Allogeneic Reduced Intensity Transplant Patient Education Binder

Transcription

1 Allogeneic Reduced Intensity Tansplant Patient Education Binde 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 Blood & Maow Tansplant Team Phone Numbes ADULT TRANSPLANT DOCTORS Navneet Majhail, MD, Diecto Steven Andesen, DO Bian Bolwell, MD Robet Dean, MD Aaon Geds, MD Betty Ky Hamilton, MD Bian Hill, MD Deepa Jagadeesh, MD Matt Kalaycio, MD Hein Liu, MD Bad Pohlman, MD Ronald Sobecks, MD BLOOD & MARROW TRANSPLANT UNIT (G110) Patti Akins, RN, Nuse Manage Danielle Boone, RN, Assistant Nuse Manage Kelly Cash, RN, Assistant Nuse Manage Emily Ives, Assistant Nuse Manage Deba Scott, RN, Assistant Nuse Manage ADVANCED PRACTICE PROVIDERS Anita Bias, CNP Elizabeth Dimmock, CNP Shannon Jaancik, PA-C Heathe Koniaczyk, CNP Joe Kohuth, PA-C Tina Piks, CNP APHERESIS (M12) Hien Liu, MD, Medical Diecto 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 nusing unit. If you ae unable to each the Hematology/Oncology Fellow, please page you nuse coodinato. Blood & Maow Tansplant Team Phone Numbes

23 BLOOD & MARROW TRANSPLANT ADMINISTRATION (R32) (fax) ADMINISTRATIVE SUPPORT STAFF Julie Cutis, RN, Pogam Administato NURSE COORDINATORS Laua Benhad, RN, Clinical Manage Lisa Chiancone, RN Kelly Cheni, RN Chistina Feao, RN Amy Healy, RN Bittany Hodgeman, RN Jamie Stan, RN Vicky Winslow, RN ADMINISTRATIVE COORDINATORS Dianne Claibone Kay Pieson Domonic Rini Gei Robinson Andie Zajc FINANCIAL SUPPORT STAFF Vanessa Hudson, Reimbusement Specialist Asia Whitted, Financial Counselo SOCIAL WORK Jane Dabney, LISW-S Chistine Lawence, LISW-S Linda McLellan, LISW-S Index # 9605 Rev. 03/18/2016

24 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

25 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.

26 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

27 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.

28 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

29 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

30 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

31 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

32 Patient Name Date of Bith Tentative Date of Cental Venous Cathete Placement Note: Antibiotic pophylaxis is equied fo all patients who have a cental venous cathete device. Dea Docto: Dental Cleaance We ae cuently woking with the above-listed patient as they ae pepaing fo a blood o maow tansplant. Given the significant degee of immune suppession associated with this pocedue and its aftemath, a thoough dental examination is necessay, with elated adiogaphs as indicated. This is to exclude the pesence of occult infections pio to the tansplant. Specifically, we would like you to addess the following issues: 1) Cleaning: (if not done in the last 6 months o if the patient is symptomatic). If the patient is neutopenic, please conside antibiotic pophylaxis if indicated. 2) Exclusion o definitive teatment of dental abscesses. 3) Exclusion of significant caies and active gingival o mucosal lesions. 4) Completion of majo dental epais o extactions if thee is a significant isk fo beakdown o infection within the next 3-6 months. We will delay admission fo the tansplant until at least one week following any extactions (longe if complications aise, o if othewise advised by you). Dental Cleaance You expetise in this egad is geatly appeciated. If any additional questions o concens aise, please do not hesitate to call ou office. Please fax a summay of you findings to o Sinceely, Blood & Maow Tansplant Pogam Cleveland Clinic 9500 Euclid Avenue R-32 Cleveland, OH

33 Notes Index #10262 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.02/27/2014

34 - 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:

35 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.

36 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

37 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

38 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?

39 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

40 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

41 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

42 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

43 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.

44 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

45 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.

46 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

47 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.

48 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

49 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

50 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.

51 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

52 - 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.

53 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

54 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.

55 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

56 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 2. To begin: Liquid antibacteial soap Pape towels 3 pefilled saline syinges 3 alcohol wipes 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.

57 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

58 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

59 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

60 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

61 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

62 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. 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.

63 How is it given? Neupogen is given by injection unde the skin (subcutaneously) using a needle 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? If you ae expeiencing pain, please contact you docto o nuse coodinato. When should I call my docto? Call you docto if you: Have a feve of F (38 C) o highe Have a skin ash. Mild to modeate bone pain Flu-like symptoms including muscle and joint aches, feve and chills, fatigue, weakness, and headaches Sevee Abdominal pain. Have shotness of beath. Expeience unusual sweating. Fluid etention Have any othe unusual symptoms. Nausea Have any questions o concens. Diahea Loss of appetite In ae instances, spleen enlagement and possible uptue may occu 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. 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. 10/27/2015

64 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

65 Notes

66 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.

67 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.

68 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.

69 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

70 - 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.

71 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

72 - 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

73 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

74 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

75 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.

76 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

77 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

78 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

79 Notes

80 The Reduced Intensity Pepaative Regimen Allogeneic Bone Maow Dono Expeience (Also called non-myeloablative o mini tansplant) Afte you docto has detemined you ae a good candidate fo a non-myeloablative o educed intensity allogeneic bone maow tansplant, and a suitable dono has been found, the dono will begin his o he own pat of the pocess. You tansplant would not be possible without the help of you dono. This section will help you bette undestand you dono s expeience and thei involvement in you tansplantation pocess. Membes of the Cleveland Clinic s Bone Maow Tansplant Pogam will be woking with you dono thoughout the entie donation pocess. You nuse coodinato will contact both you and you dono. Duing this initial convesation, you dono will be given an oveview of the donation pocess. You dono also will eceive a packet in the mail that will povide infomation about the upcoming visits to Cleveland Clinic. Dono Evaluation If you dono is a family membe, he o she, will be scheduled at Cleveland Clinic fo a full day of appointments within 30 days of the stem cell donation day. This time fame is mandated (equied) by the Food and Dug Administation (FDA). The pupose of the dono evaluation is to make sue you dono: Undestands the stem cell collection pocess Is in good medical condition to donate stem cells Having you dono complete the evaluation appointments at Cleveland Clinic will ensue that the billing will be pocessed appopiately. All of you dono s bills ae the esponsibility of you insuance company. If you dono is not elated to you, he o she will have thei evaluation done nea his o he home and the cells will be deliveed by a couie afte they have been collected. Dono Evaluation: tests needed Chest X-ay (pictue of the lungs) Electocadiogam (a gaph of the electical impulses tavelling though the heat to evaluate heat function) Uinalysis Reduced Intensity Allogeneic Dono Expeience

81 Blood tests Samples of blood will be dawn fom a vein in the dono s am and the following laboatoy tests will be pefomed: CBC complete blood count CMP compehensive metabolic panel Pegnancy test if applicable Bleeding times ABO blood type Infectious disease tests human immunodeficiency vius (HIV), cytomegalovius (CMV), toxoplasmosis, hepatitis, Epstein-Ba vius (EBV), hepes, HTLV I/II, vaicella, syphilis, West Nile vius and Chagas. Dono evaluation: meetings with the BMT Team Meeting with a tansplant docto At this appointment the tansplant docto will discuss the pocess of collecting you dono s stem cells. The docto will also discuss the tests that will be pefomed as pat of the evaluation. The docto will also eview the dono s past medical histoy and pefom a physical exam. It can take fom 7 to 12 days to eceive esults. The tansplant docto will eview the dono s esults and if any tests o lab esults ae abnomal, it is possible that you dono will be expected to etun to Cleveland Clinic fo futhe testing o fo additional appointments with othe specialists. Again, this is to ensue the safety of the donation and the health of both you and you dono. The docto will meet with you dono a second time to eview the test esults and discuss any abnomal findings on the tests. You dono will be able to ask any questions duing this time. Meeting with you bone maow nuse coodinato You dono will meet with a nuse coodinato to eview the pocess of donating stem cells. You dono will be asked to complete a Health Histoy Suvey, as equied by the FDA. The nuse coodinato will povide and explain the consent fom fo being a stem cell dono. The coodinato will also answe any questions you dono might have. Meeting with the social woke--- you dono will have the oppotunity to meet with the social woke to discuss any concens that they may have elated to the donation pocess. Meeting with the financial counselo You dono will have the oppotunity to meet with the financial counselo to discuss the pocess of billing and to answe any questions about insuance coveage fo stem cell donation. All of you dono s bills ae the esponsibility of you insuance company. Neupogen injections Afte you dono s evaluation pocess has been completed, he o she will be instucted on the Neupogen self-injections. The nuse coodinato will teach you dono how to give self-injections of Neupogen o G-CSF. If the dono is unable to give the injection, a family membe o fiend might be instucted with the dono. This medicine is given to stimulate you dono s bone maow o stem cells. These ae the cells necessay fo a successful bone maow tansplant. These injections will be stated on the Thusday befoe the stem cell collection pocedue. The dono will give the self-injections once pe day fo 5 days in a ow. Stem cell collection pocedue The next step is the peipheal stem cell collection. You dono will etun to Cleveland Clinic on Monday moning fo the placement of a tempoay cental venous cathete. Afte the cathete has been placed, you dono is sent diectly to Apheesis (M12) whee the stem cells will be collected. The collection pocedue takes 3 to 4 hous fo 2 to 3 days (Monday, Tuesday, and Wednesday), o until a minimum numbe of cells have been collected. Afte you dono s collection is complete, you will eceive you infusion of donated peipheal stem cells.

82 Recovey You dono s expeience comes to an end with the emoval of the cental venous cathete. The cathete may be emoved afte the last collection is complete o 24 hous late. The cathete is emoved by the apheesis staff at M12. 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 #10426 Poduced by Cente fo Consume Health Infomation Copyight The Cleveland Clinic Foundation. All ights eseved. Rev.12/26/2013

83 Notes

84 Sample Calenda -- Related Dono fo a Reduced-Intensity Patient Sunday Monday Tuesday Wednesday Thusday Fiday Satuday Oct. 6 Oct. 7 Multiple appts at CCF (see attached schedule) Oct. 8 Oct. 9 Oct. 10 Oct. 11 Oct. 12 Oct. 13 Oct. 14 Oct. 15 Oct. 16 Oct. 17 RN appt: Injection instuction MD appt Neupogen Injection Oct. 20 Oct. 21 Oct. 22 Oct. 23 Oct. 24 7am S15 labs 7:30 am 7:30 am Cathete Neupogen 8;15am Hb6 Desk M12 Desk M12 emoval Injection cathete placement Apheesis apheesis (please follow all instuctions); epot to M12, apheesis following cathete placement Oct. 18 Neupogen injection Oct. 19 Neupogen injection Oct Oct. 26 Oct. 27 Oct. 28 Oct. 29 Oct. 30 Oct. 31 Nov. 1 Nov. 2 Nov. 3 Nov. 4 Nov. 5 Nov. 6 Nov. 7 Nov. 8 Nov. 9 Nov. 10 Nov. 11 Nov. 12 Nov. 13 Nov. 14 Nov. 15 Nov. 16

85 NOTES:

86 The Outpatient Reduced Intensity Pepaative Regimen Allogeneic Blood o Maow Tansplant (Also called non-myeloblative o mini tansplant.) You educed intensity allogeneic tansplantation pocess began with an initial consult with you tansplant docto. It was then detemined that a educed intensity tansplant is the ight teatment option fo you. We have identified a suitably matched dono and ae now eady to poceed. Stating the tansplant pocess You will be assigned a nuse coodinato who will contact you and you dono (if you dono is elated to you) to discuss the tansplant pocess and answe you questions. At this point, you nuse will schedule you pe-tansplant evaluation (a pocess called staging) and will set a tentative calenda fo you tansplant, which outlines the 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 will be scheduled at Cleveland Clinic to meet with membes of the Tansplant Team, including you tansplant nuse, social woke, tansplant docto, financial counselo, and adiation docto. These appointments will pepae you fo you tansplant and help answe you questions. Appoval At the end of you pe-tansplant evaluation and afte the test esults ae complete, the 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. Reduced Intensity Allogeneic Blood o Maow Tansplant Dono sceening You dono will have a medical evaluation and complete a sceening pocess. The dono will be evaluated by a tansplant docto to make sue he o she is medically fit to poceed as you dono. This usually occus 30 days befoe the planned stem cell collection.

87 Getting stated Afte you medical insuance company appoves you tansplant, you will begin the teatment pocess. Fist, a cental venous cathete o hickman cathete will be placed duing an outpatient sugical pocedue. All tansplant patients must have a cental venous cathete. The cathete is used to daw blood and to infuse you chemotheapy, you dono s cells, and othe IV medicines. You can lean moe about the cathete in the section titled, Pe-Tansplant Sceening. You nuse will ode you cathete supplies and teach you how to cae fo you cathete. The teaching is done the day afte the line is placed to check the new cathete site and to make sue the line is woking coectly. You cathete will emain in place fo at least 3 to 4 months. Pepaative egimen Afte you cental venous cathete has been placed, you will be eady to begin you pepaative egimen. You pepaative egimen consists of low doses of chemotheapy and total body adiation theapy. This teatment is used to make oom in you bone maow fo you new dono cells. Typically, you dono begins Neupogen injections the day you stat you pepaative egimen. Fludaabine is the name of the chemotheapy medicine you will eceive. It is given intavenously (though you cental venous cathete) fo 30 minutes fo 3 consecutive days, stating on Thusday and ending on Satuday. Total body iadiation is given ove 5-10 minutes fo two days, stating on Monday. You will be scheduled at R10 pio to you adiation appointments and given IV hydation and medicine to help pevent side effects of you total body iadiation teatments. On Monday, while you ae eceiving you adiation, you dono will stat the pocess of donating his o he bone maow o peipheal blood stem cells. The dono s collection pocess will last 1 to 2 days. If you dono is unelated, these days might be diffeent. Infusion: Day 0 On Tuesday, you pepaative egimen will be completed and you will eceive an intavenous infusion of you dono s bone maow o peipheal blood stem cells. The dono cell infusion might be scheduled on Wednesday to coodinate with the dono s collection schedule. The day you eceive you dono s cells is efeed to as Day 0. You tansplant nuse will give this infusion to you in the outpatient teatment aea. The infusion is simila to eceiving a blood tansfusion and lasts fom 30 minutes to 1 hou. Duing you infusion, a tansplant docto will evaluate you to make sue you ae toleating you infusion without any difficulty. You will be monitoed fo 1 hou following the infusion in the outpatient clinic. Afte you infusion Afte you infusion, you will be monitoed closely evey day in the outpatient aea. Duing this time, you will stat to eceive seveal medicines, including antibiotics, antivial and antifungal medicines, and immunosuppessants. You nuse coodinato will see you evey day to ovesee you cae, eview you medicines, look fo signs and symptoms of gaft vesus host disease (GvHD) o infection, and monito you lab esults. If thee ae any changes in you condition, you nuse will notify you tansplant docto immediately. You will also have an appointment with you tansplant docto evey week o moe fequently, if needed.

88 Gaft-vesus-tumo effect Fo the next seveal weeks afte you tansplant, you will wait fo you dono s cells to gow; hopefully ceating a gaftvesus-tumo effect. This is the goal of you educed intensity tansplant. The gaft-vesus-tumo effect occus when cetain white blood cells fom you dono s blood o maow attack the diseased cells. This effect is believed to play a majo ole in you potential cue. Staying in Cleveland Afte you educed intensity tansplant, you and you 24-hou cae-patne will be equied to live in the Cleveland Metopolitan aea within a 1-hou dive fom Cleveland Clinic fo about 100 days afte you tansplant, depending on you condition. If you pemanent esidence is beyond this diving time, the Tansplant Team will help you make aangements to stay in the Cleveland Metopolitan aea. It is impotant fo you to stay close so you can be closely monitoed fo tansplantelated side effects. If a sudden change in you medical condition occus, we will diect you to go to the Cleveland Clinic Emegency Room, o we will aange fo admission to Cleveland Clinic s BMT Sevice. Fo this eason, we want you to stay within a safe diving distance to the Main Campus of Cleveland Clinic, as you local docto o hospital might not be tained to teat tansplant patients. You will eceive all of you cae on an outpatient basis. Howeve, if at any time you develop a feve o complications, you will be admitted to the hospital until you condition impoves. Going home If you condition is stable at the end of the 100 day peiod, you will be able to etun home. Even though you have etuned home, you will still be monitoed closely by the Tansplant Team, etuning to Cleveland Clinic fo follow-up appointments as indicated. If you condition wosens at any time while you ae home, you will be expected to etun to Cleveland Clinic fo teatment, and emain hee until you condition impoves. This might necessitate aanging fo local housing within the Cleveland Metopolitan aea once again fo ongoing monitoing and teatments. This might also equie you to have a 24- hou cae-give once again. Reduced Intensity Allogeneic Blood o Maow Tansplant

89 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 #10427 Poduced by Cente fo Consume Health Infomation Copyight The Cleveland Clinic Foundation. All ights eseved. Rev.02/06/2014

90 Sample Calenda fo An Outpatient Reduced-Intensity Allogeneic Tansplant Sunday Monday Tuesday Wednesday Thusday Fiday Satuday Appointment Hickman Hickman with you Placement Teaching tansplant QBID with you R10 Desk R10 Desk R10 docto Fludaabine Fludaabine Fludaabine R20 (please follow AM instuctions) BMT Nuse R Day R10 Lab/teat Day of Re St T28 total body iadiation R10 Lab/teat T28 TBI Stem Cell Infusion R R10 Lab/teat R10 Lab/teat R20 MD Possible Lab/teat Possible Lab teat R10 Lab/teat Possible Lab/teat R10 Lab/teat R20 MD R10 Lab/teat R10 Lab/teat R20 MD R10 Lab/teat R10 Lab/teat R20 MD R10 Lab/teat Please bing BMT Educational Binde to each appointment and upon admission to hospital.

91 NOTES:

92 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

93 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

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 CMV Cytomegalovius (CMV) is a common vius that infects most people at some time duing thei lives but aely causes obvious illness. It is a membe of the hepes vius family. Othe membes of the hepes vius family cause chickenpox, infectious mononucleosis, feve blistes (hepes I) and genital hepes (hepes II). Like othe hepes viuses, CMV infection can become domant fo a while and may eactivate at a late time. The vius is caied by people and is not associated with food, wate o animals. People who have had a blood o maow tansplant and who ae on immunosuppessive medication can have CMV eactivate. This eactivation can cause a vaiety of diffeent infections. If unteated these infections can be life theatening. A tansplant patient who eceived dono cells might be at isk fo developing an active CMV infection if he o she o the dono was exposed to the vius in the past. You tansplant team will be monitoing you often fo CMV with fequent blood tests. This test will indicate whethe the vius has become active. You will have these tests dawn weekly fo the fist thee months afte you tansplant. Fo the following thee months (until 6 months afte you tansplant), these tests will need to be dawn evey 2 weeks. CMV Afte 6 months, you CMV blood test will be checked at each physician appointment. If you have active gaft-vs-host disease, if you ae on pednisone, o if you have had a CMV infection, you tansplant physician may have you continue to check moe fequently. CMV blood tests need to be un at the Cleveland Clinic; theefoe, if you ae at home, a kit with tubes will be povided to you. You tansplant nuse coodinato will eithe give you kits at you appointment o you will eceive them in the mail at you home. This kit can be taken to you local lab to be dawn and mailed to the Cleveland Clinic lab. Please plan to have blood dawn Monday though Thusday so that samples ae etuned to ou labs fo pocessing on a weekday. You will be povided with a standing ode fom you tansplant physician to take with you and give to you local lab. If you get an infection cause by CMV o you CMV becomes active, you will be teated with antivial medications. These medications can be eithe oal pills o IV infusions. This will be detemined by you tansplant physician.

107 Notes _ Index #14350 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

108 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.

109 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

110 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

111 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

112 Neutopenic Pecautions Fo Allogeneic 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 the G110 o G111 inpatient units. 4. Minimize venipunctues and invasive pocedues. 5. No aspiin o non-steoids, as they might mask feves. 6. No cooked food fom outside unless appoved by the nutitionist. 7. Weekly dessing change of Hickman cathete. 8. Minimize visitos and sceen fo infection, uppe espiatoy infection, diahea, etc. 9. No tampons. 10. No suppositoies o enemas. 11. No cotton swabs. (Q-Tips ) 12. No intimate contact (sexual intecouse). 13. Except fo handwashing, only the patient is to use the bathoom. Only the patient is to occupy the bed. 14. Avoid contact with new animals. If you have pets at home, do not clean up afte them. Neutopenic Pecautions Fo Allogeneic Patients

113 Notes Index #10260 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.10/02/2015

114 - 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

115 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

116 - 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.

117 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

118 Fludaabine Phosphate BRAND NAME: Fludaa What ae some othe names fo this medicine? Fludaabine phosphate belongs to the goup of medicines called antimetabolites. What does it do? Fludaabine phosphate intefees with the gowth of cance cells, which ae eventually destoyed. How is it given? Fludaabine phosphate is injected diectly into you vein though an IV (intavenously), usually fo 30 minutes o longe. What ae some side effects I might expeience? EARLY SIDE EFFECTS These might occu within 1 week afte teatment. Dowsiness while the medicine is being given Dowsiness usually stops afte the injection is complete. Mild nausea and vomiting Taste changes, metallic taste Vomiting Rash Weakness and fatigue (moe likely with 5-day infusions) Fludaabine Phosphate Low blood counts Poo appetite Numbness and tingling of the hands and feet Chills, sweating 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 questions about you pesonal situation.

119 Notes Index #4835 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

120 Photopheesis What is photopheesis? Photopheesis o extacopoeal photoimmune theapy is a pocedue that might be ecommended by you docto to pevent o to teat gaft vesus host disease (GvHD). This pocedue offes anothe way to ty to suppess the dono lymphocytes (type of white blood cells) that stimulate immune eactions and aid in the development of GvHD. Whee is photopheesis done? The photopheesis pocedue is pefomed in the Theapeutic Apheesis Depatment located at Desk M12. Televisions ae available fo viewing duing the pocedue. Visitos ae limited in this aea. Please eat beakfast o lunch pio to you scheduled appointment. Please ty to dink plenty of fluids in the days befoe you scheduled appointment and ty to eat a low fat diet beginning the evening pio. How long does the pocedue last? The photopheesis pocess lasts about 3 to 4 hous. You might equie seveal photopheesis sessions befoe the desied esults ae achieved. You docto will develop an individual teatment plan fo you based on you disease. How is photopheesis done? Duing photopheesis, blood is taken fom one lumen of you cental venous cathete and pocessed though a cell sepaation machine. This machine emoves and teats you lymphocytes and then etuns them and the est of you blood. Photopheesis When you blood fist entes the machine, it is mixed with an anticoagulant medicine to pevent it fom clotting. Then, the cell sepaation machine collects the lymphocytes fom you blood and mixes them with the dug 8-methoxypsoalen o UVADEX. This is a photosensitizing agent that becomes active when it is exposed to ultaviolet light. The lymphocytes and UVADEX ae next exposed to ultaviolet A light inside the machine. Lastly, the lymphocytes and the est of you blood ae e-infused to you. How can this pocedue help me? By teating you lymphocytes duing photopheesis, thei function is alteed. When the teated lymphocytes ae e-infused, they will stimulate an immune esponse in you body to fight the development o pogession of GvHD.

121 You docto might use photopheesis alone o in combination with othe teatments. How will I feel duing the photopheesis pocess? You will lay comfotably in bed duing the photopheesis pocedue while you blood is taken, pocessed, and then e-infused. Photopheesis is a painless pocedue. Changes in blood volume might cause you to feel dizzy, light-headed o cold. Tell you nuse if you expeience any of these symptoms, and he o she will help elieve you discomfot. What ae the side effects? A few patients might expeience a slight dop in blood pessue duing the pocedue. This is easily coected by eceiving intavenous fluids. Anothe possible side effect is feve about 6 to 8 hous afte the pocedue. Please tell you docto if you have a tempeatue ove F. You docto might ecommend you take additional medicines such as acetaminophen (Tylenol ). Pecautions afte teatment You must avoid sunlight, even if it's indiect sunlight, fo 24 hous afte each pocedue since you will be moe sensitive to the sun. If you go outside, please apply sunsceen with at least SPF 30. Please wea UVA potective sunglasses in a "wapaound" style to potect the sides of you eyes. UVA sunglasses ae available in many colos, including clea, at most dug stoes fo about $20. It is ecommended that you wea these both inside and outside fo 24 hous afte each pocedue. Notes Index #10252 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

122 Radiation Theapy You will have an appointment pio to you fist day of adiation so they can take measuements. These measuements will be used to potect you ogans duing you adiation teatments. What is adiation theapy? Radiation theapy is a fom of cance teatment that uses high levels of adiation to kill cance cells o keep them fom gowing and dividing while minimizing damage to healthy cells. You can expect to eceive small daily doses of adiation ove a peiod of 1 to seveal days. Moe infomation egading this theapy will be povided by the Radiation Theapy Depatment. What happens on teatment day? The adiation theapist will escot you into the teatment oom. The theapist will help place you in the coect teatment position. Once the theapist is sue you ae positioned coectly, he o she will leave the oom and stat the adiation teatment. You will be unde constant obsevation duing the teatment. Cameas and an intecom ae in the teatment oom, so the theapist can always see and hea you. If you should have a poblem, you can let the theapist know. It is vey impotant that duing teatment, you emain still and elaxed. Radiation Theapy The theapist will be in and out of the oom to eposition the machine and change you position. The teatment machine will not touch you and you will feel nothing duing the teatment. Once you teatment is complete, the theapist will help you out of the teatment oom. Whee should I go on the fist day of teatment? On the fist day of teatment, check in at Desk T28 o R28, accoding to you schedule. Plan to aive a few minutes befoe you scheduled appointment. The eceptionist will give you instuctions on whee you can wait, and you will be asked to change into a hospital gown. When the adiation theapist is eady, you name will be called. The

123 theapist will meet you in the waiting aea and escot you to the teatment aea. You family and fiends will be asked to wait in the waiting aea until you finish you teatment. Common Side Effects of Radiation Theapy Skin eactions Duing you teatment, adiation must pass though you skin.you might notice some skin changes in the aea exposed to adiation. You skin might become ed, wam, and sensitive as if you had a sunbun. It might also become dake and appea tanned. It might peel o become moist and tende. Depending on the dose of adiation you eceive, you might notice a loss of hai o deceased pespiation within the teated aea. These skin eactions ae common and tempoay. They will subside gadually within 2 to 4 weeks of completing teatment. If skin changes appea outside the teated aea, tell you docto o pimay nuse. Fo infomation on how to educe skin eactions caused by adiation theapy, see the section entitled, How to Cope with Side Effects. Nausea and vomiting Radiation teatment might cause nausea (a sensation often leading to the uge to vomit). If nausea occus, it usually happens fom 2 to 6 hous afte you teatment. Nausea might o might not be accompanied by vomiting. Fo infomation on how to manage nausea and vomiting caused by adiation theapy, see the section entitled, How to Cope with Side Effects. Fatigue Eveyone has a diffeent level of enegy, so adiation teatment will affect each patient diffeently. Fo most patients, this fatigue is mild. Howeve, a loss of enegy might equie othe patients to change thei daily outine. To minimize fatigue while you ae eceiving adiation teatment: Be sue to get enough est. Eat a well-balanced, nutitious diet. Pace you activities and plan fequent est peiods. Notes Index #10261 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

124 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. Peventing Cental Line-Associated Bloodsteam Infections (CLABSi)

125 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.

126 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.

127 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

128 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

129 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

130 What You Should Know About You Medications and Pesciption Coveage Fomulay vs. Non-fomulay A fomulay is a list of medications (band and geneic/"off-band") that ae pefeed by you pesciption plan. You plan may only pay fo medications that ae on this pefeed list, o if they cove them, it may be at a highe cost to you. The pupose of a fomulay is to povide you with the least expensive medications that ae effective fo teating you health condition. Each pesciption plan has a unique fomulay; this may be available on you insuance company's website. Additionally, some plans equie you to fill you pesciptions at pefeed phamacies. Talk to you local phamacist and/o insuance company to obtain a list of pefeed phamacies and medications. Co-payments o "Co-pays" A co-pay is the amount, o potion of the cost, you ae equied to pay out-of-pocket fo you pesciption medication afte you insuance has paid thei pat. Anothe tem that is fequently used is "coinsuance" which means you ae esponsible fo a pecentage of the cost of you medication (i.e. 10% of all geneic medications) instead of a flat fee. Fomulay Ties Medications on the fomulay ae categoized into thee categoies: 1. Geneic--these "off-band" medications have the lowest co-pays and ae geneally efeed to as "Tie 1 medications" (geneic medications ae FDA appoved to be equivalent to thei band name countepats). 2. Fomulay band name--these medications, which ae only available as the band poduct because thei geneic fom is not yet available, have a highe co-pay and ae geneally efeed to as "Tie 2 medications". 3. Non-fomulay--these medications have the highest co-pays because thee may be a simila dug available on a lowe tie of the fomulay. Altenatively, a medication may be non-fomulay if it is new o extemely expensive. These ae geneally consideed "Tie 3 medications". Pio Authoization o "PA" If a medication is not included on you pesciption plan's fomulay, it is sometimes possible to obtain coveage. You docto must complete this pocess, also known as a pio authoization, by submitting the pope foms and documentation to you insuance plan. It is impotant fo you to detemine whethe o not you need a PA fo you medication befoe you attempt to have you pesciption filled fo the fist time, because the PA pocess may take a few days to complete. Additionally, some medications may equie a PA evey month, wheeas othes equie you docto to complete the pocess only one time. You Medications & Pesciption Coveage

131 Patient Name Medical Recod Numbe This woksheet was ceated so you ae awae of the potential financial impact of seveal expensive medications you may equie following tansplant. Evey patient s insuance coveage is diffeent. You should contact you insuance company to ask what you will be equied to pay fo these medicines IF they ae needed. Medication List The list only includes the most common and most expensive medications that typical patients equie following tansplant, and is not all-inclusive. You medication list will be detemined by you docto based on you specific needs and cicumstances. Cash pices listed eflect only the cuent pices offeed by the Cleveland Clinic as of Mach 18, Cash pices fo othe phamacies may vay. The cash pice is the cost of the medication WITHOUT pesciption coveage. Allogeneic Blood & Maow Tansplant Patient Medication Cost Woksheet Dug Name *(Indicates band only) ononly) Dose Monthly Quantity Indication Cash Pice (Monthly) Monthly cost to patient (co-pay) Pio Auth Needed Y o N Mail Ode o etail phamacy M o P Voiconazole tablets Pevent/teat fungal infection $2, Itaconazole (Spoanox*) 10 mg/ml solution 600 ml (4 bottles) Pevent/teat fungal infection $1, Posaconazole (Noxafil*) 40 mg/ml 630 ml (6 bottles) Pevent/teat fungal infection $6, Posaconazole (Noxafil*) 100 mg 90 tablets Pevent/teat fungal infection $5, Valganciclovi 450 mg 120 tablets Pevent/teat vial infection $6, Siolimus 1 mg 30 tablets Immunosuppessant $ Siolimus (Rapamune*) 1 mg/ml solution 60 ml (1 bottle) Immunosuppessant $ Tacolimus (Mylan) 1 mg 120 capsules Immunosuppessant $ Cyclospoine 100 mg 120 capsules Immunosuppessant $ Mycophenolate Mofetil 500 mg 120 tablets Immunosuppessant $ Ae thee estictions on what phamacy I may use to fill these pesciptions? YES NO Am I equied to use a mail ode phamacy fo any of these pesciptions? YES NO Pesciption Insuance Infomation** Plan Name: RX ID RX BIN: RXPCN: Policy Holde Name: Relationship to Policy Holde: Custome Sevice Phone No.: Date of Contact RX Goup: **This infomation can be found on you pesciption insuance cad Index # Rev. 05/01/2015

132 - 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.

133 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

134 Amoxicillin Band names: Amoxil, Timox, Wymox Class of dugs: Antibiotic Why is amoxicillin pescibed? Amoxicillin is a type of penicillin pescibed to pevent o teat infections caused by bacteia. How is amoxicillin taken? Amoxicillin is available in capsules, tablets, chewable tablets, and suspension liquid (with small paticles in it). The chewable tablet fom of this medicine should be chewed thooughly o cushed befoe swallowed. The oal liquid fom of this medicine should be shaken well befoe use and measued with a specially maked measuing spoon to measue each dose accuately. The liquid fom can be taken by itself o mixed with milk, juice, wate, ginge ale, o othe cold dinks. If you mix the liquid fom of the medicine with anothe liquid, dink it as soon as you mix it. This medicine may be taken on a full o empty stomach. Amoxicillin This medicine woks best when thee is a constant amount of it in the bloodsteam. Amoxicillin 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. 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 it, geneally twice a day. 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? BEFORE he o she pescibes this medicine, tell you health cae povide if you have eve had any unusual o allegic eactions to penicillin o cephalospoin medicines. 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 any

135 of these medicines o foods, amoxicillin might not be the ight medicine fo you. Anothe antibiotic might be pescibed instead. This medicine might change the effectiveness of oal contaceptives (bith contol pills) containing estogen. Use a second method of bith contol while taking this medicine. If you have diabetes, amoxicillin might change the esults of you blood glucose tests. Check with you docto befoe changing you diet o the dosage of you diabetes medicine. 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. 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 capsule o tablet fom of this medicine at oom tempeatue. Stoe the liquid fom of this medicine in the efigeato, but keep the liquid fom feezing. Discad liquid that is olde than 14 days. DO NOT stoe the capsule o tablet fom of 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. Keep this medicine in a tightly sealed containe. Keep this and othe medicines out of the each of childen. 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. What ae the common side effects of this dug? Amoxicillin might cause any of the following side effects: 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. Tell 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 a sevee allegic eaction. When should I call my health cae povide? Call you health cae povide ight away if you: Have a skin ash 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 o have any questions o concens Index #10425 Poduced by the Cente fo Consume Health Infomation Copyight The Cleveland Clinic Foundation. All ights eseved. Rev. 04/13

136 - Amphoteicin B Band name: Fungizone Class of dugs: Antifungal Why is amphoteicin B pescibed? Amphoteicin B is pescibed to tansplant patients to teat o pevent the development of aspegillus infection, a type of fungal infection. A tansplant patient has an inceased isk of developing infections because the immune system is suppessed. Amphoteicin B will suppess the infection and help keep the symptoms fom becoming wose. How is amphoteicin B given? This medicine is given by infusion (IV). This dug woks best when thee is a constant amount of it in the bloodsteam. In ode to achieve this, allo tansplant patients will eceive amphoteicin B daily in the hospital, stating the day afte you tansplant. Amphoteicin B must be taken fo the entie duation of teatment in ode to achieve the best esults. The dose of this dug will be diffeent fo each patient. A home cae nuse will teach you how to give youself this medicine if it is needed on an outpatient basis. Auto tansplants may eceive amphoteicin B on an as needed basis as diected by you physician. Amphoteicin B What special instuctions should I follow while using this dug? Dink plenty of fluids evey day. (We ecommend at least six to eight, 8-ounce glasses of fluid a day.) Keep taking this medicine fo the full time of teatment. Keep all appointments with you docto and the laboatoy so you esponse to the dug can be monitoed. Keep efigeated. Do not feeze.

137 What ae the common side effects and what can I do to teat them? While you ae taking amphoteicin B, fequent blood tests will be taken to pevent o minimize the development of the following seious side effects: Electolyte imbalance Taking you pescibed oal potassium and magnesium will help with this side effect. It is not uncommon to equie intavenous electolyte eplacement. Alteed kidney function Amphoteicin B might be changed to Amphoteicin B lipid complex at you docto s discetion. Alteed live function Diahea Shaking, chills, feve Medicine such as Tylenol and Benadyl will be given befoe amphoteicin B to pevent the development of feve o chills. Othe medicines might also be added if needed. Genealized muscle o joint pain Many of the side effects of amphoteicin B ae dose-elated and might go away when you health cae povide adjusts you dosage. When should I notify my health cae povide? If you have any of these symptoms, please tell you health cae povide ight away so the dosage of you medicine can be adjusted o additional medicine can be pescibed to pevent o teat these side effects: Chills, feve, o headache Nausea that does not impove afte changing you eating habits Vomiting o diahea Changes in the colo of you uine Inceased o deceased uination Changes in you vision Unusual skin changes Unusual fatigue Exteme weight loss with unknown cause Deceased appetite Difficulty beathing Soe thoat Stomach pain Numbness o tingling in hands/feet Pain o swelling at the infusion site Shotness of beath Index #6982 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. 04/11

138 - Azithomycin Band names: Zithomax, AzaSite, Zmax Class of dugs: Antibiotic (Macolide) Why is azithomycin pescibed? Azithomycin is pescibed to pevent o teat infections cause by cetain bacteia. How is azithomycin taken? Azithomycin is available in tablets, suspension liquid (with small paticles in it) o can be injected though an IV. Immediate elease Azithomycin tablets and oal suspension can be taken on an empty o full stomach. If you ae taking an extended elease suspension you should take it on an empty stomach. This medicine woks best when thee is a constant amount of it in the bloodsteam. Azithomycin must be taken fo the entie duation of teatment in ode to achieve the best esult. It is impotant that you take this medicine egulaly as pescibed. Do not stop taking it without talking to you docto. The dose of this medication 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. Azithomycin What special instuctions should I follow while using this dug? Befoe he o she pescibes this medicine, tell you health cae povide if you have eve had any unusual o allegic eactions to macolide antibiotics. 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 any of these medicines o foods, Azithomycin might not be the ight medicine fo you. Anothe antibiotic might be pescibed instead. This medication might change the effectiveness of oal contaceptives (bith contol pills) containing estogen. Use a second method of bith contol while taking this medicine.

139 Dink 2-3 lites pe day of fluid to stay hydated while taking this medication. 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. 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. How should I stoe this medicine Keep this medicine in a tightly sealed containe. Stoe this medication at oom tempeatue. If you ae taking the extended elease suspension (liquid), you should take it within 12 hous of mixing. Keep this and othe medicines out of the each of childen. What ae the common side effects of this dug? Azithomycin may cause any of the following side effects: uine output and confusion. Notify you nuse coodinato if you ae having moe than five liquid stools daily. Nausea and/o vomiting -- Notify 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 a sevee allegic eaction. When should I call my health cae povide? Call you health cae povide if you: 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 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 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 may include weakness, dizziness when standing fom a sitting position, deceased Index #14349 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 bythe Cente fo Consume Health Infomation Copyight The Cleveland Clinic Foundation. All ights eseved. Rev 04/11

140 - Amphoteicin B Lipid Complex Band name: Abelcet Class of dugs: Antifungal Why is amphoteicin B lipid complex pescibed? Amphoteicin B lipid complex is pescibed to tansplant patients to teat o pevent the development of aspegillus infection, a type of fungal infection. A tansplant patient has an inceased isk of developing infections because the immune system is suppessed. Amphoteicin B lipid complex will suppess the infection and help keep the symptoms fom becoming wose. Is thee any eason I should not use this medicine? You should not use this medicine if you have eve had an allegic eaction to amphoteicin B. How is amphoteicin B given? This medicine is given by infusion (IV). This dug woks best when thee is a constant amount of it in the bloodsteam. In ode to achieve this, allo tansplant patients will eceive amphoteicin B lipid complex daily in the hospital, stating the day afte you tansplant. Amphoteicin B lipid complex must be taken fo the entie duation of teatment in ode to achieve the best esults. The dose of this dug will be diffeent fo each patient. A home cae nuse will teach you how to give youself this medicine if it is needed on an outpatient basis. Auto tansplant patients may eceive amphoteicin B lipid complex on an as needed basis as diected by you physician. Amphoteicin B Lipid Complex What special instuctions should I follow while using this dug? Dink plenty of fluids evey day. (We ecommend at least six to eight, 8-ounce glasses of fluid a day.) Keep taking this medicine fo the full time of teatment. Keep efigeated. Do not feeze. Keep all appointments with you docto and the laboatoy so you esponse to the dug can be monitoed.

141 What ae the common side effects? While you ae taking amphoteicin B lipid complex, fequent blood tests will be taken to pevent o minimize the development of the following seious side effects: Electolyte imbalance Taking you pescibed oal potassium and magnesium will help with this side effect. It is not uncommon to equie intavenous electolyte eplacement. Alteed kidney o live function Diahea Nausea, stomach upset, vomiting Weakness, muscle camps Shaking, chills, feve Medicine such as Tylenol and Benadyl will be given befoe amphoteicin B lipid complex to pevent the development of feve o chills. Additional medicines might also be added if needed. Genealized muscle o joint pain Many of the side effects of amphoteicin B lipid complex ae dose-elated and might go away when you health cae povide adjusts you dosage. When should I notify my health cae povide? If you have any of these symptoms, please tell you health cae povide ight away so the dosage of you medicine can be adjusted o additional medicine can be pescibed to pevent o teat these side effects: Chills, feve, o headache Nausea that does not impove afte changing you eating habits Vomiting o diahea Changes in the colo of you uine Inceased o deceased uination Changes in you vision Unusual skin changes Unusual fatigue Deceased appetite Exteme weight loss with unknown cause Difficulty beathing Soe thoat Stomach pain Numbness o tingling in hands/feet Pain o swelling at the infusion site Shotness of beath 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 #11053 Heaing Impaied (TTY) Assistance Copyight The Cleveland Clinic Foundation. All ights eseved. Poduced by the Cente fo Consume Health Infomation 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 Cyclospoine Common band names: Neoal, Sandimmune, Gengaf How do I take cyclospoine? Cyclospoine is available as soft gelatin capsules o oal solution (an olive oil-based liquid). If you take the oal solution, it is best to mix it with milk, chocolate milk, apple juice, o oange juice. Use only glass containes. Refill the glass with moe juice o milk afte taking you dose, and dink the juice o milk to be sue you get all of the medicine. The soft gelatin capsules ae available in 2 stengths, 25 mg and 100 mg. Each is diffeent in size and colo. Packaged individually, these capsules should be left in the foil containes until used. Cyclospoine may be taken with wate on an empty o full stomach. In the hospital, it can be given intavenously. Cyclospoine is geneally taken twice a day. Take the moning dose with beakfast. Take the second dose 12 hous afte the fist dose. Be sue to take the pescibed doses at the same time evey day. 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 at the same time evey day as pescibed. Do not stop taking it. You might need to take immunosuppessant dugs fo the est of you life to pevent o contol gaft vesus host disease (GvHD). Cyclospoine What special instuctions should I follow while using this dug? Levels of cyclospoine in the blood can be measued. This is done to help you docto monito you theapy moe closely. It is impotant to schedule you egula lab wok appointment befoe taking you daily dose of cyclospoine (pefeably in the ealy moning). You must take the last dose of cyclospoine at least 12 hous befoe you blood tests. Bing you medicine with you to you appointment so you can take it immediately afte you blood is dawn fo the test. You must take the entie pescibed amount of cyclospoine to maintain enough immunosuppession. Follow you dosage schedule caefully.

149 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 eceive any vaccinations without you docto's appoval. Take pecautions to avoid infection while taking this medicine. If you eat gapefuit o dink gapefuit juice poducts, it is impotant that you eat o dink the same amount evey day, because this might affect you dug level. Thee ae diffeent fomulations (bands) fo cyclospoine. Please veify that you phamacist is filling the coect band. 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 is almost time fo you next dose, you may take you missed along with you egula dose then etun to you egula schedule. If you have fogotten moe than 1 dose, contact you nuse coodinato fo instuctions. What ae the common side effects of this dug? Even though the side effects of cyclospoine could be vey seious, emembe that this dug is necessay. We will take pecautions to detect these side effects and teat them befoe they become hamful. Cyclospoine might esult in any of the following side effects: Flushing This efes to a bief peiod of wamth and/o edness in you face fo 1 to 2 hous afte taking cyclospoine. This feeling disappeas within a shot time. Hai gowth Inceased hai on you face, ams, and body is common, and can be contolled, if necessay, with bleaching ceams o hai-emoval poducts. Please discuss with you tansplant docto pio to using any of these poducts Fine temos of the hands Tembling of the hands is common, especially duing the fist month of taking cyclospoine. The temo is usually mild and tends to disappea the longe you take the medicine o when you dosage is deceased. Gum swelling and mouth sensitivity to cold o heat Exteme cae in daily hygiene is necessay to keep gums in good health. Hypetension (high blood pessue) You will be asked to puchase a blood pessue cuff and to ecod you blood pessue twice daily while you ae taking cyclospoine. You may be given appopiate medicine to contol you blood pessue, if needed. It is impotant to follow othe ecommendations to help lowe you blood pessue. Alteed kidney function (nephotoxicity) You will have blood tests pefomed fequently to detect changes in kidney function. Diahea Nausea o vomiting Small, fequent meals, good mouth cae, and sucking on had candy might help. Neuological symptoms These include headache and sensing memoy loss. Dug inteactions Seveal dugs affect metabolism o excetion of cyclospoine and must be used with caution. You need to veify ALL new medicines with you docto and nuse coodinato. This includes ove-the counte (OTC) and hebal poducts. Inceased isk of infection

150 What stoage conditions ae necessay fo this dug? Stoe this medicine at oom tempeatue. Do not feeze o expose to heat ove 77 F. The liquid might gel at tempeatues below 68 F, so bing to oom tempeatue befoe dinking. cyclospoine in you blood and pevent advese side effects of the medicine. How can I educe the side effects of cyclospoine? To avoid o contol the possible side effects of cyclospoine, follow the suggestions on the next page. If you ae taveling, stoe you cyclospoine in an insulated containe. 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 the capsule fom of this medicine in the packaging it came in, tightly sealed. Cyclospoine might lose its stength if emoved fom its packaging fa in advance of taking it. The liquid fom of this medicine can be used fo 60 days afte opening. Do not use this medicine afte the expiation date on the packaging. Keep it and othe medicines out of the each of childen. Why ae blood tests impotant? Fequent blood tests allow you docto to effectively monito the levels of Notes Cyclospoine

151 Possible Side Effect Inceased isk of infection Swollen o bleeding gums Excess hai gowth Live damage Kidney damage Temos o seizues High blood pessue What You Should Do Avoid anyone who might have an infection, and epot any signs o symptoms of infection to you health cae povide. Pactice good oal hygiene to pevent swollen gums fom becoming infected. Bush you teeth and gums thooughly afte each meal with a small, soft toothbush and fluoide toothpaste. Use foam sticks instead of a toothbush if you gums ae especially soe. Keep dentues clean and fitting popely. Repot any mouth soes to you health cae povide. Notify you BMT Team befoe any dental pocedues. To emove unwanted hai, use safe bleaching techniques o ceams. Please check with you BMT Team befoe using these poducts. Visit you docto egulaly and have you blood dawn as scheduled. Repot any changes in the colo of you uine, eyes, o skin. Repot any changes in uine output, weight, o swelling duing you egula docto visits. Repot any tembling, shaking, o seizues to you docto. You dosage might need to be adjusted. Take you medicine as pescibed and limit salt in you diet. Index #10423 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

152 Fluconazole Band name: Diflucan Why is fluconazole pescibed? Fluconazole is used to pevent o teat fungal infections. Tansplant patients might develop infections because thei immune systems ae suppessed by eithe chemotheapy o in allogeneic patients by the immunosuppessive medicines they must take to pevent gaft-vesus-host disease. How is fluconazole taken? Fluconazole is geneally taken in the fom of tablets in 100 mg o 200 mg. It also comes in 50 mg, 150 mg, and suspension liquid. In the hospital, this medicine can be given intavenously. It is usually taken once daily. Fluconazole must be taken fo the entie duation of teatment in ode to achieve the best esults. The dose of this dug will be diffeent fo each patient. It is possible you will take fluconazole as long as you ae also taking immunosuppessive medicines. You might be taking this medicine and amphoteicin B at the same time. 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 you take this medicine egulaly as pescibed. Do not stop taking it without talking to you docto. Fluconazole What special instuctions should I follow while using this dug? It is impotant to tell you docto if you ae taking a medicine called cimetidine (Tagamet ), which is an antacid. Cimetidine can decease the effect of fluconazole. It is impotant to tell you docto if you ae taking medicines called anticoagulants, such as wafain (Coumadin ). Fluconazole can incease the effect of the anticoagulant, so it might be necessay to have blood tests moe fequently. If you ae taking tacolimus, you docto might ode moe fequent checks of tacolimus blood levels and might possibly change you dose of tacolimus. Please tell you health cae povide if you ae using tadalafil (Cialis ) sildenafil (Viaga), o vadenafil (Levita) fo eectile dysfunction. This dug combination

153 might cause changes in you blood pessue. If you ae taking a medicine called cyclospoine (Neoal ), you docto might ode moe fequent blood tests to check you enal (kidney) function. Keep taking fluconazole 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. 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. 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 tablet fom of this medicine at oom tempeatue. The liquid fom of this medicine can be stoed eithe at oom tempeatue o in the efigeato. Do not feeze. Thow away any unused liquid afte 2 weeks. 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 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 common side effects of this dug? Fluconazole might cause any of the following side effects: 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. Headache 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 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 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 #10995 Heaing Impaied (TTY) Assistance Poduced by the Cente fo Consume Health Infomation Copyight The Cleveland Clinic Foundation. All ights eseved. Rev. 02/11

154 Ganciclovi Band names: Cytovene Class of dugs: Antivial Why is ganciclovi pescibed? Ganciclovi is pescibed to tansplant patients to teat o pevent the development of cytomegalovius (CMV), a type of hepes vius that can cause a vaiety of diffeent infections. Ganciclovi will suppess the infection and help keep the symptoms fom becoming wose. A BMT patient who eceived dono cells might be at isk fo developing an active CMV infection if he o she o the dono was exposed to the vius in the past. How is ganciclovi given? This medicine is given by infusion (IV). This dug woks best when thee is a constant amount of it in the bloodsteam. You must take ganciclovi fo the entie duation of teatment in ode to achieve the best esults. The dose of this dug will be diffeent fo each patient. A home cae nuse will teach you how to give youself this medicine at home. What special instuctions should I follow while taking this medicine? Ganciclovi Please efe to the sepaate infomation sheet about chemotheapy pecautions unde the Medication tab in this binde. While taking this medicine, it is impotant fo men and women to use baie contaception (condom) if they ae sexually active, since thee might be an inceased isk of bith defects if pegnancy occued while taking this medicine. Continue using baie contaception fo at least 90 days following ganciclovi teatment. This medicine might cause infetility in men o women. Discuss this isk with you health cae povide befoe taking this medicine. Keep taking ganciclovi fo the full time of teatment. Be sue you always have enough medicine on hand. Check you supply befoe holidays o othe occasions when you home cae phamacy might be unable to delive you supply. Keep all appointments with you docto and the laboatoy so you esponse to the dug can be monitoed.

155 What should I do if I foget to take a dose? If you foget to take a dose, call you health cae povide fo instuctions. What stoage conditions ae necessay fo this dug? Stoe this medicine in the efigeato. Do not feeze. Keep this and othe medicines out of the each of childen. What ae the common side effects and what can I do to teat them? While you ae taking ganciclovi, fequent blood tests will be taken to pevent o minimize the development of these seious side effects: Neutopenia (low white blood cell count) If you ae told you white blood cell count is at a citical level, call you health cae povide if you develop any of these symptoms: - Feve F o highe - Mild soe thoat - Mild cough Anemia (low ed blood cell count) Thombocytopenia (low platelet count) Alteed kidney function (nephotoxicity) Blood tests will be pefomed fequently to detect any changes in kidney function. Othe common side effects include: Headache Diahea Nausea Vomiting Upset stomach Loss of appetite Dizziness Confusion Nevousness Rash When should I call my health cae povide? If you have any of these symptoms, please tell you health cae povide at you next follow-up appointment: Changes in you uine output Swelling of the feet o ankles Nausea that does not impove afte changing you eating habits If you expeience any of the following symptoms, call you health cae povide immediately: Soe thoat with feve, chills Diahea Unusual bleeding o buising Black, tay stools Pain o swelling at place of infusion Rash Unusual tiedness Mood o mental changes Index #10247 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

156 - Immune Globulins (IVIG) Othe Names: Sandoglobulin, GammImmune, Iveegam, Gammagad, Polygam, Venoglobulin What ae immune globulins? Immune globulins ae substances nomally found in you body that pefom a vaiety of functions, the most impotant being to help fight infection. You will eceive immune globulins intavenously to help boost you infection-fighting capabilities. You BMT Team will detemine how often you will eceive the infusion. Sometimes, people eceive intavenous (IV) immune globulins because it seems to incease the length of suvival of platelets, the cells esponsible fo the contol of bleeding in you body. You may ask you docto o nuse fo the exact eason why you ae eceiving immune globulins. How ae immune globulins given? Immune globulins ae given intavenously (diectly in a vein) ove a peiod of a few hous. What ae the side effects of immune globulins? Although ae, you might expeience some side effects fom the IV immune globulins. These side effects might include: Chills Flushing Immune Globulins (IVIG) Dizziness Nausea Feve Back, hip, o joint pain Headache

157 Tiedness Shotness of beath, wheezing Chest tightness Rash o hives Poblems uinating o uinating less often Patients who expeience some of these side effects might be pe-medicated with Tylenol, diphenhydamine, and/o hydocotisone. These dugs ae given to pevent futhe infusion eactions. When should I call my health cae povide? If you expeience any of these side effects o if you stat to feel diffeent in any way, call you nuse immediately. If you have any othe questions about this medicine, please ask you nuse o docto. 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 #10639 Heaing Impaied (TTY) Assistance Cente fo Consume Health Infomation Copyight The Cleveland Clinic Foundation. All ights eseved. Rev. 04/12

158 Immunosuppessant Medicines Why do I need to suppess my immune system? In ode fo you dono's cells to establish themselves in you body, the cells involved with ecognizing "foeign" cells must be suppessed. You will be on seveal diffeent immunosuppessant medicines at the same time because each medicine suppesses you immune system in a diffeent way. They ae used to pevent o contol gaft vesus host disease (GvHD). The Tansplant Team will monito the atio of dono and ecipient DNA on a outine basis though a blood test. Once you dono's cells ae fully matued, you tansplant docto will detemine the best tape schedule fo you. You might be taking none, one, o seveal immunosuppessant medicines at diffeent times afte tansplant. You might need to be taking immunosuppessant medicines fo an indefinite length of time to contol GvHD. While you ae on any suppessive medicine, you ae at isk fo life-theatening infections. You nuse coodinato will eview pecautions with you to pevent infection. You must always watch fo signs of infection, and notify you Tansplant Team immediately at the fist sign. When should I call my health cae povide? Call you health cae povide RIGHT AWAY if you have any of these waning signs of infection: Feve of o F (38 o C). Sweats o chills Skin ash Pain, tendeness, o swelling Wound o cut that won't heal Immunosuppessant Medicines Red, wam, o daining soe Soe thoat, scatchy thoat, o pain when swallowing Sinus dainage, nasal congestion, headaches, o tendeness along the uppe cheekbones Pesistent dy o moist cough that lasts moe than 2 days White patches in you mouth o on you tongue

159 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 Also, contact you health cae povide if you have any othe symptoms that cause concen o if you have any questions. Notes Index #10418 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

160 Itaconazole Band name: Spoanox Class of dugs: Antifungal Why is itaconazole pescibed? Itaconazole is pescibed to tansplant patients to teat o pevent the development of aspegillus infection, a type of fungal infection. A tansplant patient has an inceased isk of developing infections because the immune system is suppessed. How is itaconazole taken? Itaconazole is geneally taken in the fom of capsules o liquid that is swallowed. If the liquid fom of this medicine is pescibed, use a specially maked measuing cup to measue each dose accuately. This dug woks best when thee is a constant amount of it in the bloodsteam. You must take itaconazole fo the entie duation of teatment in ode to achieve the best esults. The dose of this dug will be diffeent fo each patient. You will pobably take itaconazole as long as you ae also taking immunosuppessive medicines. You might be taking this medicine and an additional antifungal (amphoteicin B) at the same time. 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. Itaconazole What special instuctions should I follow while taking this medicine? Itaconazole should be taken at least 2 hous befoe taking magnesium supplements and antacids such as Pepcid, Pilosec, and Nexium if these medicines ae pescibed fo you. Liquid itaconazole is best absobed on an empty stomach with a glass of cola, which will incease you stomach s acidity, making the medicine moe effective. Please tell you health cae povide if you ae using the dug tadalafil (Cialis ), Sildenafil (Viaga), o Vadenafil (Levita) fo eectile dysfunction. This dug combination might cause changes in you blood pessue.

161 It is best to take the tablet fom of itaconazole with food. Keep taking itaconazole fo the full time of 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. 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. 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 this medicine at oom tempeatue. DO NOT stoe the capsule fom of 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. Stoe the liquid fom of this medicine in the efigeato, but make sue it does not feeze. Keep this medicine in a tightly sealed containe. Keep this and othe medicines out of the each of childen. 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. What ae the common side effects and what can I do to teat them? While you ae taking itaconazole, fequent blood tests will be taken to pevent o minimize the development of alteed live function, a seious side effect of this medicine. Nausea is a common side effect of itaconazole. To manage nausea, eat small, fequent meals and avoid spicy o geasy foods. When should I call my health cae povide? If you have any of these symptoms, please tell you health cae povide at you next follow-up appointment: Changes in you uine output Nausea that does not impove afte changing you eating habits Constipation, diahea Headache If you expeience any of the following symptoms, call you health cae povide immediately: Feve o chills Skin ash, itching o unusual skin changes Soe thoat Changes in the colo of you uine Changes in you vision Unusual fatigue Exteme weight loss with unknown cause Unusual bleeding o buising Stomach pain Loss of appetite Index #9064 Heaing Impaied (TTY) Assistance Poduced by the Cente fo Consume Health Infomation Copyight The Cleveland Clinic Foundation. All ights eseved. Rev. 02/11

162 - Methotexate Band names: Folex, Folex PFS, Mexate, Mexate-AQ, Rheumatex, Texall What ae some othe names fo this medicine? Methotexate is also called MTX. What does it do? Methotexate blocks an enzyme needed by cance cells to live. This intefees with the gowth of cance cells, which ae eventually destoyed. Methotexate is also used to pevent gaft vesus host disease in BMT patients eceiving cells fom a dono. This medicine is classified as an antimetabolite. How is it given? Methotexate is an intavenous solution that is injected though you cental venous cathete. What ae some side effects I might expeience? Deceased blood counts Nausea and vomiting Methotexate Poo appetite Diahea 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. Skin ash Inceased sensitivity to the sun

163 Hai loss Eye iitation Loss of fetility Kidney toxicity 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 #4884 Heaing Impaied (TTY) Assistance Poduced by the Cente fo Consume Health Infomation Copyight The Cleveland Clinic Foundation. All ights eseved. Rev/v 02/11

164 - Mycophenolate Mofetil Common band name: CellCept Type of medicine: Immunosuppessant How is this medicine taken? Mycophenolate mofetil is available in capsule o tablet fom in 250 mg and 500 mg doses. It is also available in liquid fom. In the hospital, this medicine can be given intavenously. Geneally, mycophenolate mofetil is taken 2 to 3 times pe day. Swallow the capsules o tablets whole. Do not beak, cush, chew, o open the capsules o tablets befoe swallowing. Mycophenolate mofetil may be taken with o without food. 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 at the same time evey day as pescibed. Do not stop taking it. You might need to take immunosuppessant dugs fo the est of you life to pevent o contol gaft vesus host disease (GvHD). What special instuctions should I follow while using this dug? Do not take mycophenolate mofetil at the same time as an antacid, since absoption of this medicine will be deceased. Do not take antacids (Maalox, Mylanta, Tums ), cholestyamine, o ion within 2 hous of taking this medicine. Mycophenolate Mofetil Do not beak, cush, chew, o open the capsules o tablets befoe swallowing. The powde in the capsule should not come in diect contact with you skin o mucous membanes, and inhalation should be avoided. If skin contact does occu, wash you skin immediately and thooughly with soap and wam wate. You must take all of the pescibed amount of mycophenolate mofetil to maintain enough immunosuppession. Follow you dosage schedule caefully. 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.

165 Do not have any vaccinations without you docto's appoval. Take pecautions to avoid infection while taking this medicine. Use a eliable fom of bith contol duing teatment and fo 6 weeks afte teatment ends. 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 has been moe than 3 hous since you missed dose, call you nuse coodinato fo advice. Taking you medicine doses too close togethe can be hamful. What ae the common side effects of this dug? Diahea Nausea o vomiting Mycophenolate mofetil can cause bith defects. Theefoe, you should use baie contaception (condom) plus anothe fom of bith contol if you ae sexually active, even if you ae thought to be infetile. This pactice should be continued fo 6 weeks afte you docto discontinues this medicine. You should not ty to get pegnant while you ae taking this medicine. High blood pessue Headache Swelling What stoage conditions ae necessay fo this dug? Stoe this medicine, both pills and liquid, at oom tempeatue. Do not feeze o expose to heat ove 77 o F. Liquid might be kept in the efigeato as well. If you ae taveling, stoe you medicine in an insulated containe. 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 The liquid fom of this medicine can be used fo 60 days afte opening. Do not use this medicine afte the expiation date on the packaging. Keep it and othe medicines out of the each of childen. Thee is an inceased isk of infection. Avoid anyone who might have an infection, and epot any signs o symptoms of infection to you health cae povide. This medicine might cause a change in the white blood cell count. Have you blood dawn egulaly so you health cae povides can monito you white blood cell count. 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 #4679 Heaing Impaied (TTY) Assistance Poduced by the Cente fo Consume Health Infomation Copyight The Cleveland Clinic Foundation. All ights eseved. Rev. 02/11

166 - 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.

167 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

168 Pentamidine Band names: NebuPent, Pentam 300 Why is pentamidine given? Pentamidine is given to pevent the development of pneumonia caused by the bacteia Pneumocystis cainii. Allogeneic tansplant patients who ae unable to take sulfa dugs, such as Bactim, may be pescibed this teatment. How is pentamidine given? A espiatoy theapist will administe the pentamidine aeosol teatment using a device called a nebulize (a plastic tube that is held between you lips). The pentamidine aeosol teatment is deliveed though the nebulize until the entie dose is gone, usually 30 to 40 minutes. The pentamidine teatments ae given evey 30 days. The aeosol teatments can be given in the R10 Outpatient Depatment if you ae eceiving othe pescibed teatments that day o at A90 in the Respiatoy Theapy Depatment. You teatments will be aanged by you BMT Team. What special instuctions should I follow while taking this medicine? This medicine can cause coughing, difficulty beathing, o wheezing. A bochodilato (which opens you aiways), such as albuteol, might be given with the pentamidine aeosol teatment. This will allow the medicine to be given moe easily and to help pevent futhe advese effects. What ae the common side effects of this dug? Fatigue Dizziness Coughing Nausea Deceased appetite Pentamidine When should I call my health cae povide? Call you health cae povide immediately o call 911 if you expeience any of the following symptoms: Chest pain Constant coughing Difficulty beathing

169 Notes Index #10760 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

170 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.

171 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.

172 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.

173 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

174 - Sulfamethoxazole and Timethopim Double Stength Band name: Bactim DS Class of dugs: Antibiotic Why is Bactim DS pescibed? Bactim DS is usually pescibed to pevent o teat a specific bacteial infection called Pneumocystis cainii pneumonia. This infection can affect the lungs o bain. Bactim DS can also be used to teat a vaiety of bacteial infections including uinay tact infections. Tansplant patients might develop this infection because thei immune systems ae suppessed by the immunosuppessive dugs they must take to pevent gaft vesus host disease (GvHD). How is Bactim DS taken? Bactim DS is geneally taken in the fom of tablets o suspension liquid (with small paticles in it). The tablet fom of this medicine is taken with a full glass of wate (8 ounces). The oal liquid fom of this medicine should be shaken well befoe use and measued with a specially maked measuing spoon to measue each dose accuately. 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 consulting you docto. What special instuctions should I follow while using this dug? Review all of you allegies with you tansplant physician including allegies to foods, pesevatives, and dyes. Tell you health cae povide if you have eve had any unusual o allegic eactions to any of these medicines: sulfa medicines, fuosemide (Lasix ), thiazide diuetics (wate pills), oal diabetes medicines, glaucoma medicine, dichlophenamide (Daanide ), methazolamide (Neptazane ), o timethopim (Timpex ) BEFORE he o she pescibes Bactim DS. If you ae allegic to any of these medicines you should NOT take Bactim DS. Anothe antibiotic might be pescibed instead. Sulfamethoxazole and Timethopim

175 This medicine causes inceased sensitivity to sunlight. Avoid diect sunlight (especially fom 10 a.m. to 3 p.m., if possible) and tanning beds. Wea a sunblock with an SPF of at least 30 and, wea potective clothing, including a hat and sunglasses. Sensitivity to sunlight might continue fo many months afte you stop taking Bactim DS. Keep taking Bactim DS fo the full time of 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. 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. 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 this medicine (both 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? Bactim DS might cause any of the following side effects. Some of these side effects (such as headache o nausea) can be avoided o elieved by dinking plenty of wate daily. Anemia (blood poblems esulting fom a eduction in the numbe of ed blood cells) Anemia is often a esult of taking Bactim DS ove a long peiod of time. Loweed white cell count Sensitivity to sunlight Dizziness Diahea Headache Loss of appetite Nausea with o without vomiting Skin ash When should I call my health cae povide? Call you health cae povide ight away if you: Have skin eactions Have sevee nausea o vomiting 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 #4675 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. 05/11

176 Tacolimus Common band name: Pogaf (FK506) Type of medicine: Immunosuppessive agent How is tacolimus taken? Tacolimus is available in capsule fom in 0.5 mg, 1 mg, o 5 mg doses. In the hospital, this medicine can be given intavenously. It is also available as an ointment fo the skin. Take tacolimus exactly as you docto diects. Tacolimus woks best when it is constantly in the bloodsteam. Ty to take it aound the same time each day. Levels of tacolimus in the blood can be measued. This will help you docto monito you theapy closely. Changes in you diet might affect absoption of this dug. Do not change the type o amount of food you eat without talking with you docto. 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 at the same time evey day as pescibed. Do not stop taking it. You might need to take immunosuppessant dugs fo the est of you life to pevent o contol gaft vesus host disease (GvHD). Tacolimus What special instuctions should I follow while using this dug? It is best to take tacolimus on an empty stomach. Take it 1 hou befoe o 2 hous afte meals. Swallow capsules whole. Do not chew, beak, o cush capsules. It is impotant to schedule you egula lab wok appointment befoe taking you daily dose of tacolimus (pefeably in the ealy moning). You must take the last dose of tacolimus at least 12 hous befoe you blood tests. Bing you medicine with you to you appointment so you can take it immediately afte you blood is dawn fo the test. You must take all of the pescibed amount of tacolimus to maintain enough immunosuppession. Follow you dosage schedule caefully. 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 vaccinations without you docto's appoval.

177 Take pecautions to avoid infection while taking this medicine. Do not take antacids (Maalox, Mylanta, Tums ), cholestyamine, o colestipol within 2 hous of taking this medicine. Antacids could impai the absoption of tacolimus. Do not take this medicine with any gapefuit o gapefuit juice poducts. Do not take St. John s wot while taking this medicine. What should I do if I foget a dose? If it has been less than 3 hous since you missed dose, take the missed dose and etun to you egula schedule. Howeve, if it is almost time to take you next scheduled dose, simply skip the missed dose and poceed with you egula schedule. Do not take a double dose. If you miss moe than 1 dose, please call you health cae povide fo specific instuctions. What ae the common side effects? The most common side effects include: Hypeglycemia (inceased blood glucose level) Blood tests will be pefomed fequently to monito you blood glucose level. Tell you nuse coodinato if you develop fequent uination o inceased thist. If you blood glucose levels ae outinely high, you might be pescibed medicine to contol you glucose levels. Alteed kidney function (nephotoxicity) Blood tests will be pefomed fequently to detect changes in kidney function. You BMT docto may decide to change o tempoaily stop you tacolimus dose if the blood tests indicate an alteed kidney function. Do not stop taking this medicine without you docto s appoval. Hypekalemia (inceased potassium level) Blood tests will be pefomed fequently to measue you potassium level. Neuotoxicity such as temos, headaches o confusion These symptoms ae usually associated with inceased levels of tacolimus in you blood. Theefoe, fequent blood tests 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. will be done to monito you levels to pevent advese side effects. Inceased isk of infection Avoid anyone who might have an infection, and epot any signs o symptoms of infection to you health cae povide. Hypetension (high blood pessue) You will be asked to puchase a blood pessue cuff and ecod you blood pessue twice daily while you ae taking tacolimus. If needed, you might be pescibed medicine to contol you blood pessue. It is impotant to follow othe ecommendations to help lowe you blood pessue, such as following a low-sodium (low-salt) diet. Hypomagnesemia (low magnesium levels) Blood tests will be pefomed fequently to measue you magnesium level. You may need to take a magnesium supplement. Nausea o vomiting Diahea What stoage conditions ae necessay fo this dug? Stoe this medicine at oom tempeatue. Do not feeze o expose to heat ove 77 F. If you ae taveling, stoe you medicine in an insulated containe. 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. Do not use this medicine afte the expiation date on the packaging. Keep it and othe medicines out of the each of childen. Why ae blood tests impotant? Fequent blood tests allow you docto to effectively monito the levels of tacolimus in you blood and pevent advese side effects of the Index #10074 Poduced by the Cente fo Consume Health Infomation Copyight The Cleveland Clinic Foundation. All ights eseved. Rev. 04/13

178 Valganciclovi Band Name: Valcyte Class of Dugs: Antivial Why is valganciclovi pescibed? Valganciclovi is pescibed to tansplant patients to teat o pevent the development of cytomegalovius (CMV), a type of hepes vius that can cause a vaiety of diffeent infections. Valganciclovi will suppess the infection and help keep the symptoms fom becoming wose. A BMT patient who eceived dono cells might be at isk fo developing an active CMV infection if he/she o the dono was exposed to the vius in the past. How is valganciclovi taken? Valganciclovi is geneally taken as tablets. This dug woks best when thee is a constant amount of it in the bloodsteam. Valganciclovi must be taken fo the entie duation of teatment in ode to achieve the best esults. The dose of this dug 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. It is impotant that you take this medicine egulaly as pescibed. Do not stop taking it without talking to you docto. Valganciclovi You dosage might be deceased o even stopped afte seveal months, o when the infection has subsided. What special instuctions should I follow while using this dug? Take you tablet with food o milk so you body will absob it completely. Thow away any tablet that is boken o cushed. Do not touch o allow anyone to touch a boken o cushed tablet. If you o someone else does touch the tablet, wash the medicine off of you hands completely, using wam wate and soap. While taking this medicine, it is impotant fo men and women to use baie contaception if they ae sexually active, since thee might be an inceased isk of bith defects if pegnancy occued while taking this medicine. Continue using baie contaception fo at least 90 days following valganciclovi teatment.

179 This medicine can cause dowsiness, dizziness, o changes in muscle coodination o contol. Do not dive, opeate machiney, o paticipate in any potentially dangeous activity until you know how the medicine affects you. This medicine might cause infetility. Discuss this isk with you health cae povide befoe taking it. Take valganciclovi fo the full length of teatment. Be sue that 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. This medicine might cause light sensitivity (photosensitivity). Avoid diect sunlight, and wea sunsceen with an SPF of 30 o geate. 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 this medicine 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. Keep this medicine in a tightly sealed containe. Keep this and othe medicines out of the each of childen. 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. What ae the common side effects of this dug? While you ae taking valganciclovi, fequent blood tests will be taken to pevent o minimize the development of these seious side effects: Neutopenia (low white blood cell count) Anemia (low ed blood cell count) Thombocytopenia (low platelet count) Valganciclovi might esult in any of these othe side effects: Dowsiness Dizziness Incease o decease in uination Eye pain o changes in vision Changes in muscle coodination o contol Feve o chills Soe thoat Unusual tiedness o weakness Headache Nausea/vomiting Diahea Touble sleeping When should I call my health cae povide? Call you health cae povide ight away if you: 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 Index #10308 Poduced by the Cente fo Consume Health Infomation Copyight The Cleveland Clinic Foundation. All ights eseved. Rev

180 Voiconazole Band name: Vfend Class of dugs: Antifungal Why is voiconazole given? Voiconazole is given to tansplant patients to pevent o teat the development of aspegillus o othe fungal infections. A tansplant patient has an inceased isk of developing infections because the immune system is suppessed. How is voiconazole given? Voiconazole is geneally taken as tablets twice daily. You pesciption label tells you how many tablets to take and how often to take them. Follow these instuctions caefully, and ask you docto o phamacist to explain anything you do not undestand. It is impotant that you take this medicine as pescibed. Do not stop taking it without talking to you docto. What special instuctions should I follow while using this dug? Take voiconazole 1 hou befoe meals o 1 hou afte a meal since food may intefee with absoption. Tell you health cae team if you ae taking sildenafil (Viaga ), vadenafil (Levita ), o tadalafil (Cialis ). These ae all medicines used to teat eectile dysfunction. These dug combined with voiconazole might cause dangeous changes in you blood pessue. Voiconazole Visual changes ae commonly associated with voiconazole, especially duing the fist few doses. These might include blued vision, colo changes, inceased sensitivity to light (photophobia), and changes in visual acuity (shapness). Avoid tasks such as diving o opeating machiney if you expeience any of these changes. These changes ae geneally evesible and decease with time. Discuss this with you tansplant team. Take voiconazole fo the entie duation of teatment. Be sue you always have enough voiconazole on hand. Check you supply befoe a holiday o weekend, o othe occasions when you might be unable to efill you pesciption.

181 Keep all appointments with you docto and the lab so you esponse to the dug can be monitoed. How should I stoe this medicine Stoe it at oom tempeatue. DO NOT stoe the capsule fom of this medicine in diect sunlight, in the bathoom, nea a sink, o in any damp place. Heat o moistue might cause the medicine 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? You will have fequent blood tests while taking voiconazole to monito the development of alteed live function, a seious side effect of this medicine. Visual changes might occu while taking voiconazole. Discuss this with you BMT team. Voiconazole tables contain lactose, which might cause inceased diahea in patients who ae lactose intoleant (patients who lack the enzyme to help beak down lactose), which is found in daiy poducts. Discuss this with you BMT Team. When should I call my health cae povide? If you have any of the following symptoms, please tell you health cae povide at you next followup appointments: Diahea Nausea that doesn t impove afte changing you eating habits Call you health cae povide immediately if you expeience any of the following symptoms: Feve o chills Skin ash o itching Soe thoat Changes in you vision o hallucinations that ae tempoay Changes in the colo of you uine Unusual fatigue Bleeding o unexplained buising Stomach pain Loss of appetite Call 911 o epot to the neaest emegency oom of you have: Chest pain Heat palpitations o a apid heat ate Index #12160 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

182 Posaconazole Band name: Noxafil Why is posaconazole pescibed? Posaconazole is used to teat o pevent infections with fungal oganisms. A tansplant patient has an inceased isk of developing such infections because the immune system is suppessed. How is posaconazole taken? Posaconazole is taken as a liquid thee times a day (fo pophylaxis) o fou times a day (fo teatment). You pesciption tells you how often to take the medication. Follow these instuctions caefully and ask you docto o phamacist to explain anything you do not undestand. It is impotant that you take this medication as pescibed, even if feeling bette (fungal infections may take weeks o months of theapy). Do not stop taking it without talking to you docto. What special instuctions should I follow while using this dug? Take this medication with food, pefeably with fatty meals (sou ceam, whole milk, ice-ceam). Avoid gapefuit juice while taking this medication. Avoid alcohol (includes wine, bee, and liquo). Posaconazole Shake well befoe use. Do not take any new pesciptions, ove-the-counte medications, vitamins, o hebal poducts duing theapy without consulting pescibe. Be sue you always have enough posaconazole on hand. Check you supply befoe a holiday o weekend, o othe occasions when you might be unable to efill you pesciption. Keep all appointments with you docto and the lab so you esponse to the dug can be monitoed. If you ae taking tacolimus (Pogaf ) o cyclospoine (Neoal, Sandimmune ), you docto might ode moe fequent checks of tacolimus o cyclospoine blood levels

183 and might possibly change you dose of tacolimus o cyclospoine. Posaconazole may inteact with seveal othe medications. Check with you docto befoe taking any new medications, including ovethe-counte and hebal poducts. What should I do if I foget to take a dose? Take a missed dose as soon as possible. If it is almost time fo the next dose, skip the missed dose and etun to you egula schedule. Do not take a double dose o exta doses. How should I stoe this medicine? Stoe this medicine at oom tempeatue. Do not feeze. Potect fom light. Keep this and othe medicines out of the each of childen. What ae some possible side effects of this medicine? Nausea o vomiting. Small fequent meals, fequent mouth cae, sucking had, suga-fee candy, o chewing suga-fee gum may help. Diahea Belly pain Headache Low potassium level. Signs include feeling tied, weak, numbness, o tingling; muscle camps; constipation; vomiting; o fast heatbeat. 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. Live damage can aely occu. You will have fequent blood tests while taking posaconazole to monito the development of alteed live function, a seious side effect of this medicine. When should I call my health cae povide? If you suspect an ovedose, call you local poison contol cente o emegency depatment immediately. Signs of a life-theatening eaction. These include wheezing; chest tightness; feve; itching; bad cough; blue skin colo; fits; o swelling of face, lips, tongue, o thoat. Difficulty beathing Sevee swelling Fast heatbeat o passing out Sevee belly pain Sevee diahea Sevee nausea o vomiting Not able to eat Signs of low potassium Significant weight gain Dak uine o yellow skin o eyes Feeling extemely tied o weak Any ash No impovement in condition o feeling wose Index #14679 Heaing Impaied (TTY) Assistance Poduced by Patient Education and Health Infomation Copyight The Cleveland Clinic Foundation. All ights eseved. Rev. 10/10

184 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.

185 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

186 Leupolide Acetate Band name: Lupon Depot Why is leupolide acetate pescibed? Leupolide acetate is used in pe-menopausal women to pevent sevee menstual bleeding duing blood and maow tansplantation. Leupolide acetate woks by peventing the elease of homones that lead to ovulation and menstuation. How and when should leupolide be used? Leupolide acetate is an intamuscula injection that is given pio to tansplantation (appoximately 2-4 weeks befoe hospital admission). The injection may be given duing an office visit. Sites of administation include the buttocks aea, font of the thigh, o deltoid muscle (muscle aound the shoulde). What do I need to tell my docto BEFORE I take this dug? If you ae allegic to any medications o chemicals, including what happened when you wee exposed to the substance If you ae pegnant o may be pegnant If you ae beastfeeding If you have unexplained vaginal bleeding What special instuctions should I follow while using this dug? Leupolide Acetate Keep all appointments with you docto so you esponse to the dug can be monitoed Avoid diving o doing tasks that equie you aletness until you see how this dug affects you Use baie methods of contaception, such as condoms, while on this medication Notify you physician if you become pegnant while on this theapy Do not beastfeed while taking this medication

187 What ae the common side effects? This dug may aise cetain homone levels in you body duing the fist few weeks of theapy. This may esult in beakthough bleeding. Notify you docto if this does not impove within a few weeks of stating theapy. The most common side effects ae due to the diect effects of the medication on menstuation. Most patients do not expeience all of the side effects listed. Some side effects that may occu include: Hot flashes Headache Mood changes Vaginal dyness Change in beast size and beast soeness o tendeness Nausea and vomiting Injection site buning/pain Bone loss Call you healthcae povide if these symptoms ae pesistent o sevee. When should I call my healthcae povide? Call you healthcae povide ight away if you: Develop signs of an allegic eaction such as ash, hives, itching, wheezing, tightness in the chest o thoat, o touble beathing Develop signs of depessed mood, thoughts of killing youself o othes, nevousness, emotional ups and downs, anxiety, o lack of inteest in life Have any othe symptoms that ae concening Index #15776 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.04/28/2015

188 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

189 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 Amy Healy, R.N o ext Page: , ask fo page #25619 Bittany Hodgeman, R.N o ext Page: , ask fo page # Jamie Stan, R.N o ext Page: , ask fo page #23199 Victoia Winslow, R.N o ext Page , ask fo page #80918 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. 06/01/2015

190 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.

191 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.

192 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.

193 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.

194 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.

195 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

196 Follow-Up Appointments Fo Reduced-Intensity Allogeneic Tansplant Patients Staying in Cleveland Afte you tansplant, you and you cae-patne will be equied to live in the Cleveland Metopolitan aea within a 1-hou dive fom Cleveland Clinic fo a minimum of 100 days afte you tansplant. The length of time you ll need to stay in Cleveland will be detemined by you docto. It is impotant fo you to stay in the Cleveland Metopolitan aea afte you tansplant so you can be monitoed closely. If you pemanent esidence is beyond this distance, you will be equied to make aangements to stay locally. You Social Woke can povide you with esouces. Whee will I go fo my follow-up appointments? You follow-up appointments will be scheduled in the Outpatient Clinic, located in the Taussig Cance Institute. You may pak in the Visito s Paking Gaage located on East 93d between Cheste and Euclid Avenues. Discounted paking vouches ae available at the attendant s booth in the paking gaage o at the Cashie s Office in the H aea of Cleveland Clinic. Unfotunately, we ae not able to validate you paking tickets. How often do I need to go to follow-up appointments? You follow-up appointments will be scheduled daily fo possibly the fist month afte you tansplant. Afte that, you appointments will be at least once a week. Although Clinic visits ae fequent at fist, they will gadually tape off as you condition impoves. If at any time you develop a feve o complications, you might have moe fequent appointments, o you might need to be admitted to the hospital until you condition impoves. It is impotant that you symptoms ae closely monitoed. Although eadmissions might be discouaging, they ae vey common. Because these appointments play a vital ole in effectively monitoing you pogess, it is vey impotant that you attend all appointments as scheduled. You appointment days might vay, depending on you docto s schedule. How long ae the follow-up appointments? You follow up appointments could last fom 2-8 hous, depending upon you lab esults and the teatment needed. Follow-Up -- Reduced-Intensity-Allogeneic

197 What should I bing? Bing you moning dose of cyclospoine (Neoal ) o tacolimus (Pogaf ) on these days. (Do not take it befoe you appointment.) You might want to bing a book, video, o activities with you. A television and DVD playe ae available in most teatment ooms. Please bing you BMT education manual so we can eview you ecod of tempeatue, blood pessue, and medicines. You may bing food o snacks fom home. The teatment aea offes soups, cackes, and beveages. Thee is also a Bisto in the Taussig Cance Cente whee you can buy beakfast and lunch. What happens duing my follow-up appointments? You will be assessed and have blood tests at each appointment. Many times, these ae the only ways GvHD, infections o othe complications can be detected. 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. If you condition is stable, you labwok might become less fequent but it will always be necessay. OTHER TESTS In addition to blood tests, these othe tests might be pefomed duing you follow-up appointments: Chest X-ays These ae pefomed as needed at R22 to check you lungs and to detect the possible development of a lung infection. i Immunoglobulins (Iveegam, Gammagad ) This medicine is infused ove seveal hous to boost you immune system. The fequency of the infusions will be detemined by a blood test that measues you immunoglobulin levels. Blood tansfusions Depending on the esults of you complete blood count, you might eceive a ed blood cell tansfusion and/o platelet tansfusion. Electolyte infusion Fo example, if you potassium o magnesium levels ae low, you might eceive eithe o both of these impotant mineals infused into you cental venous cathete. If you eat foods high in electolytes, you might be able to help decease the need fo intavenous electolyte eplacement. Note: Thee is moe infomation in this manual about foods high in specific electolytes. CONSULTATION WITH THE DOCTOR AND NURSE You will meet at least once a week with you docto and nuse coodinato to assess you health, addess you concens, and povide you with esouces you might need. You social woke can be contacted if thee ae any concens that you may need to discuss with he. Notify you nuse o docto of you equest. These appointments become less fequent as you ecove. Thee ae many times when you will be eceiving teatment at the same time you docto appointment is scheduled. If this occus, and you ae not eceiving blood o platelets, please take you IV pump/medicine to the R-20 font desk to check in fo you docto appointment. *Please notify you R10 nuse when you leave and when you etun to R10. Index #10433 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

198 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

199 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

200 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

201 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

202 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

203 Small Childen If you have small childen and ae unable to avoid changing soiled diapes, it is necessay to wea gloves and a mask followed by hand washing with soap and wate afte emoving gloves. When possible have anothe peson change diapes. Wate safety Afte you tansplant, avoid walking, wading, swimming, o playing in eceational wate such as ponds, swimming pools, lakes, whilpools, wate fountains and hot tubs. Avoid dinking well wate fom pivate wells o fom public wells in small communities because tests fo micobial contamination ae pefomed too infequently. Dinking well wate fom municipal wells seving highly populated aeas is thought to be safe because the wate is tested 2 times/day fo bacteial contamination. If you dink tap wate, outinely monito the mass media (adio, television, and newspapes) in you aea to immediately implement any boil-wate advisoy. A boil-wate advisoy means that all tap wate should be boiled fo at least 1 minute befoe dinking. You may consume bottled wate if it has been pocessed to emove cyptospoidium by 1 of 3 pocesses: evese osmosis, distillation, o 1-µm paticulate absolute filtation. The Intenational Bottled Wate Association can be contacted in the United States at (703) o at thei website bottledwate.og to obtain contact infomation egading wate bottles. Fo a list of filtes cetified unde National Sanitization Foundation (NSF) Standad 053 fo Cyst (i.e., cyptospoidium) emoval, contact the NSF Intenational consume line o NSF.og. Tavel safety Please do not plan to tavel to developing counties without fist talking to you tansplant docto. Cetain counties can pose significant isks fo exposue to substances, such as viuses o micooganisms, that can cause disease o infection. Vaccinations It is beneficial fo family membes and household contacts to be vaccinated to minimize exposue to vaccine-peventable diseases (such as tetanus, polio, measles, mumps, ubella, influenza, and pneumococcal.) Discuss influenza vaccines with you BMT team. Recommendations fo a possible evaccination schedule ae included in this handout. Childen in the household of an immunocompomised patient should eceive the MMR (measles, mumps, and ubella) vaccine. Although MMR is a live vaccine, household tansmission does not occu. The vaicella (chicken pox) vaccine is also a live vaccine. The Ameican Academy of Pediatics ecommends that the child in the household eceive the vaccine. The vaicella (chicken pox) vaccine poses a vey small isk of household tansmission, usually only if the vaccinated child develops a ash. If the vaccinated child develops a ash, the tansplant patient might be placed on acyclovi if he o she is not aleady taking it. It would be much iskie fo the tansplant patient if the child got the actual chicken pox vius.

204 When to call Watch fo ealy signs of infection. It is vey impotant to notify the Blood & Maow Tansplant Team o you local docto if any of these signs o symptoms of infection occu: n n n n n n Feve of F (38.0 C) (even if you feel well). Shotness of beath Cough with yellow o geen sputum (phlegm) o a dy, pesistent cough Sweats o chills, even if you have a nomal tempeatue. Soe thoat, scatchy thoat, o pain when swallowing Sinus dainage, nasal congestion, headaches, o tendeness along the uppe cheekbones n Touble uinating: pain o buning, constant uge, o fequent uination This might also be a side effect of chemotheapy called hemohagic cystitis. When this occus, thee might be blood o blood clots in you uine n n n n n n Cloudy o foul-smelling uine Redness, swelling, tendeness, o dainage at the site of you cental venous cathete Diahea, with o without camping Lesions (soes) o white patches in you mouth o on you tongue Skin ash Vaginal discomfot, itching, o unusual dischage Peventing Infection Afte Blood & Maow Tansplant n If you become awae that you have been exposed to chickenpox, step thoat, hepes, o mononucleosis, the flu o any othe espiatoy vius.

205 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 #4511 Poduced by the Cente fo Consume Health Infomation Copyight The Cleveland Clinic Foundation. All ights eseved. Rev. 05/05/2014

206 Health Infomation Fo Patients and the Community Vaccinating Recipients of Hematopoietic Stem Cell Tansplants A hematopoietic stem cell tansplant (HSCT) esults in immunosuppession because of the hematopoietic ablative theapy administeed befoe the tansplant, dugs used to pevent o teat gaft-vesus-host disease, and in some cases, fom the undelying disease pocess necessitating tansplantation. As a esult, HSCT ecipients should be evaccinated outinely afte HSCT, egadless of the souce of the tansplanted stem cells. Taken fom the CDC Centes fo Disease Contol and Pevention. Please note that vaccination does not occu at you fist appointment with the Infectious Disease physician but athe appoximately six months afte you tansplant. Date of HCST Months fom HSCT Appoximate month and yea / / / / / GET YOUR INACTIVATED INFLUENZA VACCINE EVERY FALL Pevna 1 Hib 2 Tdap 3 Twinix 4 HPV 5 Polio 6 Pevna Hib Td 7 Twinix HPV Polio Pevna Hib Td Polio 1 Pevna = 13-valent conjugated pneumococcal vaccine 2 Hib = Haemophilus influenzae conjugate vaccine 3 Tdap = tetanus toxoid, diphtheia toxoid & acellula petussis vaccine 4 Twinix = combined hepatitis B vius and hepatitis A vius vaccines 5 HPV (Gadasil) = quadivalent human papilloma vius vaccine only fo those yeas old Meningococcal 8 Pevna o Pneumovax 9 HPV Twinix MMR 10 Vaivax 11 6 Polio = inactivated polio vaccine 7 Td = tetanus toxoid & diphtheia toxoid 8 Meningococcal vaccine = Menacta (quadivalent meningococcal conjugate vaccine). If concomitant administation with Pevna, use Menveo (quadivalent meningococcal conjugate vaccine) 9 Pneumovax = 23-valent polysacchaide pneumococcal vaccine. Give Pneumovax if no chonic gaft-vesus-host disease (GVHD). Give Pevna if ongoing chonic GVHD. 10 MMR = mumps-measles-ubella. If measles antibody is unpotective, no ongoing GVHD, not on immunosuppessive medications and has not eceived IVIG in the peceding 8-11 months. 11 Vaivax = vaicella zoste (Chicken pox) vaccine. If vaicella zoste antibody is unpotective, no ongoing GVHD, not on immunosuppessive medications & has not eceived IVIG in the peceding 8-11 months. Please note that Zostavax (shingles vaccine) is containdicated. In addition to the above schedule, if the patient is planning to tavel out of the United States of Ameica, we ecommend scheduling a visit to an Intenational Tavel Clinic seveal months in advance.

207 NOTES Copyight The Cleveland Clinic Foundation. All ights eseved. Poduced by the Cente fo Consume Health Infomation. Index # Rev. 6/7/2017 Index #15555

208 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

209 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.

210 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)

211 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

212 Health Infomation Fo Patients and the Community Food Safety Guidelines Accoding to the Centes fo Disease Contol and Pevention (CDC), each yea 1 in 6 Ameicans (o 48 million people) gets sick fom and 3,000 die of foodbone diseases. Reducing foodbone illness by just 10% would keep 5 million Ameicans fom getting sick each yea. Pope food safety and handling can easily pevent as well as educe the incidence of foodbone-elated illness. Food safety is impotant in peventing infections in all populations. Howeve, thee ae cetain goups that ae at high isk of foodbone illness. These populations include: Pegnant women Adults ove 65 yeas of age Infants and young childen People with weakened immune systems, such as those who have HIV/AIDs, cetain types of cance, and those undegoing chemotheapy o adiation theapy People who have had ogan o bone maow tansplants People who ae taking immune-suppessing medications People with diabetes Below ae two categoies of food. 1. High-isk Foods you should be awae ae moe isky while you ae immunosuppessed 2. Low -isk Foods that can be eaten safely if handled popely. No food is safe if it is mishandled. Food Goup Fuits Low-Risk Foods Cooked fuits fom fozen, fesh, o died Canned fuit Pasteuized fuit juices Fesh fuits well washed Washed and peeled fuit High-Risk Foods to Avoid Fesh-squeezed, unpasteuized fuit juices Had-to-clean fuits such as aspbeies and blackbeies Gains All cooked gains (i.e. beads, cackes, muffins, pancakes, baked goods, etc.) All cooked and eady-to-eat ceeal Raw, uncooked gain poducts (i.e. whole oats, wheat gem) Spouted gains

213 Food Goup Low-Risk 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 meat section elated to the appopiate meat tempeatues.) Packaged luncheon meats and hot dogs cooked until steaming hot Well-cooked eggs (whites and yolk fim, including had-boiled eggs; see detailed section on eggs below) 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/oasted nuts and nuts baked in foods 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 (using low-isk food ingedients) Pasteuized whipped topping--dy, efigeated, and fozen Commecial pasteuized eggnog Pasteuized vegetable juices Cooked fozen, fesh, and canned vegetables Well-washed aw vegetables (Refe to cleaning section fo pope washing guidelines.) Cooked spouts Raw and undecooked meat, poulty, pok, wild game, fish (including cold smoked salmon, lox, sushi, and pickled fish), and seafood Undecooked o aw eggs All meats fom the deli counte (including had, cued salami in natual wap), undecooked 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) Bie, feta, camembet, and fames cheese if made fom unpasteuized milk. Check food labels: unpasteuized soft cheeses may be eaten only if cooked in foods Cheeses with added hebs, vegetables, chili peppes Soft-seve ice ceam, custad, o yogut Unefigeated ceam o custad bakey poducts e. g. ceam pie, custad-filled donut, ceam puff, etc., unless shelf-stable 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 bas o delis (excludes salads made in estauant kitchens using low-isk ingedients) Pepaed salads fom the deli counte (i.e., potato salad, macaoni salad) Raw spouts - alfalfa, clove o mung bean

214 Food Goup Low-Risk Foods High-Risk Foods to Avoid Entees Well-cooked entees, cooked all the way though to the appopiate tempeatue (See cooking section fo tempeatue guidelines) Cooked soups Foods containing aw o undecooked meat o meat substitutes, pate, soft-cooked eggs Any uncooked o undecooked soup such as gazpacho (Mexican tomato and cucumbe soup), vichyssoise (cucumbe/squash soup), beet boscht, and summe fuit soups Beveages 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 Mate tea (unless pasteuized) Sun tea (sun-bewed) Cold bewed tea with wam o cold wate Well wate (unless tested yealy fo colifoms o boiled fo at least one minute) Unpasteuized wine and bee (i.e., home-bewed and cetain micobewey bees) Unpasteuized cold-pessed juices Miscellaneous Packaged chips, popcon, petzels, cackes 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) Canned o shelf-stable pickles, elish, olives (efigeate afte opening) Candy, gum Raw o unpasteuized honey Yeast, including aw, uncooked bewe s yeast (Avoid all contact with food o dink pepaations using aw yeast Fesh salad dessing made with aw eggs, 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 All deli foods, deli cheeses, and pepaed deli salads Raw cookie dough Salsa in the efigeated section

215 Shopping q q q q q q q q q q q Check the expiation date and do not buy outdated food. Do not puchase bulging, dented, o usted cans. Do not use unefigeated eggs o eggs with cacked o boken shells. Choose fesh poduce with no mold o buises. 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. Do not consume the food/beveage samples in the stoe. Check that the tampe-esistant seals have not been destoyed. Make the gocey stoe the last stop befoe going home. Refigeate the necessay items when you aive home. Tanspot goceies in a coole in hot weathe. Shop ealy when shopping at fames makets to decease the chance of food sitting out too long. 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 q q q q q q 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. Wash you hands immediately afte pepaing aw foods. Use only clean utensils and wok sufaces. Can openes should be washed afte each use. Wash all fesh poduce (including poduce with skins o inds) thooughly unde unning wate befoe pepaing. 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. You do not need to e-wash foods if you ae using pe-cut, bagged, o packaged poduce that has been pe-washed and has been labeled as eady-to-eat. Vinega and lemon have been shown to educe bacteia on poduce due to thei acidic natue. A simple method is to place vinega and wate in a spay bottle, spay poduce, let sit fo a few minutes, and inse with cool wate. Replace used dish cloths, sponges, and kitchen towels fequently. Kitchen sponges can be sanitized in the dishwashe. Squeeze thooughly and allow to ai dy. Rinse and clean the tops of cans befoe opening, especially beveage cans. (Avoid dinking fom beveage cans.)

216 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. All plastic and wooden cutting boads wea out ove time. Once cutting boads become excessively won o develop had-to-clean gooves, they should be discaded. 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, items such as gound meat, stew meat, poulty, seafood, should emain safe and good quality fo an additional day o two befoe cooking; ed meat cuts (such as beef, pok o lamb oasts, chops and steaks) should be good fo 3 to 5 days. 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 submege the food in COLD tap wate and change (dain and efill) wate evey 30 minutes until meat is thawed. Foods that ae thawed in cold tap wate should be cooked immediately. Do NOT efeeze. In the micowave When defosting food in the micowave, 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. Micowaving When heating convenience o fozen meals, make sue to cook food popely to ensue all potentially hamful bacteia have been destoyed. Read all package instuctions and cook to the full amount. Know when to use a micowave o conventional oven; cooking instuctions diffe depending on the appliance. Know you micowave's wattage: if it is below the package ecommendations, the food must be cooked longe. Use a food themomete! It can help you detemine if the food is cooked popely. Eggs q q q q Thooughly cook eggs befoe you eat them.egg whites and yolks must be fim to the touch. Do not eat aw eggs o dishes made with aw eggs, such as aw cookie dough, homemade ice ceam, Caesa salad dessing, o eggnog. Do not eat eggs pepaed "sunny-side up" o "ove-easy," o eggs that ae unny. You can substitute a pasteuized egg poduct (vaious foms such as whole in-shell, efigeated o fozen liquid egg, o powdeed egg whites ae available) fo aw eggs in most ecipes. Meats 1. Cook all meats and othe dishes until they ae well-done. 2. Avoid aw fish and seafood, such as sushi, oystes, o clams. 3. Use a meat themomete when cooking at home to contol the intenal tempeatue of meats. The themomete should be inseted at the thickest point in the flesh. See the chat below. 4. Lunch meats/meats/ cheeses must be cooked until steaming o heated to ove 165 degees. Cooking Many bacteia that cause food-bone illnesses ae destoyed by heat, so thoough cooking helps to pevent food-bone illnesses. Eggs, meat, and poulty ae especially pone to contamination.

217 Meat Intenal tempeatue Gound beef, pok, veal, lamb...at least 160 F Gound tukey, chicken...at least 165 F Fesh beef, lamb...at least 145 F with 3-minute est time Poulty...at least 165 F Pok...at least 145 F with 3-minute est time Fish...at least 145 F Leftoves...at least 165 F The updated tempeatues ae fom the foodsafety.gov website. The entie URL is: Contolling tempeatue Bacteia gow fastest between 40 F and 140 F a ange that includes oom tempeatue so efigeating foods o cooking them pomptly helps pevent food-bone illnesses. q q q q Keep hot food hot (above 140 F). Keep cold food cold (below 40 F). Cooked leftoves can be saved 3 to 4 days at efigeato tempeatue below 40 degees F; if tempeatues ise above this, limit to 2 days. Don't puchase efigeated foods afte thei expiation date. Food stoage q Divide leftoves into small units and stoe in shallow containes fo quick cooling. q Refigeate leftoves within 2 hous of cooking. q Discad leftoves that wee kept at oom tempeatue fo moe than 2 hous. q Reheat leftoves o heat patially cooked foods to 165 degees Fahenheit (F) thoughout befoe seving. q Bing leftove soups, sauces, and gavies to a olling boil befoe seving. q Stoe cold foods in tempeatues of less than 40 degees F. 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. Eating away fom home q q q q q q q Avoid buffets, food vendos, potlucks, and any food sevice 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. Ask fo no ganish with the meals. Additional guidelines ae available at and Additional food safety infomation is available at: Cente fo Human Nutition, M17/ Digestive Disease Institute 9500 Euclid Avenue, Cleveland, OH Appointments: (Main Campus) , ext Poduced by the Cente fo Consume Health Infomation The Cleveland Clinic Foundation /15

218 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.

219 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

220 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.

221 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

222 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

223 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.

224 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

225 Notes

226 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

227 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

228 DAILY MEDICATION LOG (Sample) Befoe taking you medicines, please check the pesciption labels to veify the medicine stength and coect dosage. In the spaces povided below, please ecod you pescibed medicine dose and scheduled times, and check the appopiate spaces afte you ve taken each medicine. 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. Impotant: Please notify you nuse coodinato via voice mail at least 2 weeks befoe you un out of you medicine so it can be efilled. Week of: (date) Medication Cellcept Take ½ hou befoe itaconazole Medication Pogaf Take on an empty stomach. Take ½ hou befoe itaconazole. Take at the same time/the same way evey day. Dose Time M T W Th F Sa Su 500 mg 9 a.m. 500 mg Noon 500 mg 6 p.m. 1 mg 8 a.m. 1 mg 8 p.m. Medication Liquid itaconazole Take on an empty stomach with cola. OR itaconazole capsules 20ml/200mg 5 p.m. Take with food. 200 mg 6 p.m. Medication Pednisone 30 mg 9 a.m. Take with beakfast. Medication Neoal Take with beakfast. Medication Antacid Take at bedtime. Take at least 2 hous afte itaconazole. 9 a.m. 10 p.m.

229 NOTES:

230 DAILY MEDICATION LOG Befoe taking you medicines, please check the pesciption labels to veify the medicine stength and coect dosage. In the spaces povided below, please ecod you pescibed medicine dose and scheduled times, and check the appopiate spaces afte you ve taken each medicine. 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. Impotant: Please notify you nuse coodinato via voice mail at least 2 weeks befoe you un out of you medicine so it can be efilled. Week of: (date) Dose Time M T W Th F Sa Su Medication Medication Medication Medication Medication Continued on back

231 Week of: (date) Dose Time M T W Th F Sa Su Medication Medication Medication Medication Medication Medication Medication Medication

232 Gaft Vesus Host Disease: An Oveview What is gaft vesus host disease? Gaft vesus host disease (GvHD) is a condition that might occu afte an allogeneic tansplant. In GvHD, the donated bone maow o peipheal blood stem cells view the ecipient s body as foeign, and the donated cells/bone maow attack the body. Thee ae two foms of GvHD: Acute gaft vesus host disease (agvhd). Chonic gaft vesus host disease (cgvhd). As an allogeneic tansplant ecipient, you might expeience eithe fom of GvHD, both foms, o neithe. Acute gaft vesus host disease Risk factos Seveal factos ae thought to incease the development of acute GvHD. The most impotant facto is dono/ecipient HLA (human leukocyte antigen) match, in which thee ae diffeences between you and you dono. The diffeences can cause dono cells to ecognize you cells as foeign, and lead to an immune esponse against you tissues and ogans. Recipients who have eceived peipheal blood stem cells/bone maow fom an HLA mismatched elated dono ( o fom an HLA matched unelated dono) have an inceased isk of developing acute GvHD. Othe dono/ ecipient factos that might incease the isk of developing agvhd include: Gaft Vesus Host Disease A female dono who has been pegnant in the past The advanced age of eithe the dono o the ecipient When/whee it might occu Acute GvHD might occu once the dono's cells have engafted in the tansplant ecipient. It might develop in you skin, live, eyes, o gastointestinal tact, and symptoms might appea within weeks afte you tansplant.

233 Diagnosis You BMT docto can make the diagnosis of a GvHD duing a physical exam by obseving cetain symptoms and/o by evaluating the esults of site biopsies and lab values. Symptoms to epot Because of the inceased isk of developing infections, it is vey impotant to epot any feves of F o highe to you BMT Coodinato duing business hous. Afte hous, call Clinic Opeato at , ask to speak to the Hematology Fellow on call, who can tiage symptoms and detemine ugency. Please epot any physical changes you might expeience to you BMT Team. Symptoms of acute GvHD might include any of the following: Skin ash o eddened aeas on the skin (signs of agvhd of the skin) Please epot if you skin is itchy. Yellow discoloation of the skin and/o eyes, and abnomal blood test esults (signs of agvhd of the live) Nausea, vomiting, diahea, o abdominal camping (signs of agvhd in the gastointestinal tact, o gut ) Inceased dyness/iitation of the eyes (signs of GvHD of the eyes) Teatment If agvhd occus, you docto will discuss available teatment options with you and you family. Many patients ae successfully teated with inceased immunosuppession in the fom of oal o intavenous steoid medicines. Chonic Gaft vesus Host Disease Risk factos Some doctos believe that cgvhd is a late phase of agvhd, while othes believe it is a sepaate condition that is simila to an autoimmune pocess. Patients who have an inceased isk of developing cgvhd ae those who have eceived stem cells/bone maow fom an HLA (human leukocyte antigen) mismatched elated dono o fom an HLA matched unelated dono, patients that may have aleady expeienced acute GvHD, and olde ecipients. When/whee it might occu Chonic GvHD can appea at any time afte allogenic tansplant o seveal yeas afte you tansplant. Chonic GvHD might occu in the skin, live, eyes, mouth, lungs, gastointestinal tact, neuomuscula system, o genitouinay tact. Diagnosis You BMT docto might be able to make the diagnosis of cgvhd duing a physical exam by obseving cetain symptoms and/o by evaluating the esults of site biopsies and lab values. Some symptoms of cgvhd might be vey vague, which might make the diagnosis possible only afte othe causes ae excluded. Symptoms to epot Because of the inceased isk of developing infections, it is vey impotant to epot any feves of F o highe to you BMT Coodinato duing business hous. Afte hous, contact the Oncology fellow on-call. Please epot any physical changes you might expeience to you BMT Team. Symptoms of chonic GvHD might include any of the following: Rash, aised, o discoloed aeas, skin thickening o tightening (signs of cgvhd of the skin) Abdominal swelling, yellow discoloation of the skin and/o eyes, and abnomal blood test esults (signs of cgvhd of the live) Dy eyes o vision changes (signs of cgvhd of the eyes) Dy mouth, white patches inside the mouth, pain o sensitivity to spicy foods (signs of oal cgvhd, of the mouth) Shotness of beath o changes seen on you chest X-ay (signs of dy cough pulmonay cgvhd of the lungs) Difficulty swallowing, pain with swallowing, o

234 weight loss (signs of cgvhd of the gastointestinal tact o gut ) Fatigue, muscle weakness, o pain (signs of neuomuscula cgvhd, of the neves and muscles) Inceased need to uinate (uinay fequency), buning o bleeding with uination, vaginal dyness/ tightening, o penile dysfunction (signs of cgvhd of the genitouinay system, bladde, o sexual ogans) Teatment If cgvhd occus, you docto will discuss available teatment options with you and you family. Long-tem immunosuppessive medicines ae usually the teatment egimen fo cgvhd. Fungal, bacteial, and vial infections ae a majo isk with this teatment option since you immune system will be suppessed fo a vey long time. You docto will pescibe seveal medicines to help pevent these life-theatening infections fom occuing. Pevention Tissue typing labs have been developing and using moe pecise DNA level tests to enable you BMT Team to select the best HLA matched dono fo you. We ty to lowe you isk of developing GvHD by giving you peventive (pophylactic) immunosuppessive medicines afte you tansplant. These medicines will decease the ability of you dono's T cells to stat an immune esponse against you own tissues. Fungal, bacteial, and vial infections ae majo isks with this pophylactic medicine egimen, since you immune system will be suppessed and have a deceased ability to fight infection. Reseach New, and hopefully bette, methods to pevent GvHD ae being studied in clinical tials. The use of photopheesis, diffeent immunosuppessive dugs, and new monoclonal antibodies given to ecipients afte tansplant, as well as methods to emove dono T cells pio to tansplant, ae examples of some of that eseach. IMPORTANT NOTE While GvHD can deeply impact you quality of life, it does have some benefit. The same immune esponse esponsible fo attacking you nomal cells is also monitoing and destoying any suviving cance cells. This is called the gaft vesus tumo effect. Patients who develop GvHD have lowe disease elapse ates. Gaft Vesus Host Disease

235 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 #10255 Poduced by the Cente fo Consume Health Infomation Copyight The Cleveland Clinic Foundation. All ights eseved. Rev.02/27/2014

236 Gaft Vesus Host Disease of the Eyes GvHD of the eyes is one of the isks associated with an allogeneic tansplant. In GvHD of the eyes, the donated bone maow o peipheal blood stem cells (called the gaft) view the ecipient s body as foeign, and the donated cells/bone maow attack the eyes (the host). Symptoms of GvHD of the Eyes Symptoms of GvHD of the eyes might include any of the following, and you should epot them to you BMT Coodinato as soon as you notice them: Buning eyes Dy eyes Gitty feeling in the eyes Blued vision Inceased sensitivity to light Excessive teaing In patients that have GvHD of the eyes, the teas poduced ae not effective at moistuizing the eyes. The sevee dyness can be vey uncomfotable and can make eading o watching television difficult. If left unteated, GvHD of the eyes can cause pemanent damage to eye tissues, scaing of the conea and impaiing vision. NOTE: If you ae expeiencing any of these symptoms, weaing contact lenses is not ecommended. Diagnosis To detect the development of GvHD of the eyes, each BMT patient is monitoed closely thoughout the BMT pocess. This monitoing includes egula physical exams duing which cetain symptoms ae evaluated, and blood tests and diagnostic tests ae pefomed. Gaft Vesus Host Disease of the Eyes If you have any symptoms of GvHD of the eyes, please epot them to you Blood & Maow Tansplant Team. You BMT docto will pefom a physical exam and will efe you to an ophthalmologist (eye specialist). A test to detect tea poduction, called a Schime s test, might be pefomed. Duing this test, a small stip of teated pape might be placed against the white of you eye to detemine if you eyes ae poducing teas.

237 Teatment If GvHD of the eyes is diagnosed, the ophthalmologist will discuss available teatment options with you and you family. You teatment plan will be adjusted. You might aleady be taking immunosuppessive dugs [such as cyclospoine, (Neoal ) o tacolimus (Pogaf )] to pevent the onset of GvHD. These medicines might be changed to teat you condition. To teat you dy eye condition, atificial teas o ointment might be ecommended to keep you eyes moist. If these teatments ae pescibed, hee s how to give youself eye dops o ointment: Wash you hands with soap and wam wate. Dy them with a clean towel. Use a mio. Look up to the ceiling with both eyes. Pull the lowe lid of you eye down with one hand. Hold the eye dops bottle in you othe hand. (Rest pat of you hand on you foehead if necessay to keep it steady.) Place a dop inside you lowe lid. The tip of the bottle should not touch you eye. Close you eyes fo a minute afte putting in the dop. If you ae pescibed both eye dops and eye ointment, use the eye dops fist. If you have moe than 1 eye medicine to put in you eyes, wait about 5 minutes afte the fist medicine befoe putting in the second medicine. Anothe teatment method fo dy eyes is called tempoay punctal occlusion. This involves tempoaily plugging the ducts that dain the teas out of you eyes. This pocedue will help deteimine if pemanent plugs can supply an 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. adequate supply of teas to you eyes. If the tempoay pocedue woks well, a pemanent pocedue will be pefomed duing which silicone is used to keep the teas fom daining so they can lubicate the eyes popely. Symptom management To manage the symptoms of eye Gaft vesus Host Disease, follow these guidelines: Wea potective eyewea to shield you eyes fom the wind. Many sunglasses ae now available in a "wapaound" style. Point ca vents away fom you eyes and point heating and cooling ducts away fom the aeas in which you spend a lot of time (especially in the bedoom). Remind youself to blink moe fequently when you ae woking on you compute o watching TV. Keep the ai moist indoos when the funace is on. Avoid the use of a haidye as much as possible. Notify you nuse coodinato befoe using any ove-the-counte medicines to elieve dy eye symptoms. Ealy detection and pevention To detect eye poblems ealy and to pevent eye poblems fom becoming wose, visit you eye cae specialist at least once pe yea. At an annual visit, you eye cae specialist will check you coective lens pesciption (eyeglasses o contact lenses) and you oveall eye health. Check with you BMT Team befoe puchasing new eyeglasses o contacts. Index #10244 Poduced by the Cente fo Consume Health Infomation Copyight The Cleveland Clinic Foundation. All ights eseved. Rev.02/27/2014

238 Gaft Vesus Host Disease of the Live What is gaft vesus host disease of the live? Gaft vesus host disease (GvHD) of the live is one of the isks associated with an allogeneic tansplant. In GvHD of the live, the donated bone maow peipheal blood stem cells (called the gaft) view the ecipient s body as foeign, and the donated cells/bone maow attack the live (the host). GvHD of the live can esult in damage to the bile ducts, intefeing with the flow of bile out of the live. This damage can vay in seveity. Doctos can detemine the seveity of the damage by pefoming diagnostic tests, such as a live biopsy o blood tests. To detect GvHD of the live, each BMT patient is monitoed closely thoughout the tansplant pocess. This monitoing includes egula physical exams duing which cetain symptoms ae evaluated blood tests, and diagnostic tests. Symptoms Symptoms of GvHD of the live might include any of the following: Abnomal blood test esults that indicate the pesence of inceased live enzymes in the blood (These abnomal live enzymes include biliubin, AST, ALT, GGT, and alkaline phosphate.) Pain o tendeness in the uppe ight abdomen Enlaged live, detected duing an abdominal exam Yellow discoloation of the skin and/o eyes Rapid weight gain A. Live B. Gallbladde C. Cadia D. Stomach E. Common bile duct F. Duodenum G. Panceas H. Kidney Gaft Vesus Host Disease of the Live

239 Swelling in the ams o legs (edema) Fluid build-up in the abdomen Confusion Tea coloed uine Diagnosis GvHD of the live might be diagnosed with these tests: Blood tests ae done to measue the live enzymes and poteins poduced by the live. Imaging tests such as an ultasound and/o CT scan ae done to povide a pictue of the live, its vessels and bile ducts, and to detemine if thee is an obstuction. A live biopsy is done to obtain a sample of live cells. These cells ae then examined unde a micoscope to confim the diagnosis of GvHD of the live. Teatment If GvHD of the live is diagnosed, you docto will discuss available teatment options with you and you family. You teatment plan will be adjusted. Many patients ae teated by suppessing thei immune system with dugs such as cyclospoine, methotexate, tacolimus, pednisone, methylpednisolone, monoclonal antibodies, o ATG. Long-tem teatment with immunosuppessive medicine fo GvHD will equie you to also take antibiotic, antifungal, and antivial medicines to pevent life-theatening infections. It is impotant to be awae of the signs and symptoms of infection, and epot them to you BMT Team ight away. Long-tem teatment with steoids might also incease you isk of developing osteopoosis, cataacts, o joint poblems such as hip avascula necosis. You BMT docto will constantly monito fo these potential side effects. Repot any bone o joint pain o vision changes to you BMT Team. Symptom management You can help manage you teatment of live GvHD by avoiding alcoholic beveages and medicines such as Tylenol that can cause additional stess to you live. 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 #10245 Poduced by the Cente fo Consume Health Infomation Copyight The Cleveland Clinic Foundation. All ights eseved. Rev. 02/27/2014

240 Gaft Vesus Host Disease of the Skin GvHD of the skin is one of the isks associated with an allogeneic tansplant. In GvHD of the skin, the donated bone maow o peipheal blood stem cells (called the gaft) view the ecipient s body as foeign, and the donated stem cells/bone maow attack the skin (the host). What is acute gaft vesus host disease of the skin? Acute gaft vesus host disease (agvhd) of the skin might occu once the dono s bone maow/stem cells have engafted in the tansplant ecipient. The skin is often the fist ogan affected by gaft vesus host disease and can occu any time afte engaftment. Symptoms of agvhd Symptoms of agvhd of the skin might include any of the following. Repot them to you BMT Coodinato as soon as you notice them: Reddened and aised ash Sunbun-like appeaance that might be itchy and wam to the touch Reddened palms of the hands o soles of the feet that can be painful These skin symptoms might also be caused by chemotheapy, dug allegies, o by vial infections. What is chonic gaft vesus host disease of the skin? Chonic gaft vesus host disease (cgvhd) of the skin can appea at any time afte an allogenic tansplant o seveal yeas afte you tansplant. Symptoms of cgvhd Symptoms of cgvhd of the skin might include any of the following. Repot any of these symptoms to you tansplant coodinato as soon as you notice them: Dy, itchy ash Sevee thickening o tightening of the skin that limits mobility Raised skin lesions (soes) Dakening of the skin Mottling (blotchiness) Redness Deceased o absent pespiation (because the sweat glands aen t functioning popely) Possible thinning of body hai and nail loss Gaft Vesus Host Disease of the Skin

241 Diagnosis To detect the development of GvHD of the skin, each Blood and Maow Tansplant (BMT) patient is monitoed closely thoughout the BMT pocess. This monitoing includes egula physical exams duing which symptoms ae evaluated and blood tests and diagnostic tests ae pefomed. If you have any symptoms of GvHD of the skin, please epot them to you BMT Team. You BMT docto will pefom a physical exam and might be able to make a diagnosis, based on you symptoms. If you docto is unsue about the cause of you skin poblem, he o she might efe you to a dematologist fo a test called a punch skin biopsy of the affected aea. Duing this test, a local anesthetic (pain-elieving) medicine will be applied to numb the aea and then a small sample of tissue on the affected aea will be emoved and evaluated unde a micoscope in the Pathology laboatoy. The biopsy aea will be closed with 1 o 2 stitches that will be emoved in about 10 days. You will need to keep the aea clean and dy. This pocedue is usually quick and painless. If cetain chaacteistics ae pesent in the skin sample, a diagnosis of GvHD of the skin can be made. Teatment If GvHD of the skin is diagnosed, you docto will discuss available teatment options with you and you family. You teatment plan will be adjusted. You might aleady be taking immunosuppessive dugs [such as cyclospoine, (Neoal ) o tacolimus (Pogaf )] to pevent the onset of GvHD. These medicines might be changed to teat you condition. Steoid teatment fo both acute and chonic GvHD usually begins once the diagnosis is made. Oal o intavenous steoids might be given. Steoids help suppess the immune system and decease its ability to ecognize the skin cells as foeign. 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. Othe medicines that might be used to teat GvHD include mycophenolate (CellCept ), ATG, and expeimental monoclonal antibodies. You docto might ecommend teatment pocedues such as photopheesis o total lymphoid iadiation. These pocedues will be explained to you in moe detail if you docto ecommends these teatments. Long-tem teatment with immunosuppessive medicine fo GvHD will equie you to also take antibiotic, antifungal, and antivial medicines to pevent life-theatening infections. It is impotant to be awae of the signs and symptoms of infection, and epot them to you BMT Team ight away. Long-tem teatment with steoids might also incease you isk of developing osteopoosis, cataacts, o joint poblems such as hip avascula necosis. You BMT docto will constantly monito you fo these potential side effects. Repot any bone o joint pain o vision changes to you BMT Team. Symptom management Skin gaft vesus host disease often causes dy, itchy skin. You can help decease the discomfot of this symptom by keeping you skin well-moistuized. Dink plenty of fluids, apply Vaseline (petoleum jelly) to you lips, bathe with a non-dying soap such as Aveeno, apply moistuizing lotion to you skin seveal times each day, and avoid all sun exposue, which can cause inceased skin damage. You BMT docto might pescibe topical steoid medicine to apply to you skin. Skin GvHD and UV Sun Exposue UV ay sun exposue can be hamful to the skin, causing sunbuns and/o skin cances. Also, UV ay exposue to those who have had an allogeneic tansplant can tigge o wosen skin GvHD. It is ecommended to wea a hat, long sleeves, long pants, and sunsceen with at least a SPF of 45 if you ae outside in the sun. Howeve, avoiding sun exposue is the best pevention. Please note that even on cloudy days, skin exposue to UV ays still occus; theefoe, pecautions should still be taken. Index #10434 Poduced by the Cente fo Consume Health Infomation Copyight The Cleveland Clinic Foundation. All ights eseved. Rev. 02/27/2014

242 Gaft Vesus Host Disease of the Gastointestinal (GI) Tact What is gaft vesus host disease of the gastointestinal tact? Gaft vesus host disease (GvHD) of the gastointestinal (GI) tact is one of the isks associated with an allogeneic tansplant. In GvHD of the GI tact, (also efeed to as the intestines o the gut ), the donated bone maow o peipheal blood stem cells (called the gaft) view the ecipient s body as foeign, and the donated cells/bone maow attack the GI tact (the host). Symptoms Repot these symptoms of GvHD of the GI tact to you nuse coodinato as soon as you notice them so the pope diagnosis can be made and pompt teatment can be stated: Inceased nausea Sevee diahea (The stools ae usually geen and watey, but blood might also be pesent in the stool in moe sevee cases.) Exteme weight loss Abdominal camping and bloating Late signs of GvHD of the GI tact might include: Deceased saliva causing dy mouth, difficulty swallowing, o mouth soes Chonic loose stools Gastointestinal Tact Phaynx Esophagus Stomach Small intestine (small bowel) Lage intestine (colon) Rectum GvHD of the Gastointestinal (GI) Tact Diagnosis To detect GvHD of the GI tact, each Blood & Maow Tansplant (BMT) patient is monitoed closely thoughout the BMT pocess. This monitoing includes egula physical exams duing which cetain symptoms ae evaluated, and blood tests and diagnostic tests ae pefomed.

243 If you have any of the symptoms of GvHD of the GI tact, please epot them to you BMT Team. You BMT docto will pefom a physical exam and might efe you to a gastoenteologist, a docto who specializes in teating conditions of the GI tact. The gastoenteologist will need to take a biopsy (tissue sample) of the aea that is suspected of causing symptoms. The biopsy is pefomed duing one of these pocedues: Colonoscopy is an outpatient pocedue duing which the ectum and the inside of the lowe lage intestine (colon) ae examined. Duing a colonoscopy, a docto uses a colonoscope (a long, thin, flexible instument about 1/2 inch in diamete) to view the lining of the colon. The colonoscope is inseted though the ectum and advanced to the lage intestine. Uppe endoscopy (EGD) is an outpatient pocedue duing which the inside of the uppe digestive system is examined. Duing the pocedue, a docto uses an endoscope (a long, thin, flexible instument about 1/2 inch in diamete) to examine the inside of the uppe digestive system. The endoscope is inseted though the esophagus (the food pipe leading fom you mouth into you stomach) and into you stomach. The esults of the biopsy might take seveal days to be evaluated and epoted to you BMT docto. Teatment If the diagnos of GvHD of the GI tact is confimed, you docto will monito you symptoms to make sue the condition is not getting wose. Some of the tests that might be pefomed to monito you symptoms include a stool volume test, and an evaluation of the colo and consistency of stool. You will be asked questions about the seveity of you symptoms, especially nausea and abdominal camping. You docto will also monito you nutitional status to make sue you ae not developing any deficiencies. When the diagnosis of GvHD of the GI tact is confimed, you docto will discuss available teatment options with you and you family. The teatment you eceive fo GvHD of the GI tact will be detemined by the seveity of you symptoms. Many patients ae successfully teated with outpatient steoid theapy (pednisone, methylpednisolone) to suppess you immune system and educe symptoms. If you symptoms (weight loss, nausea, diahea, o camping) wosen, inpatient teatment might be necessay. In the hospital, you will eceive highe doses of steoids and IV hydation to pevent dehydation. As a esult of gastointestinal GvHD, you lose impotant nutients and potein, which may lead to malnouishment. One way to detemine nutitional deficiencies is with blood wok measuing total potein and albumin. Albumin helps to maintain the fluid in you veins. If you albumin level dops, the fluid will escape fom you veins into you tissue, causing sevee swelling, especially in you legs. This can be vey uncomfotable, but is not pemanent. IV nutition (called total paenteal nutition o TPN) is given to help teat these nutition deficiencies. Duing this time, you may not be allowed to eat o dink anything, which gives you GI tact a chance to heal. Although TPN povides nutients, it is not as effective as eal food. When you tansplant docto detemines you symptoms ae unde contol, you will be taught to slowly intoduce liquids and food into you diet. If you intestinal tact is not quite eady fo liquid and food, you symptoms might etun. If this happens, you might need to "est you gut" a little longe. Fo this peiod of time, TPN will be you only souce of nutition.