutabaga Spinach Squash Sweet Potatoes Tomatoes Tomato juice V-8 Juice White Potatoes Magnesium is also an electolyte (mineal) that is involved in bone minealization, building of potein, tansmission of neve impulses, and nomal muscula contaction. Significant souces of magnesium include: Chocolate Halibut Legumes Leafy geen vegetables Meat Milk Nuts Peanut butte Milk Nuts Peanut Butte Spinach Tofu Tuna Whole gain ceeal Nutition Afte Blood & Maow Tansplant Sodium Sodium is an electolyte essential fo wate egulation and electical activities of the body, such as neve impulse tansmission and muscula contaction. Ou diets aely lack sodium. A healthy peson equies about 200 mg of sodium daily, but the aveage sodium intake is estimated to be 6,000 to 18,000 mg daily. Excessive sodium intake can lead to high blood pessue (hypetension)

153 and fluid etention. Reduce you sodium intake to less than 2,300 mg each day. Notes Since allogeneic tansplant ecipients might aleady be expeiencing hypetension o fluid etention/swelling (edema) caused by steoids such as pednisone, tacolimus (Pogaf ), o cyclospoine (Neoal ) it is cucial to avoid a diet high in sodium. Alcohol Afte you tansplant, you might have deceased live function due to the effects of high-dose chemotheapy, gaft-vesus-host disease (GvHD), o metabolism of medicines. Since the live metabolizes alcohol, avoid all alcoholic beveages. Alcohol can cause malnutition by attacking the stomach lining, leading to malabsoption and excetion of many nutients. Befoe dinking bee, wine, o othe alcoholic beveages, ask you BMT docto. Index 4382 This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Poduced by Nutition Theapy Depatment Copyight the Cente fo Consume Health Infomation, The Cleveland Clinic Foundation. All ights eseved. Rev.03/31/2014

154 Food Safety Guidelines Please eview the nutition section of the Taussig binde My Jouney given to you Fo autologous tansplant patients While thee ae no estictions on food you ae allowed to eat, choosing safe foods is impotant duing the fist month afte dischage. Fo allogeneic tansplant patients Food safety is impotant in peventing infections while you ae taking immunosuppessive medicine and while you cental line is in place. You should always pactice food safety guidelines. You cannot taste, see, o smell most bacteia that cause food-bone illness o infection. If you ae not sue about a food s safety, thow it out. You should choose foods that do not upset you stomach. You might still have some nausea/vomiting and diahea afte you ae dischaged. Soft, bland foods can be moe gentle on you stomach, wheeas spicy foods will pobably make an upset stomach wose. If you ae still having diahea afte dischage, avoid milk poducts. Chemotheapy can cause some people to become tempoaily lactose intoleant. Below ae two categoies of food. 1. High isk Foods you should be awae ae moe isky while you ae immunosuppessed 2. Safe Foods you can eat any time Food Goup Safe Foods High Risk Foods to Avoid Food Safety Guidelines Fuit Gains Cooked, fozen, fesh and died fuit Canned fuit Pasteuized fuit juices Well-washed fuit (afte dischaged) Washed and peeled fuit All cooked gains (i.e. beads, cackes, muffins, pancakes, baked goods, etc.) All cooked and eady-to-eat ceeal Fesh-squeezed, unpasteuized fuit juices. Had-to-clean fuits such as aspbeies and blackbeies Raw, uncooked gain poducts (i.e. whole oats, wheat gem)

155 Food Goup Safe Foods High Risk Foods to Avoid Meat and meat substitutes Milk and milk poducts Vegetables Well-done meats, well-cooked poulty, cooked fish, and seafood (See the Food Safety section elated to the appopiate meattempeatues. Packaged luncheon meats and luncheon meats/hotdogs cooked until steaming hot. Well-cooked eggs (whites and yolk fim, including had-boiled eggs) Cooked tofu (To cook, cut tofu into 1-inch o smalle cubes, and boil fo at least 5 minutes in wate o both befoe eating o using in ecipes) Cooked nuts (nuts in baked poducts), peanut butte Pasteuized daiy poducts (milk, cheese, ceam, butte, yogut) Packaged cheese with pasteuized milk (mild/medium chedda, mozzaella, Swiss, pamesan) Packaged ice ceam/bas, fozen yogut, shebet, homemade milkshakes (following food safety guidelines) Pasteuized whipped topping- dy, efigeated, and fozen Commecial pasteuized eggnog Pasteuized vegetable juices Cooked fozen, fesh, and canned vegetables Well-washed aw vegetables (afte dischage) Raw and undecooked meat, poulty, pok, wild game, fish (including cold smoked salmon, lox, sushi, aw oystes and aw clams and pickled fish), and seafood Undecooked o aw eggs All meats fom the deli counte (including had, cued salami in natual wap), unde cooked hotdogs, and pocessed meats Undecooked o aw tofu Unoasted nuts, oasted nuts in the shell. All miso and tempeh poducts Pepaed foods fom the deli counte (i.e. seafood salad, tuna salad) Unpasteuized daiy poducts (milk cheese, ceam, butte, yogut) Unpasteuized cheeses o cheese containing molds (bleu, stilton, gogonzola, oquefot) Shap chedda, bie, feta, camembet, fame s cheese, and often mexican-style cheese like queso blanco fesco Cheese fom the deli counte, cheese with chili peppe o uncooked vegetables Soft seve ice ceam o yogut Unefigeated ceam o custad bakey poducts e. g. ceam pie, custad filled donut, ceam puff, etc. unless shelf stable Eggnog unless pasteuized Fesh, aw mushooms Fesh-squeezed, unpasteuized vegetable juices Raw hebs, died hebs, and spices (i.e. peppe, oegano) not cooked into a ecipe Salads fom salad ba, deli o estauants (only while in the hospital) Pepaed salads fom the deli counte (i.e. potato salad, macaoni salad) Raw spouts - alfalfa, clove o mung bean

156 Food Goup Safe Foods High Risk Foods to Avoid Entees Well-cooked entees, cooked all the way though to the appopiate tempeatue (See Food Safety guidelines fo cooking tempeatues.) Cooked soups Foods containing aw o undecooked meat o meat substitutes (i.e. undecooked eggs in Fench Toast, omelets and salad dessing) Any uncooked o undecooked soup Beveages Miscellaneous Tea made with boiling wate Commecially bottled distilled, sping, and natual wates Tap wate (This is usually safe if fom a city wate supply. If in doubt, boil fo at least one minute.) Canned, bottled, powdeed, beveages Instant and bewed coffee o tea, cold bewed tea made with boiling wate` Commecially packaged bewed hebal tea Nutition supplement beveages, packaged o canned. Packaged chips (i.e. potato chips, con chips, petzels, popcon) Salt, ganulated suga, bown suga Pasteuized honey Jam, jelly, syup (efigeated afte opening) Oil, shotening, and efigeated lad Magaine, butte, and cooked gavies/sauces Commecially packaged condiments (efigeated afte opening) Pickles, pickle elish, olives (efigeated afte opening) Candy, gum Mate tea (unless pasteuized) Cold bewed tea with wam o cold wate Well wate (unless tested yealy fo colifoms o boiled fo at least one minute) Unpasteuized bee (i.e. home-bewed and cetain micobewey bees) Raw o unpasteuized honey Yeast, including aw, uncooked bewe s yeast (Avoid all contact with aw yeast, and do not make bead poducts.) Fesh salad dessing made with aw eggs,like Caesa, unacceptable cheeses (See Milk and Milk Poducts section.), o aw hebs and spices. All moldy, outdated food poducts All estauant/fast foods,deli and vendo foods (only while in the hospital) All deli foods unless cooked until steaming hot Raw cookie dough Salsa in the efigeated section Food Safety Guidelines

157 Shopping q Avoid puchasing foods fom the deli unless cooked until steaming hot. q Check the expiation date and do not buy outdated food. q Do not puchase bulging, dented o usted cans. q Avoid any eggs with cacked shells. q Choose fesh poduce with no mold o buises. q Do not puchase items fom the bulk bins unless the item is individually wapped e.g. candy o unless the food is to be cooked. q Do not consume the food/beveage samples in the stoe. q Check that the tampe esistant seals have not been destoyed. q Make the gocey stoe the last stop befoe going home. Do not leave goceies in a hot ca. q Refigeate the necessay items when you aive home. Cleaning Most food-elated illnesses ae caused by impope food handling. You can educe you chances of getting food-bone illnesses o infections by popely cleaning, handling, and cooking foods, as well as contolling food tempeatue. Keeping food and food pepaation aeas clean is an impotant pat of peventing food fom being contaminated. Keep shelves, counte tops, efigeatos, feezes, utensils, sponges, towels, and othe kitchen items clean. In addition: q Wash you hands with soap befoe handling food. Use wam wate and wash with soap fo 15 to 20 seconds, including all aeas of the hands. Dy them with a clean cloth o pape towel, and tun off the faucet with a towel o pape towel. q q q q q q Wash you hands immediately afte pepaing aw foods. Use only clean utensils and wok sufaces. Can openes should be washed afte each use. Use a clean vegetable scubbe to assue all soil has been emoved fom the oute skin o peel. It is impotant to emove bacteia fom the outside and avoid tansfeing it to the inside flesh. Be especially caeful when cleaning lettuce leaves. Dit o insects can be on the inside between the leaves. Be sue to wash each leaf well. Rinse and clean the tops of cans befoe opening, especially beveage cans. (Avoid dinking fom beveage cans.) Do not stoe food supplies unde the sink. Avoid placing the chemicals and cleaning solutions nea food supplies. Food handling q Cutting boads Bacteia on aw foods can contaminate cooked foods if you use the same cutting boad. To pevent contamination, use sepaate cutting boads fo aw and cooked foods o sanitize the cutting boads thooughly afte each use. Cutting boads can be sanitized by fist washing the boad with wam, soapy wate, then washing it again with a solution of 1 tablespoon of bleach to 4 cups of wam wate. Let this solution sit on the boad fo 2 minutes, then inse the boad with clean, hot wate. Avoid using plastic cutting boads, as they tend to habo bacteia.

158 q Thawing foods Follow safe food thawing guidelines published by the U.S. Depatment of Agicultue. The guidelines state that thee ae 3 safe ways to defost you food, which ae: In the efigeato Afte thawing in the efigeato, gound meat and poulty should emain safe fo an additional day o 2 befoe cooking. Red meat should emain safe fo an additional 3 to 5 days. Foods can be efozen without cooking if they ae defosted in the efigeato. In cold unning wate When thawing food in cold wate, be sue the food package o bag does not leak. Bacteia fom the suounding envionment o ai could be intoduced into the food.it is necessay to check the tap wate fequently to be sue it stays cold. Also, it is ecommended to change the wate evey 30 minutes until the meat poduct is thawed. Foods that ae thawed in cold tap wate should be cooked befoe efeezing. In the micowave When defosting food in the micowave, emove the oiginal packaging. It is impotant to cook the food immediately because some aeas of the food might begin to cook while thawing. Foods thawed in the micowave should be cooked befoe efeezing. Cooking Many bacteia that cause food-bone illnesses ae destoyed by heat, so thoough cooking helps to pevent food-bone illnesses. Eggs and meat ae especially pone to contamination. Foods can be cooked fom a fozen state. Allow about an additional 50% time longe to cook the fozen meat o fozen poulty. Eating away fom home Food Safety Guidelines q q q q q q Avoid buffets, food vendos, pot lucks and any food sevice o steet vendo whee thee is a question about safe food handling and pepaation. When able, ty odeing individually packaged foods, condiments, beveages, seasonings, etc. to minimize the isk of bacteial contamination. You can ask the waite/waitess how the food will be pepaed. Request feshly made food athe than an item sitting unde a heat lamp. Ode food to be cooked until well done. If foods ae not well cooked, especially the meats, send them back. Additional guidelines ae available at

159 Notes Index This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Poduced by Nutition Theapy Depatment Copyight The Cleveland Clinic Foundation Cente fo Consume Health Infomation. All ights eseved. Rev.06/13

160 Resuming Sexual Activity Sexuality is an impotant pat of a loving elationship. Kissing, hugging, and touching ae acts of love that may be esumed afte you ae dischaged fom the hospital. Will my sexual desie change afte my tansplant? You might notice a decease in sexual desie afte you tansplant. Factos that can have an impact on sexual desie include homonal changes, excessive fatigue, cance pain o teatment, o changes in you self-image. As you homone levels etun to nomal and as you egain you stength and enduance, you sexual desie should etun to nomal. If you have any concens about the changes in you sexual desie, please discuss them with you docto, nuse, o social woke. When can I have sex again afte my tansplant? We ecommend having a platelet count of at least 50,000 pe cubic millimete befoe engaging in sexual intecouse. Because you immune system is now weake than nomal, you should avoid sexual pactices that could esult in oal exposue to feces. To educe you isk of exposue to sexually-tansmitted infections such as CMV, HIV, hepatitis, and hepes, and because some medications can be passed to you patne duing sexual activity, we ecommend the use of latex condoms. Will I have to take homones afte my tansplant? In women, chemotheapy and adiation theapy cause changes in ovaian function and deceased homone levels. Because of these changes, you may eceive a pesciption fo estogen supplements afte you tansplant. You pimay cae povide can discuss you specific estogen teatment with you. Resuming Sexual Activity In addition, some women stop having thei menstual cycles afte a tansplant and might benefit fom homone eplacement theapy to elieve menopausal symptoms.

161 What can I do to teat vaginal dyness? Some women might expeience vaginal dyness afte tansplant because of the changes in homone levels. Wate-soluble lubicants such as K-Y Jelly o Astoglide can be useful duing intecouse to decease the discomfot of vaginal dyness. Communicate with you patne Talk to you patne. Tell you patne how you feel, especially if you have mixed feelings about sex afte you tansplant. Encouage you patne to communicate with you, especially if you notice changes in you patne s esponsiveness. Communicating with you patne can help you both bette undestand you feelings and desies. Take time fo intimacy If you health cae povide has told you to limit you sexual activity, o if you ae not in the mood fo intecouse, emembe to take time fo intimacy with you patne. Being intimate does not equie having intecouse. Love and affection can be expessed in many ways. Enjoy you time togethe. You can take long, omantic walks, have candlelit dinnes, o give each othe back ubs. Some men might expeience a deceased o absent spem count afte cance teatment. Some women stop having thei menstual cycles afte a tansplant and begin menopause. Howeve, do not assume you ae unable to fathe a child o get pegnant unless this has been medically veified. You may equest testing fom you doctos. Concens about being biologically able to have childen might be distessing, so it might help to seek counseling with you BMT social woke. It might help you to talk about fetility loss and its impact on you and you patne o futue patne. If you do wish to stat a family afte cance teatment, talk to you health cae povide about the timing of a pegnancy afte teatment. Impotance of bith contol Even though infetility (the inability to have childen) might occu afte cance teatment, it is still possible to get pegnant, so both men and women should use bith contol afte teatment. Bith contol is impotant afte you tansplant because the medicines you will be taking might be hamful to a developing fetus. Follow you health cae povide s ecommendations on the appopiate method of bith contol to use. Fo moe infomation about sexuality afte you tansplant, please ead the booklet, "Sexuality and Cance" povided by the Ameican Cance Society. A copy of this booklet is available on G110 o fom you Tansplant Team. Will I be able to have childen afte my tansplant? The chemotheapy and adiation theapy you eceived as you pepaative egime can affect you ability to have childen (fetility) in the futue. Index #10248 This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Poduced by the Cente fo Consume Health Infomation Copyight The Cleveland Clinic Foundation. All ights eseved. Rev.02/27/2014

162 Taking You Blood Pessue (Twice a Day ) You will need to have you own blood pessue cuff to check you blood pessue twice a day. Thee ae many vaieties, so it is impotant that you undestand how to use yous. You will need to bing you blood pessue cuff to the hospital pio to dischage fo instuction on you paticula model. What is blood pessue? With each beat of the heat, blood is pumped out of the heat into the blood vessels, which cay the blood thoughout the body. Blood pessue is the measuement of the pessue o foce inside you blood vessels (ateies) with each beat of the heat. Blood pessue is detemined by the pumping action of the heat, ability of the atey walls to stetch, and the amount of blood in the blood vessels. How is blood pessue ecoded? Blood pessue is witten as two numbes, such as 120/80. The fist numbe is the systolic pessue. Systolic pessue is the pessue in the ateies when the heat beats and fills the ateies with blood. The second numbe is the diastolic pessue. Diastolic pessue is the pessue in the ateies when the heat ests between beats. What is a nomal blood pessue eading? Type of blood pessue eading Ideal blood pessue High blood pessue Low blood pessue Taking You Blood Pessue Systolic 120 Ove 140 Unde 90 Diastolic 80 Ove 90 Unde 50 These ae geneal guidelines fo nomal blood pessues. You baseline blood pessue might be highe o lowe, so it is impotant to watch fo inceases o deceases fom you baseline blood pessue.

163 If you have eceived a tansplant fom a dono, (allogeneic tansplant), you may be taking cetain medications, such as Neoal o Pogaf, that may cause high blood pessue. It is not unusual fo tansplant patients to take medications to lowe blood pessue (anti-hypetensives) When to call Call you health cae povide if you have Consecutive diastolic blood pessue eadings that emain in the mid-90s o highe ove a 24- to 36-hou peiod. One systolic eading > 160 o < 90 One diastolic eading > 110 o < 50 What should I do if I have high blood pessue? Hypetension (high blood pessue) Most of the time thee ae no symptoms. People can develop heat disease and kidney poblems without knowing they have high blood pessue. That is why it is so impotant to check you blood pessue twice a day until instucted othewise. If you have a sevee headache, confusion, changes in you vision o nosebleeds, contact you docto immediately o go to the emegency oom The goal of theapy, is to lowe you blood pessue. If you have high blood pessue: Eat healthy foods that ae low in salt and fat. Lose weight, if you ae oveweight. Limit alcohol to no moe than 1 dink (bee, wine, o whiskey) each day, if you docto allows alcohol. Execise egulaly. Quit smoking. Take high blood pessue medicine if you health cae povide pescibes it, and follow you health cae povides diections caefully. Have egula blood pessue checks, and check you own blood pessue at home as ecommended by you health cae povide. Hypotension (low blood pessue) Low blood pessue, o hypotension, occus when blood pessue duing and afte each heatbeat is much lowe than usual. This means the heat, bain, and othe pats of the body do not get enough blood. Causes: Dehydation Medications Sudden change in position/postue Symptoms: Bluy vision Confusion Dizzines Fainting (syncope) Light-headedness Sleepiness Weakness Fast heat ate Call you docto immediately o go to the emegency oom if you have any of the following symptoms: Black o maoon stools Chest pain Dizziness, light-headedness Fainting Feve highe than degees F Iegula heatbeat Shotness of beath If you have low blood pessue, you docto may ecommend cetain steps to pevent o educe you symptoms. This may include: Avoiding alcohol Avoiding standing fo a long time Dinking plenty of fluids Getting up slowly afte sitting o lying down

164 Using compession stockings to incease blood pessue in the legs Avoid hot showes o excessive heat A membe of the BMT Team will be checking you at you follow-up appointment, a few days afte you hospital dischage, fo low blood pessue (hypotension) and othostatic hypotension. Othostatic hypotension can be bought on by a sudden change in body position, most often when shifting fom lying down to a standing position. This type of low blood pessue usually lasts only a few seconds o minutes. We will give you IV fluids if we find you have low blood pessue o othostatic hypotension. When should I check my blood pessue? Follow you docto s instuctions fo when and how often to check you blood pessue. You blood pessue is usually lowest in the moning afte you wake up fom sleeping and is lowe when lying down than when sitting o standing. Keep in mind that cetain factos can cause blood pessue to tempoaily ise. Blood pessue nomally ises as a esult of: Stess, emotional upset Smoking Cold tempeatues Execise A full stomach Full bladde Caffeine Cetain medicines Avoid any of these factos you can when taking you blood pessue. Measue you blood pessue in the moning and evening, and ecod it on the Daily Recodkeeping Log. Please bing this log with you to all of you follow-up appointments. How to Take You Blood Pessue It is impotant to lean the pope technique fo taking you blood pessue. With epeated pactice, you will be able to detemine an exact blood pessue eading. Inflation Bulb Manual blood pessue monito Ai-elease Valve Am Cuff Stethoscope Pessue gauge A. Positioning 1. Find a quiet place. You will need to listen fo you heat beat. 2. Sit in a chai next to a table that s at a height close to the level of you heat. Taking You Blood Pessue

165 3. Relax fo a few minutes befoe stating. 4. Roll up the sleeve on you left am o emove any tight-sleeved clothing, if needed. (It s best to take you blood pessue fom you left am, if possible. The left am is ecommended because the lagest atey coming fom the heat, called the aota, is on the left side of the body.) 5. Rest you left am comfotably on the table, with you palm facing up. 6. Sit up staight with you back against the chai, legs uncossed. 7. Rest you foeam on the table with the palm of you hand facing up B. Locate you pulse Locate you pulse by lightly pessing you index and middle finges slightly to the inside cente of the bend of you elbow. Hee you can feel the pulse of the bachial atey. C. Secue the cuff 1. Wap the cuff aound you uppe am. The lowe edge of the cuff should be about 1 inch above the bend of you elbow. Pope positioning of the manual monito You am should be esting on the table with you palm up. 2. Place the stethoscope s cicle sound piece inside the cuff, ove the pulse felt in you uppe am. 3. Fasten the staps on the cuff tight enough to keep the sound piece in place. 4. Make sue the cuff is not too tight. You should be able to place 2 finges between you am and the cuff. 5. Place the eapieces of the stethoscope into you eas. Tilt the ea pieces slightly fowad to get the best sound. D. Closing the aiflow valve and inflating the cuff 1. Hold the pessue gauge in you left hand and the bulb in you ight (as shown above). 2. Close the aiflow valve on the bulb by tuning the scew clockwise until you can t tun in futhe. Make sue the valve is not closed too tightly, so that it can be opened easily with 1 hand. 3. Inflate the cuff by squeezing the bulb with you ight hand. You might hea you pulse in the stethoscope. 4. Watch the gauge. Keep inflating the cuff until the gauge eads about 20 to 30 points (mm Hg) above the last systolic (fist) eading. At this point, you should not hea you pulse in the stethoscope. Inflating the cuff inceases the pessue inside the cuff above the pessue in you am. This tempoaily stops the blood flow. E. Deflating the cuff Keeping you eyes on the gauge, slowly elease the pessue in the cuff by tuning the aiflow valve counte clockwise. Allow the aow on the gauge to move at a slow, steady pace. This pemits time fo you to get a eading. F. Detecting measuements 1. As the pessue falls, the blood begins to flow, causing a beating sound. 2. When you hea the fist clea beating sound, memoize the eading on the gauge. This eading is you systolic pessue. 3. Keep listening while the beating sound changes in loudness. 4. Remembe the numbe on the gauge when the hythmic beating stops. This is you diastolic pessue.

166 G. Opening the aiflow valve 1. Tun the scew counte clockwise to open the valve. 2. Allow all of the ai to flow out of the cuff. H. Repeating the measuement 1. If you eleased the pessue too quickly o you could not hea the beating clealy, DO NOT ty to inflate the cuff again ight away. 2. Deflate the am cuff completely by letting all the ai out. 3. Afte waiting 1 minute, stat again fom the beginning by eapplying the cuff. If you ae using a digital monito: Follow steps A Positioning, B. Locate you Pulse and C1. Secue the cuff. 1. Hold the bulb in you ight hand. 2. Pess the powe button. All display symbols should appea biefly, followed by a zeo. This indicates that the monito is eady. 3. Inflate the cuff by squeezing the bulb with you ight hand. If you have a monito with automatic cuff inflation, pess the stat button. 4. Watch the gauge. Keep inflating the cuff until the gauge eads about 30 points (mm Hg) above you expected systolic pessue. 5. Sit quietly and watch the monito. 6. Pessue eadings will be displayed on the sceen. Fo some devices, values may appea on the left, then on the ight. Most devices will also display you pulse ate. 7. Wait fo a long beep. This means that the measuement is complete. Note the pessues on the display sceen. Systolic pessue appeas on the left and diastolic pessue on the ight. You pulse ate may also be displayed in between o afte this eading. 8. Allow the cuff to deflate. Impotant: If you did not get an accuate eading, DO NOT inflate the cuff ight away. Wait one minute befoe epeating the measuement. Stat by eapplying the cuff. Recoding the measuement Follow you docto s odes on when to take you blood pessue and how often to take it. Note the date and time fo each blood pessue eading. Recod you eadings by putting the systolic (fist) pessue eading ove the diastolic (last) pessue eading. Systolic Diastolic Index # This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Poduced by Cente fo Consume Health Infomation Copyight The Cleveland Clinic Foundation. All ights eseved. Rev. 02/27/2014 Taking You Blood Pessue

167 Notes

168 DAILY RECORDKEEPING LOG In the spaces povided below, please ecod blood pessue (take and ecod twice a day), tempeatue (take and ecod twice a day), and the time you took these eadings. Always cay this sheet with you. You docto will need to see it duing you appointments, and you might need it in case of an emegency. WEEK OF: (Date) TIME M TU W TH F SA SU BLOOD PRESSURE TEMPERATURE WEEK OF: (Date) TIME M TU W TH F SA SU BLOOD PRESSURE TEMPERATURE WEEK OF: (Date) TIME M TU W TH F SA SU BLOOD PRESSURE TEMPERATURE

169 WEEK OF: (Date) TIME M TU W TH F SA SU BLOOD PRESSURE TEMPERATURE WEEK OF: (Date) TIME M TU W TH F SA SU BLOOD PRESSURE TEMPERATURE WEEK OF: (Date) TIME M TU W TH F SA SU BLOOD PRESSURE TEMPERATURE WEEK OF: (Date) TIME M TU W TH F SA SU BLOOD PRESSURE TEMPERATURE Index Poduced by Cente fo Consume Health Infomation Copyight The Cleveland Clinic Foundation All ights eseved. Rev. 04/2013

170 Fequent Laboatoy Testing You will have you blood dawn each day you ae in the hospital and each time you come to the outpatient aea fo a physician o teatment appointment. This may seem excessive, but blood tests ae a vital tool in monitoing you medical status duing and afte a tansplant. Chemotheapy, infection, gaft-vesus-host disease (GvHD) and medications you ae taking may affect you blood esults. The following is a list of blood tests that may be done fequently. This list is intended to help you undestand what you physicians and nuses may be monitoing. Feel fee to ask you nuse fo copies of you test esults at you appointments. Lab Test What does it measue? What might be done if the esult is abnomal CBC (Complete Blood Count) WBC (White Blood Count) This lab test measues the following: WBC, RBC, HGB, HCT, PLT. (See below) These ae the types of cells in you blood that fight infection. As you engaft afte tansplant, you total WBC numbe will incease. Often, infections and steoids will cause an elevated WBC. The use of Neupogen (G-CSF) o Neulasta can cause an elevated WBC If you WBC is low, you docto might ode Neupogen o Neulasta to boost you WBC count Fequent Laboatoy Testing RBC (Red Blood Count) HGB (Hemoglobin) RBC is a measue of the numbe of cells in you blood that ae composed of hemoglobin. RBC ciculate in you blood fo 120 days befoe being eplaced by new cells. This is a potein that enables ed blood cells to cay oxygen fom the lungs to you tissues and cay cabon dioxide fom the tissues to the lungs. If you HGB is too low, you will eceive a ed blood cell tansfusion. You docto might ode Pocit, Epogen o Aanesp as well.

171 Lab Test What does it measue? What might be done if the esult is abnomal HCT (Hematocit) HCT measues the pecentage of RBC in you blood. PLT (Platelets o thombocytes) DIFFERENTIAL Neutophils (ANC-) Absolute Neutophil Count PLT ae cells that help you blood clot. Afte an allo tansplant, low platelets might indicate the pesence of GVHD o infection. Cetain medications can also cause platelet counts to dop. This lab test is made up of seveal diffeent components. (See Below). It indicates a pecentage of the diffeent types of WBCs making up the total WBC count. These ae a specific type of WBC that ae the body's fist line of defense against infection. If you PLT count dops too low, you will eceive a platelet tansfusion. If this esult is too low, you docto might ode a Neupogen (G-CSF) o Neulasta injection. Lymphocytes Eosinophils These ae a specific type of WBC that attach to foeign antigens and destoys them. Togethe with neutophils, lymphocytes make up the majoity of you total WBC. These ae a specific type of WBC that esponds to allegic eactions. This lab value can incease with GVHD. Basophils Monocytes These ae a specific type of WBC that ae thought to help the body esist sevee allegic eaction states, although thei function isn't completely undestood. This is a specific type of WBC that is the body's second line of defense to fight off infection.

172 Lab Test What does it measue? What might be done if the esult is abnomal CMP (Compehensive Metabolic Panel) This is a goup of lab tests (See Below) that measue chemical components in you blood. It might eflect the function of seveal ogans. Total potein can be an indicato of you nutitional status. This value can be affected by GVHD. If you ae eceiving TPN (IV nutition), you medical team will monito this numbe closely. Total Potein (TP) Albumin (ALB) Calcium (Ca) This is a potein that is mostly found in the live. It maintains nomal distibution of wate in you body. A shap decline in albumin leads to swelling (edema). This value can be affected by the pesence of GVHD. If you ae eceiving TPN (IV nutition), you medical team will monito this numbe closely. Calcium is impotant in keeping you bones stong. Ou bodies excete calcium daily so it is impotant to get you ecommended daily allowance of calcium. A dietitian might be consulted fo caloic monitoing and possible dietay ecommendations, including TPN. A dietitian might be consulted fo caloic monitoing and possible dietay ecommendations, including TPN. If you calcium is too low o if you ae on steoid theapy, you docto might ask you to take a calcium supplement Fequent Laboatoy Testing Total Biliubin (Total Bili) Biliubin is an indicato of you live function and the condition of you ed blood cells. This value can be elevated due to live damage fom chemotheapy o GVHD. Alkaline Phosphatase (Alk Phos) Alk Phos is a live enzyme that can be elevated in both skeletal and live diseases. GVHD can also incease the level of Alk Phos in you blood.

173 Lab Test What does it measue? What might be done if the esult is abnomal Aspatate aminotansfease (AST) AST is an enzyme that is eleased into the blood. It can eflect cellula damage. It can also help to assess heat and live function. Blood Uea Nitogen (BUN) Ceatinine (Ceat) Sodium (Na) BUN eflects you potein intake and kidney function. An elevated value can eflect dehydation. This value will be monitoed closely if you ae on TPN. Ceatinine is a measuement of you kidney function. Cetain medicines such as antibiotics, Pogaf o cyclospoine can affect you kidneys. If you ae on these medicines, you ceatinine will be measued closely. Sodium is an electolyte that affects wate distibution. Adjustments in you medicines might be made accoding to you ceatinine levels. Potassium (K) This is an electolyte that is essential to maintaining electical conduction within the cadiac and skeletal muscles. Cetain medicines can affect potassium levels. It is common to need potassium eplacement duing and afte you BMT. Chloide (Cl) Chloide is an electolyte that helps egulate blood volume and ateial pessue. Anion Gap This lab test helps to distinguish types of metabolic acidosis and kidney function. Cabon Dioxide (CO2) CO2 eflects the adequacy of gas exchange in the lungs.

174 Lab Test What does it measue? What might be done if the esult is abnomal Alanine tansaminase (ALT) ALT is an enzyme that detects acute live tissue damage. Glucose Lactic Dehydogenase (LDH) Gamma Glutamyl Tanspeptidase (GGT) Uic Acid Magnesium (Mg) Glucose is the body's majo souce of enegy. This test is a measuement of the amount of suga in the blood. Steoid theapy affects you glucose levels. LDH is an enzyme that detects tissue changes, including live, lung and RBC damage. It can be affected by GVHD and cetain cance diagnoses such as lymphoma. GGT is an enzyme used to assess live function. An elevated GGT can be an indication of GVHD. Uic acid helps to detect gout o kidney dysfunction. It might become elevated soon afte high-dose chemotheapy as cance cells ae destoyed (tumo lysis). Mg is an electolyte that is vital to neuomuscula function. Cetain medicines can affect you Mg levels. High glucose might be teated by adjusting you diet, o with medicines, such as insulin. Medicines, including Allopuinal, might be pescibed It is common to need magnesium eplacement duing and afte you BMT Fequent Laboatoy Testing Quantitative Immunoglobulins (IgG, IgA, IgM) These ae poteins that help evaluate immune function. If levels ae low, you docto might ode immunoglobulin infusions; ie, IVIG Feitin Feitin is a majo ion-stoage potein diectly elated to the amount of available ion stoed in the body. This lab value is monitoed closely to evaluate possible ion oveload fom eceiving multiple RBC tansfusion. If you feitin level is too high, you docto might pescibe cetain medicines to help you body get id of the exta ion.

175 Lab Test What does it measue? What might be done if the esult is abnomal Pothombin Time (PT o Po time) /INR Plasma Thombin Time (PTT o Thombin clotting time) This is one of two blood tests done to evaluate you blood clotting system. An abnomal value can show the potential fo abnomal bleeding. This value can be affected by alcohol consumption. This monitos the effectiveness of cetain medicines, such as coumadin. This is one of two blood tests done to evaluate you blood clotting system. This monitos the effectiveness of cetain medicines, such as Hepain. If you ae taking Coumadin (wafain) you dosage may be adjusted. Cyclospoine (CSA) Neoal Pogaf (Tacolimus) CMV DNA detection Notes This test indicates the amount of CSA in you blood. This test indicates the amount of Pogaf in you blood. This blood test is done to detemine the pesence of a vius in you blood called CMV (cytomegalovius). If levels ae too high o too low, you dose of CSA might be adjusted. If levels ae too high o too low, you dose of Pogaf might be adjusted. If you have a positive CMV test esult, you docto will ode cetain medicines to teat the vius. _ This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Index #11073 Poduced by the Cente fo Consume Health Infomation Copyight The Cleveland Clinic Foundation. All ights eseved. Rev.02/25/2014

176 Follow-Up Appointments Fo Autologous Tansplant Patients Meeting with you nuse coodinato Befoe you ae dischaged, you nuse coodinato will meet with you to eview all you post-tansplant needs, including you follow-up appointments. You nuse coodinato will contact you local oncologist to update him o he on you hospital stay and to discuss all of you dischage needs. You test esults, lab esults, dischage summay, and dischage instuctions will be faxed to you local oncologist. You insuance company will also be notified of you dischage and follow-up plan. Whee will I go fo my follow-up appointments? Within 2-3 days of you dischage, you will have an appointment at R10 in the Taussig Cance Institute. You will have blood wok dawn. You may need blood poducts, electolytes, o IV fluids. A membe of the BMT team will speak with you to discuss any symptoms o poblems that you may be having. They will also eview you medications and answe any questions you o you family membes may have. The BMT team may decide that additional appointments need to be scheduled at Taussig Cance Institute depending on how quickly you ae ecoveing. You will be scheduled with you tansplant physician within 1-2 weeks of dischage When you etun home, if you pimay oncologist is local, he/she may need to see you within a week to assess fo signs of dehydation o infection. You will need to have blood wok dawn at least weekly, and the esults faxed to you BMT coodinato. Follow-Up -- Autologous If you ae taking medications fo you blood pessue o you ae being dischaged on new medications fo blood pessue, please have a family membe bing in a blood pessue cuff to G110 a few days befoe you ae dischaged. The nuses on G110 will check you blood pessue cuff fo accuacy. You will be asked to check you blood pessue along with you tempeatue twice daily. Nuse coodinato follow-up calls You nuse coodinato will initially call you at least once a week to check on you pogess duing you ecovey peiod. Duing the phone convesation, you nuse will

177 talk to you about you daily tempeatue ecod, fluid intake, appetite, nausea, vomiting, diahea, skin changes, lab esults, medicines, blood pessue, and enegy level. You ae expected to contact you nuse coodinato if thee ae any changes in you condition (fo example, if you have a feve, inceased nausea, inceased diahea, changes in you nomal beathing patten, etc.). Following you one-month appointment at Cleveland Clinic, you nuse will contact you peiodically fo the fist yea afte you tansplant to assess you ongoing ecovey. One-Month follow-up appointment One month afte you dischage date, you will etun to Cleveland Clinic to see you tansplant docto. This appointment is necessay to assess any emaining side efffects, and to make sue you ae ecoveing well fom you tansplant. You docto might epeat beathing tests at the one month follow-up appointment and peiodically fo the fist yea if necessay. How long is the follow-up appointment? You follow-up appointments could last fom 2 to 8 hous, depending upon the tests and teatment needed. What happens duing my follow-up appointment? Blood tests In ode fo the Tansplant Team to effectively monito you health, blood tests including a complete blood count and chemisty pofile will be pefomed. Additional blood tests might be odeed and you teatment plan modified accoding to you condition. Othe tests In addition to blood tests, these othe tests will be pefomed duing you follow-up appointments: Chest X-Rays If needed, ae pefomed at R22 to check you lungs to detect the development of pneumonia o possible infection. Pulmonay function test (PFT) If needed, this is done at A90 to check you lung function and to make sue the chemotheapy medicines have not caused any lung function changes. Consultation with Infectious Disease docto You will meet with an Infectious Disease docto to discuss eimmunization needs afte tansplant in accodance with CDC (Cente fo Disease Contol) guidelines. Consultation with Social Woke You will meet with you tansplant Social Woke in R32 fo a bief follow-up assessment and to discuss life afte tansplant. Consultation with the docto and nuse You will meet with you docto and nuse coodinato to eview you test esults, assess you health, addess you concens, and povide you with esouces you might need. Follow-up appointments with you local oncologist Afte you one-month follow up appointment at Cleveland Clinic, you will etun to the cae of you pimay oncologist. Even though you might not be in diect contact with you tansplant docto and nuse coodinato, we ae still concened about you. We ae available should you equie us in the futue. Occasionally, a membe of the BMT Team will contact you local oncologist fo updates. This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Index #10431 Poduced by the Cente fo Consume Health Infomation Copyight The Cleveland Clinic Foundation. All ights eseved. Rev.02/25/2014

178 Autologous Tansplant Patients and Cae Patnes Things to Know Befoe You ae Dischaged Know how to take cae of you tiple lumen Cental line cathete. This includes flushing all lumens daily and changing caps and dessing weekly. (If you ae dischaged with you cathete). Know how to take you tempeatue, how often to take it, what is consideed a feve, and whom to call when you have one. Know the low white blood cell (neutopenic) pecautions and estictions, and how long to follow these estictions. Know the low platelet (thombocytopenic) pecautions and estictions, and how long to follow these estictions. Know when to call the Tansplant Team and whom to call. Undestand you medicines, why you ae taking each medicine, what the dose is, how often to take it, and how to take it. Make sue you have all pesciptions needed fo all medicines. Know when you initial follow up appointment in R10 is scheduled. Know when to follow up with you BMT docto. Know when you ae having follow-up labs dawn, whee and how often you ae having them dawn. Undestand nutition afte tansplant. Undestand sexuality afte tansplant. Undestand adjustment to life afte tansplant. Know when you should see o talk to you nuse coodinato. If you ae being dischaged on blood pessue medications: You blood pessue cuff should be checked fo accuacy befoe dischage. Know how to use the blood pessue cuff. You should know abnomal anges to epot and whom to tell. You should keep a log of all blood pessue eadings and bing the log with you to each outpatient appointment. Things to Know Befoe You ae Dischaged -- Autologous

179 Notes This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Index # Poduced by the Cente fo Consume Health Infomation Copyight The Cleveland Clinic Foundation. All ights eseved. Rev 02/25/2014

180 Taking You Tempeatue (Twice a Day) Using a themomete to monito you tempeatue can help you manage an illness. A ise in you tempeatue is usually caused by an illness o infection and is usually one of the fist signs of a potential poblem. Fo autologous tansplant patients, you should check you tempeatue twice a day fo 2 weeks afte dischage. Fo allogeneic tansplant patients, you should check you tempeatue twice a day while you ae taking immunosuppessive medicines and while you have a cental line. Nomal body tempeatue Nomal body tempeatue is about 98.6 degees Fahenheit (o 37 degees Celsius). You tempeatue often vaies fom 1 to 2 degees Fahenheit (.5 to 1 degees Celsius) thoughout the day. You tempeatue is usually low in the moning and gadually inceases duing the day, eaching its high in the late aftenoon o evening. Electonic themometes We ecommend that you puchase an oal electonic themomete. Please follow the manufactue s instuctions fo ecommended use. Taking You Tempeatue

181 CONVERSION CHART Fahenheit to Centigade (Celsius) Fahenheit Centigade Notes This infomation is not intended to eplace the medical advice of you docto o health cae povide. Please consult you health cae povide fo advice about a specific medical condition. Index #10258 NORMAL Poduced by the Cente fo Consume Health Infomation Copyight The Cleveland Clinic Foundation. All ights eseved. Rev.02/25/2014

182 Peventing Infection Afte Blood & Maow Tansplant Afte you tansplant, you immune system is weak and you ae at isk fo infection. Even though you white blood cell count might be nomal, you immune system is still ecoveing. Theefoe, infections might still occu. Causes of infection The usual causes of infection afte a tansplant include: Month 1 bacteia, fungi, hepes simplex vius Month 2 cytomegalovius (CMV), othe viuses, bacteia, and fungi* Month 3 vaicella zoste vius, bacteia, fungi*, community acquied espiatoy vius * These ae moe common afte allogeneic tansplants than autologous BMTs, paticulaly in patients with gaft-vesus-host-disease (GvHD). Detecting infection One of the easiest and most impotant ways to detect signs of infection is to take you tempeatue. You should take and ecod you tempeatue twice a day. Fo you convenience, you may use the tempeatue ecoding chat located in the Follow-Up Cae Afte You Tansplant section of this binde. Allogeneic patients should continue to take you tempeatue twice a day until all of you immunosuppessive medicines have been discontinued by you tansplant team and you cental line has been emoved. (Unless instucted othewise by you tansplant team). PREVENTING INFECTION Autologous patients should follow these estictions fo six months. If you ae on maintenance teatment (such as ituximab o lenalidomide) these estictions should be followed while on maintenance medications. Allogeneic patients should follow these estictions while taking immunosuppessive medications and while the cental line is in place. Avoiding Envionmental Exposues Pay close attention to hygiene This is necessay to help pevent infection. You may showe o bathe nomally, as long as you don t submege you cental venous cathete unde wate. Daily cleansing with soap and wate is the fist line of defense against bacteia on the skin. Peventing Infection Afte Blood & Maow Tansplant

183 To help minimize infection and gum bleeding, daily oal (mouth) cae is necessay. You may use a soft, nylon-bistled toothbush o sponge toothette to cae fo you teeth and gums. Bush you teeth and gums thooughly with fluoide toothpaste afte each meal. Use a mouth wash o inse as ecommended by you health cae povide. Pevent infections tansmitted by diect contact Thoough hand washing is cucial, especially duing the fist 6 months afte you BMT o while taking immunosuppessive medicines. Wash you hands with soap and wam wate. The use of hygienic hand ubs (hand sanitize) is ecommended when you ae outside you home, if soap and wam wate ae not available. (Keep in mind that these hand sanitizes do not pevent tansmission of the bacteia esponsible fo causing C diff. colitis.) Afte sexual contact if hands touch genital o anal aea Remembe to wash you hands even if you wea gloves. Pevent infections tansmitted by diect contact and espiatoy tansmission Avoid gadening, mulching, aking, mowing, caving, faming, o diect contact with soil and plants. Diect contact with soil and plants inceases you exposue to potential pathogens (substances that can cause disease) including aspegillus and cyptococcus. These pathogens can cause seious fungal infections. If you must do any of these activities (e.g. you ae a fame), wea mask and gloves. Avoid having anything in you yad that collects wate, such as bid baths o empty buckets. Standing wate attacts mosquitoes which can tansmit West Nile Vius. Handwashing is necessay: Befoe eating Befoe and afte pepaing food Afte touching pets o animals Afte sneezing, coughing, o blowing you nose Afte going outdoos Befoe and afte any cental venous cathete cae o intavenous infusions Befoe taking oal medicines Afte touching soiled linens o clothes Afte changing diapes Afte using the bathoom This does not mean you should avoid the outdoos. Walking, biking, and many othe outdoo activities ae not only enjoyable but will pomote good health. Pevent espiatoy infections Avoid close contact with people who have espiatoy illnesses (cough, cold, etc.). Be especially caeful aound school-aged childen, since they ae often exposed to othe childen who ae ill. Avoid cowded aeas whee you ae unable to contol the distance between you and othes. Some might feel "safe" weaing a mask when they ae outside the home. This is a pesonal choice, but you ae not equied to wea a mask when you go outside you home. If you choose to

184 wea a mask, you should still avoid situations, such as cowds, that might incease you isk of infection. Conside weaing a mask on aiplanes and buses. Avoid constuction sites, including homes o buildings that ae being epaied o emodeled. These dusty envionments incease you exposue to molds. Avoid tobacco and maijuana use. The use of these substances, along with exposue to envionmental tobacco smoke (second-hand smoke), inceases you isk fo bacteial, vial, and fungal infections. Avoid wood-buning fieplaces, stoves, and pits since the wood can contain fungus. Avoid house cleaning that will distub dust and mold, causing it to move into the ai (such as vacuum cleaning, dusting, and scubbing down showes). Once you have the enegy, it is not hamful to ion, wash clothes, dy clothes, wash dishes and cook. Avoid the use of a oom humidifie due to the wate-haboing bacteia. Pevent pet-tansmitted infections It is not necessay to pat with you pets. Howeve, it is impotant to minimize diect contact with animals, especially animals that ae ill. Please delegate the cae of you pets to othe family membes o fiends. It is ecommended to avoid contact with eptiles, ducklings, o chicks to pevent salmonella. If you have a cat, do not place the litte box in kitchens, dining ooms, o othe aeas whee food pepaation and eating occu. In addition, have someone else handle the daily litte box cleaning duing the fist 6 months afte tansplant and when you ae taking immunosuppessive medicines to educe you isk of acquiing toxoplasmosis. Please keep you cats inside and do not adopt o handle stay cats. If you have a dog, do not handle o clean up bowel movements. If hunting, do not gut animals and avoid polonged contact with eath matte (eg. wild tukey hunting equies laying on eath suounded by vegetative matte fo cove). If fishing, avoid cleaning the fish. Peventing Infection Afte Blood & Maow Tansplant