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201711317

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UWHC,UWMF,

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Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Beacon Protocols,Brain

CSC Brain Temozolomide(42D:Daily) Concurrent XRT VER 9-13-17 (HL 991)

CSC Brain Temozolomide(42D:Daily) Concurrent XRT VER 9-13-17 (HL 991) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Brain


CSC BRAIN TEMOZOLOMIDE(42D:DAILY) CONCURRENT XRT VER: 9-13-17 –  Properties
Pre-Cycle –  11/6/2017 through 11/12/2017 (7 days), Planned
Day 1, Pre-Cycle –  Planned for 11/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: High Grade Glioma (Adjuvant), High-Risk Low Grade Glioma (Adjuvant); THERAPY (Stupp regimen):
temozolomide 75 mg/m2 by mouth once daily continuously up to Day 42; CYCLE LENGTH: 6 weeks concurrent XRT plus
4 weeks rest; COURSE: Length of radiotherapy.  
NOTE(1): May be followed by Maintenance Phase temozolomide (Health Link Protocol # 992 after a four week break).
NOTE (2): If BSA greater than 2.2 m2, consider dosing at adjusted body weight.
Treatment Plan Summary (2)
DISEASE: High Grade Glioma (Adjuvant), High-Risk Low Grade Glioma (Adjuvant); THERAPY (Combs regimen):
temozolomide 50 mg/m2 by mouth once daily continuously up to Day 42; CYCLE LENGTH: 6 weeks concurrent with XRT
plus 4 weeks rest with no post-radiation temozolomide; COURSE: length of radiotherapy.
NOTE (1): this dose level is to be used in elderly patients or patients with poor performance status or multiple co-
morbidities.
NOTE (2): If BSA greater than 2.2 m2, consider dosing at adjusted body weight.
Note to All Staff (1)
Monitor for sudden and precipitous drop in Platelet count typically between week 3 to 5, as it is often followed by
precipitous drop in ANC and White Blood Cells 7 to 10 days later. If Platelet count drops suddenly (close to or below
100K/uL), stop temozolomide and consider using pegfilgrastim before ANC goes below 1200/µL to ensure adequate
stem cells available for stimulation. Most often seen in young women, can be life-threatening and may require many
weeks of Platelet support.
Note to All Staff (2)
Pneumocystis Carinii prophylaxis required during radiation. Consider using pentamidine, sulfamethoxazole-
trimethoprim, or dapsone.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected: S Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S Approximate, Expires: S+397, Routine
GLUCOSE
Expected: S Approximate, Expires: S+397, Routine
BUN
Expected: S Approximate, Expires: S+397, Routine
CREATININE
Expected: S Approximate, Expires: S+397, Routine
CALCIUM
Expected: S Approximate, Expires: S+397, Routine
ALBUMIN
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Zztestonc,Fiona F [2462287]
11/13/2017 10:30:19 AM Page 1 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

Expected: S Approximate, Expires: S+397, Routine
PROTEIN, TOTAL
Expected: S Approximate, Expires: S+397, Routine
BILIRUBIN, TOTAL
Expected: S Approximate, Expires: S+397, Routine
AST/SGOT
Expected: S Approximate, Expires: S+397, Routine
ALT/SGPT
Expected: S Approximate, Expires: S+397, Routine
ALKALINE PHOSPHATASE
Expected: S Approximate, Expires: S+397, Routine
Take Home Medications
Note to All Staff (1)
For nausea not controlled by ondansetron, switch to another 5-HT3-receptor antagonist. Avoid the use of
prochlorperazine.
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth 1 hour before temozolomide for first 7 days then 1/2-1 tab every 8 hours as needed., Disp-30
tab, R-5, starting S
Cycle 1 –  11/13/2017 through 1/21/2018 (70 days), Planned
Day 1, Cycle 1 –  Planned for 11/13/2017
Treatment Plan Information
Reference Information (1)
GLIOMA: Stupp R, et al. N Engl J Med 2005;10:987-96.
Reference Information (2)
GLIOMA: Combs S, et al. Int J Radiat Oncol Biol Phys 2008;71(4):999-1005.
Reference Information (3)
GLIOMA: Vogelbaum MA, et al. J Neurooncol 2015;124(3):413-20.
Reference Information (4)
GLIOMA: Strowd RE, et al. J Neurooncol 2016;127(1):165-71.
Reference Information (5)
GLIOMA: Fisher BJ, et al. Int J Radiat Oncol Biol Phys 2015;91(3):497-504.
Treatment Plan Summary
DISEASE: High Grade Glioma (Adjuvant), High-Risk Low Grade Glioma (Adjuvant); THERAPY (Stupp regimen):
temozolomide 75 mg/m2 by mouth once daily continuously up to Day 42; CYCLE LENGTH: 6 weeks concurrent XRT plus
4 weeks rest; COURSE: Length of radiotherapy.  
NOTE(1): May be followed by Maintenance Phase temozolomide (Health Link Protocol # 992 after a four week break).
NOTE (2): If BSA greater than 2.2 m2, consider dosing at adjusted body weight.
Treatment Plan Summary (2)
DISEASE: High Grade Glioma (Adjuvant), High-Risk Low Grade Glioma (Adjuvant); THERAPY (Combs regimen):
temozolomide 50 mg/m2 by mouth once daily continuously up to Day 42; CYCLE LENGTH: 6 weeks concurrent with XRT
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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Zztestonc,Fiona F [2462287]
11/13/2017 10:30:19 AM Page 2 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

plus 4 weeks rest with no post-radiation temozolomide; COURSE: length of radiotherapy.
NOTE (1): this dose level is to be used in elderly patients or patients with poor performance status or multiple co-
morbidities.
NOTE (2): If BSA greater than 2.2 m2, consider dosing at adjusted body weight.
Note to All Staff (1)
Monitor for sudden and precipitous drop in Platelet count typically between week 3 to 5, as it is often followed by
precipitous drop in ANC and White Blood Cells 7 to 10 days later. If Platelet count drops suddenly (close to or below
100K/uL), stop temozolomide and consider using pegfilgrastim before ANC goes below 1200/µL to ensure adequate
stem cells available for stimulation. Most often seen in young women, can be life-threatening and may require many
weeks of Platelet support.
Note to All Staff (2)
Pneumocystis Carinii prophylaxis required during radiation. Consider using pentamidine, sulfamethoxazole-
trimethoprim, or dapsone.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin,
Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase
Treatment Parameters
Hold and notify authorizing prescriber for Platelets less than or equal or 105K/µL or greater than 100K/µL decrease
since last Platelet count or ANC less than or equal to 1000/µL.
Treatment Parameters (2)
Notify authorizing prescriber to start Zoster prophylaxis for Absolute Lymphocyte Count less than 400/µL.
Nursing Procedure, Assessment and Monitoring
Note to All Staff (1)
For nausea not controlled by ondansetron, switch to another 5-HT3-receptor antagonist. Avoid the use of
prochlorperazine.
Patient Instructions(1)
Educate/reinforce with patient regarding oral chemotherapy and home safety.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
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Zztestonc,Fiona F [2462287]
11/13/2017 10:30:19 AM Page 3 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): temozolomide (Dispensed on
Day 1 of each cycle).
Take Home Medications (delete all that do not apply)
temozolomide (TEMODAR) 180 MG cap
Take *** capsules once daily at bedtime. Take continuously. Swallow whole on empty stomach. Total daily dose= ***
mg, R-1, starting S
Round dose to available capsule sizes. Dosing based on *** mg/m2. This is a 42-day supply. Please divide dose into 21
day supply with 1 refill.
temozolomide (TEMODAR) 140 MG cap
Take *** capsules once daily at bedtime. Take continuously. Swallow whole on empty stomach. Total daily dose= ***
mg, R-1, starting S
Round dose to available capsule sizes. Dosing based on *** mg/m2. This is a 42-day supply. Please divide dose into 21
day supply with 1 refill.
temozolomide (TEMODAR) 100 MG cap
Take *** capsules once daily at bedtime. Take continuously. Swallow whole on empty stomach. Total daily dose= ***
mg, R-1, starting S
Round dose to available capsule sizes. Dosing based on *** mg/m2. This is a 42-day supply. Please divide dose into 21
day supply with 1 refill.
temozolomide (TEMODAR) 20 MG cap
Take *** capsules once daily at bedtime. Take continuously. Swallow whole on empty stomach. Total daily dose= ***
mg, R-1, starting S
Round dose to available capsule sizes. Dosing based on *** mg/m2. This is a 42-day supply. Please divide dose into 21
day supply with 1 refill.
temozolomide (TEMODAR) 5 MG cap
Take *** capsules once daily at bedtime. Take continuously. Swallow whole on empty stomach. Total daily dose= ***
mg, R-1, starting S
Round dose to available capsule sizes. Dosing based on *** mg/m2. This is a 42-day supply. Please divide dose into 21
day supply with 1 refill.
Supportive Care Medications
Note to All Staff (1)
Verify patient has PCP prophylaxis medication or treatment scheduled.
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC with DIFF.
DAY 15 FOLLOW-UP
LABS: CBC with DIFF
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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Zztestonc,Fiona F [2462287]
11/13/2017 10:30:19 AM Page 4 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

DAY 22 FOLLOW-UP
LABS: CBC with DIFF
DAY 29 FOLLOW-UP
RETURN TO CLINIC for appointment with the provider; LABS: CBC with DIFF.
DAY 36 FOLLOW-UP
LABS: CBC with DIFF.
DAY 43 FOLLOW-UP
LABS: CBC with DIFF.
DAY 50 FOLLOW-UP
LABS: CBC with DIFF.
DAY 57 FOLLOW-UP
LABS: CBC with DIFF.
Day 64 Follow-Up
LABS: CBC with DIFF.
DAY 71 FOLLOW-UP
(Day 1 of post radiation) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF (assuming this
protocol will be followed by CSC Brain Temozolomide(28D:1-5) Maintenance Phase).
Lab Only - Day 8, Cycle 1 –  Planned for 11/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: High Grade Glioma (Adjuvant), High-Risk Low Grade Glioma (Adjuvant); THERAPY (Stupp regimen):
temozolomide 75 mg/m2 by mouth once daily continuously up to Day 42; CYCLE LENGTH: 6 weeks concurrent XRT plus
4 weeks rest; COURSE: Length of radiotherapy.  
NOTE(1): May be followed by Maintenance Phase temozolomide (Health Link Protocol # 992 after a four week break).
NOTE (2): If BSA greater than 2.2 m2, consider dosing at adjusted body weight.
Treatment Plan Summary (2)
DISEASE: High Grade Glioma (Adjuvant), High-Risk Low Grade Glioma (Adjuvant); THERAPY (Combs regimen):
temozolomide 50 mg/m2 by mouth once daily continuously up to Day 42; CYCLE LENGTH: 6 weeks concurrent with XRT
plus 4 weeks rest with no post-radiation temozolomide; COURSE: length of radiotherapy.
NOTE (1): this dose level is to be used in elderly patients or patients with poor performance status or multiple co-
morbidities.
NOTE (2): If BSA greater than 2.2 m2, consider dosing at adjusted body weight.
Note to All Staff (1)
Monitor for sudden and precipitous drop in Platelet count typically between week 3 to 5, as it is often followed by
precipitous drop in ANC and White Blood Cells 7 to 10 days later. If Platelet count drops suddenly (close to or below
100K/uL), stop temozolomide and consider using pegfilgrastim before ANC goes below 1200/µL to ensure adequate
stem cells available for stimulation. Most often seen in young women, can be life-threatening and may require many
weeks of Platelet support.
Note to All Staff (2)
Pneumocystis Carinii prophylaxis required during radiation. Consider using pentamidine, sulfamethoxazole-
trimethoprim, or dapsone.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Fiona F [2462287]
11/13/2017 10:30:19 AM Page 5 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected: S+7 Approximate, Expires: S+365, Routine
Treatment Conditions
Treatment Parameters
Hold and notify authorizing prescriber for Platelets less than or equal or 105K/µL or greater than 100K/µL decrease
since last Platelet count or ANC less than or equal to 1000/µL.
Treatment Parameters (2)
Notify authorizing prescriber to start Zoster prophylaxis for Absolute Lymphocyte Count less than 400/µL.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 1 –  Planned for 11/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: High Grade Glioma (Adjuvant), High-Risk Low Grade Glioma (Adjuvant); THERAPY (Stupp regimen):
temozolomide 75 mg/m2 by mouth once daily continuously up to Day 42; CYCLE LENGTH: 6 weeks concurrent XRT plus
4 weeks rest; COURSE: Length of radiotherapy.  
NOTE(1): May be followed by Maintenance Phase temozolomide (Health Link Protocol # 992 after a four week break).
NOTE (2): If BSA greater than 2.2 m2, consider dosing at adjusted body weight.
Treatment Plan Summary (2)
DISEASE: High Grade Glioma (Adjuvant), High-Risk Low Grade Glioma (Adjuvant); THERAPY (Combs regimen):
temozolomide 50 mg/m2 by mouth once daily continuously up to Day 42; CYCLE LENGTH: 6 weeks concurrent with XRT
plus 4 weeks rest with no post-radiation temozolomide; COURSE: length of radiotherapy.
NOTE (1): this dose level is to be used in elderly patients or patients with poor performance status or multiple co-
morbidities.
NOTE (2): If BSA greater than 2.2 m2, consider dosing at adjusted body weight.
Note to All Staff (1)
Monitor for sudden and precipitous drop in Platelet count typically between week 3 to 5, as it is often followed by
precipitous drop in ANC and White Blood Cells 7 to 10 days later. If Platelet count drops suddenly (close to or below
100K/uL), stop temozolomide and consider using pegfilgrastim before ANC goes below 1200/µL to ensure adequate
stem cells available for stimulation. Most often seen in young women, can be life-threatening and may require many
weeks of Platelet support.
Note to All Staff (2)
Pneumocystis Carinii prophylaxis required during radiation. Consider using pentamidine, sulfamethoxazole-
trimethoprim, or dapsone.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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Zztestonc,Fiona F [2462287]
11/13/2017 10:30:19 AM Page 6 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

CBC WITH DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
Treatment Conditions
Treatment Parameters
Hold and notify authorizing prescriber for Platelets less than or equal or 105K/µL or greater than 100K/µL decrease
since last Platelet count or ANC less than or equal to 1000/µL.
Treatment Parameters (2)
Notify authorizing prescriber to start Zoster prophylaxis for Absolute Lymphocyte Count less than 400/µL.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 22, Cycle 1 –  Planned for 12/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: High Grade Glioma (Adjuvant), High-Risk Low Grade Glioma (Adjuvant); THERAPY (Stupp regimen):
temozolomide 75 mg/m2 by mouth once daily continuously up to Day 42; CYCLE LENGTH: 6 weeks concurrent XRT plus
4 weeks rest; COURSE: Length of radiotherapy.  
NOTE(1): May be followed by Maintenance Phase temozolomide (Health Link Protocol # 992 after a four week break).
NOTE (2): If BSA greater than 2.2 m2, consider dosing at adjusted body weight.
Treatment Plan Summary (2)
DISEASE: High Grade Glioma (Adjuvant), High-Risk Low Grade Glioma (Adjuvant); THERAPY (Combs regimen):
temozolomide 50 mg/m2 by mouth once daily continuously up to Day 42; CYCLE LENGTH: 6 weeks concurrent with XRT
plus 4 weeks rest with no post-radiation temozolomide; COURSE: length of radiotherapy.
NOTE (1): this dose level is to be used in elderly patients or patients with poor performance status or multiple co-
morbidities.
NOTE (2): If BSA greater than 2.2 m2, consider dosing at adjusted body weight.
Note to All Staff (1)
Monitor for sudden and precipitous drop in Platelet count typically between week 3 to 5, as it is often followed by
precipitous drop in ANC and White Blood Cells 7 to 10 days later. If Platelet count drops suddenly (close to or below
100K/uL), stop temozolomide and consider using pegfilgrastim before ANC goes below 1200/µL to ensure adequate
stem cells available for stimulation. Most often seen in young women, can be life-threatening and may require many
weeks of Platelet support.
Note to All Staff (2)
Pneumocystis Carinii prophylaxis required during radiation. Consider using pentamidine, sulfamethoxazole-
trimethoprim, or dapsone.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected: S+21 Approximate, Expires: S+365, Routine
Treatment Conditions
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Zztestonc,Fiona F [2462287]
11/13/2017 10:30:19 AM Page 7 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Treatment Parameters
Hold and notify authorizing prescriber for Platelets less than or equal or 105K/µL or greater than
100K/µL decrease since last Platelet count or ANC less than or equal to 1000/µL.
Treatment Parameters (2)
Notify authorizing prescriber to start Zoster prophylaxis for Absolute Lymphocyte Count less than 400/µL.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 29 , Cycle 1 –  Planned for 12/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: High Grade Glioma (Adjuvant), High-Risk Low Grade Glioma (Adjuvant); THERAPY (Stupp regimen):
temozolomide 75 mg/m2 by mouth once daily continuously up to Day 42; CYCLE LENGTH: 6 weeks concurrent XRT plus
4 weeks rest; COURSE: Length of radiotherapy.  
NOTE(1): May be followed by Maintenance Phase temozolomide (Health Link Protocol # 992 after a four week break).
NOTE (2): If BSA greater than 2.2 m2, consider dosing at adjusted body weight.
Treatment Plan Summary (2)
DISEASE: High Grade Glioma (Adjuvant), High-Risk Low Grade Glioma (Adjuvant); THERAPY (Combs regimen):
temozolomide 50 mg/m2 by mouth once daily continuously up to Day 42; CYCLE LENGTH: 6 weeks concurrent with XRT
plus 4 weeks rest with no post-radiation temozolomide; COURSE: length of radiotherapy.
NOTE (1): this dose level is to be used in elderly patients or patients with poor performance status or multiple co-
morbidities.
NOTE (2): If BSA greater than 2.2 m2, consider dosing at adjusted body weight.
Note to All Staff (1)
Monitor for sudden and precipitous drop in Platelet count typically between week 3 to 5, as it is often followed by
precipitous drop in ANC and White Blood Cells 7 to 10 days later. If Platelet count drops suddenly (close to or below
100K/uL), stop temozolomide and consider using pegfilgrastim before ANC goes below 1200/µL to ensure adequate
stem cells available for stimulation. Most often seen in young women, can be life-threatening and may require many
weeks of Platelet support.
Note to All Staff (2)
Pneumocystis Carinii prophylaxis required during radiation. Consider using pentamidine, sulfamethoxazole-
trimethoprim, or dapsone.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected: S+28 Approximate, Expires: S+365, Routine
Treatment Conditions
Treatment Parameters
Hold and notify authorizing prescriber for Platelets less than or equal or 105K/µL or greater than 100K/µL decrease
since last Platelet count or ANC less than or equal to 1000/µL.
Treatment Parameters (2)
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Zztestonc,Fiona F [2462287]
11/13/2017 10:30:19 AM Page 8 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Notify authorizing prescriber to start Zoster prophylaxis for Absolute Lymphocyte Count less than 400/µL.
Supportive Care Medications
Note to All Staff (1)
Verify patient has PCP prophylaxis medication or treatment scheduled.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 36, Cycle 1 –  Planned for 12/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: High Grade Glioma (Adjuvant), High-Risk Low Grade Glioma (Adjuvant); THERAPY (Stupp regimen):
temozolomide 75 mg/m2 by mouth once daily continuously up to Day 42; CYCLE LENGTH: 6 weeks concurrent XRT plus
4 weeks rest; COURSE: Length of radiotherapy.  
NOTE(1): May be followed by Maintenance Phase temozolomide (Health Link Protocol # 992 after a four week break).
NOTE (2): If BSA greater than 2.2 m2, consider dosing at adjusted body weight.
Treatment Plan Summary (2)
DISEASE: High Grade Glioma (Adjuvant), High-Risk Low Grade Glioma (Adjuvant); THERAPY (Combs regimen):
temozolomide 50 mg/m2 by mouth once daily continuously up to Day 42; CYCLE LENGTH: 6 weeks concurrent with XRT
plus 4 weeks rest with no post-radiation temozolomide; COURSE: length of radiotherapy.
NOTE (1): this dose level is to be used in elderly patients or patients with poor performance status or multiple co-
morbidities.
NOTE (2): If BSA greater than 2.2 m2, consider dosing at adjusted body weight.
Note to All Staff (1)
Monitor for sudden and precipitous drop in Platelet count typically between week 3 to 5, as it is often followed by
precipitous drop in ANC and White Blood Cells 7 to 10 days later. If Platelet count drops suddenly (close to or below
100K/uL), stop temozolomide and consider using pegfilgrastim before ANC goes below 1200/µL to ensure adequate
stem cells available for stimulation. Most often seen in young women, can be life-threatening and may require many
weeks of Platelet support.
Note to All Staff (2)
Pneumocystis Carinii prophylaxis required during radiation. Consider using pentamidine, sulfamethoxazole-
trimethoprim, or dapsone.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected: S+35 Approximate, Expires: S+365, Routine
Treatment Conditions
Treatment Parameters
Hold and notify authorizing prescriber for Platelets less than or equal or 105K/µL or greater than 100K/µL decrease
since last Platelet count or ANC less than or equal to 1000/µL.
Treatment Parameters (2)
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Zztestonc,Fiona F [2462287]
11/13/2017 10:30:19 AM Page 9 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Notify authorizing prescriber to start Zoster prophylaxis for Absolute Lymphocyte Count less than 400/µL.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 43, Cycle 1 –  Planned for 12/25/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: High Grade Glioma (Adjuvant), High-Risk Low Grade Glioma (Adjuvant); THERAPY (Stupp regimen):
temozolomide 75 mg/m2 by mouth once daily continuously up to Day 42; CYCLE LENGTH: 6 weeks concurrent XRT plus
4 weeks rest; COURSE: Length of radiotherapy.  
NOTE(1): May be followed by Maintenance Phase temozolomide (Health Link Protocol # 992 after a four week break).
NOTE (2): If BSA greater than 2.2 m2, consider dosing at adjusted body weight.
Treatment Plan Summary (2)
DISEASE: High Grade Glioma (Adjuvant), High-Risk Low Grade Glioma (Adjuvant); THERAPY (Combs regimen):
temozolomide 50 mg/m2 by mouth once daily continuously up to Day 42; CYCLE LENGTH: 6 weeks concurrent with XRT
plus 4 weeks rest with no post-radiation temozolomide; COURSE: length of radiotherapy.
NOTE (1): this dose level is to be used in elderly patients or patients with poor performance status or multiple co-
morbidities.
NOTE (2): If BSA greater than 2.2 m2, consider dosing at adjusted body weight.
Note to All Staff (1)
Monitor for sudden and precipitous drop in Platelet count typically between week 3 to 5, as it is often followed by
precipitous drop in ANC and White Blood Cells 7 to 10 days later. If Platelet count drops suddenly (close to or below
100K/uL), stop temozolomide and consider using pegfilgrastim before ANC goes below 1200/µL to ensure adequate
stem cells available for stimulation. Most often seen in young women, can be life-threatening and may require many
weeks of Platelet support.
Note to All Staff (2)
Pneumocystis Carinii prophylaxis required during radiation. Consider using pentamidine, sulfamethoxazole-
trimethoprim, or dapsone.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected: S+42 Approximate, Expires: S+365, Routine
Treatment Conditions
Treatment Parameters
Hold and notify authorizing prescriber for Platelets less than or equal or 105K/µL or greater than 100K/µL decrease
since last Platelet count or ANC less than or equal to 1000/µL.
Treatment Parameters (2)
Notify authorizing prescriber to start Zoster prophylaxis for Absolute Lymphocyte Count less than 400/µL.
Follow-Up
VERIFY APPOINTMENTS
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Zztestonc,Fiona F [2462287]
11/13/2017 10:30:19 AM Page 10 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 50 , Cycle 1 –  Planned for 1/1/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: High Grade Glioma (Adjuvant), High-Risk Low Grade Glioma (Adjuvant); THERAPY (Stupp regimen):
temozolomide 75 mg/m2 by mouth once daily continuously up to Day 42; CYCLE LENGTH: 6 weeks concurrent XRT plus
4 weeks rest; COURSE: Length of radiotherapy.  
NOTE(1): May be followed by Maintenance Phase temozolomide (Health Link Protocol # 992 after a four week break).
NOTE (2): If BSA greater than 2.2 m2, consider dosing at adjusted body weight.
Treatment Plan Summary (2)
DISEASE: High Grade Glioma (Adjuvant), High-Risk Low Grade Glioma (Adjuvant); THERAPY (Combs regimen):
temozolomide 50 mg/m2 by mouth once daily continuously up to Day 42; CYCLE LENGTH: 6 weeks concurrent with XRT
plus 4 weeks rest with no post-radiation temozolomide; COURSE: length of radiotherapy.
NOTE (1): this dose level is to be used in elderly patients or patients with poor performance status or multiple co-
morbidities.
NOTE (2): If BSA greater than 2.2 m2, consider dosing at adjusted body weight.
Note to All Staff (1)
Monitor for sudden and precipitous drop in Platelet count typically between week 3 to 5, as it is often followed by
precipitous drop in ANC and White Blood Cells 7 to 10 days later. If Platelet count drops suddenly (close to or below
100K/uL), stop temozolomide and consider using pegfilgrastim before ANC goes below 1200/µL to ensure adequate
stem cells available for stimulation. Most often seen in young women, can be life-threatening and may require many
weeks of Platelet support.
Note to All Staff (2)
Pneumocystis Carinii prophylaxis required during radiation. Consider using pentamidine, sulfamethoxazole-
trimethoprim, or dapsone.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected: S+49 Approximate, Expires: S+365, Routine
Treatment Conditions
Treatment Parameters
Hold and notify authorizing prescriber for Platelets less than or equal or 105K/µL or greater than 100K/µL decrease
since last Platelet count or ANC less than or equal to 1000/µL.
Treatment Parameters (2)
Notify authorizing prescriber to start Zoster prophylaxis for Absolute Lymphocyte Count less than 400/µL.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 57, Cycle 1 –  Planned for 1/8/2018
Treatment Plan Information
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Zztestonc,Fiona F [2462287]
11/13/2017 10:30:19 AM Page 11 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: High Grade Glioma (Adjuvant), High-Risk Low Grade Glioma (Adjuvant); THERAPY (Stupp regimen):
temozolomide 75 mg/m2 by mouth once daily continuously up to Day 42; CYCLE LENGTH: 6 weeks concurrent XRT plus
4 weeks rest; COURSE: Length of radiotherapy.  
NOTE(1): May be followed by Maintenance Phase temozolomide (Health Link Protocol # 992 after a four week break).
NOTE (2): If BSA greater than 2.2 m2, consider dosing at adjusted body weight.
Treatment Plan Summary (2)
DISEASE: High Grade Glioma (Adjuvant), High-Risk Low Grade Glioma (Adjuvant); THERAPY (Combs regimen):
temozolomide 50 mg/m2 by mouth once daily continuously up to Day 42; CYCLE LENGTH: 6 weeks concurrent with XRT
plus 4 weeks rest with no post-radiation temozolomide; COURSE: length of radiotherapy.
NOTE (1): this dose level is to be used in elderly patients or patients with poor performance status or multiple co-
morbidities.
NOTE (2): If BSA greater than 2.2 m2, consider dosing at adjusted body weight.
Note to All Staff (1)
Monitor for sudden and precipitous drop in Platelet count typically between week 3 to 5, as it is often followed by
precipitous drop in ANC and White Blood Cells 7 to 10 days later. If Platelet count drops suddenly (close to or below
100K/uL), stop temozolomide and consider using pegfilgrastim before ANC goes below 1200/µL to ensure adequate
stem cells available for stimulation. Most often seen in young women, can be life-threatening and may require many
weeks of Platelet support.
Note to All Staff (2)
Pneumocystis Carinii prophylaxis required during radiation. Consider using pentamidine, sulfamethoxazole-
trimethoprim, or dapsone.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected: S+56 Approximate, Expires: S+365, Routine
Treatment Conditions
Treatment Parameters
Notify authorizing prescriber to start Zoster prophylaxis for Absolute Lymphocyte Count less than 400/µL.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 64, Cycle 1 –  Planned for 1/15/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: High Grade Glioma (Adjuvant), High-Risk Low Grade Glioma (Adjuvant); THERAPY (Stupp regimen):
temozolomide 75 mg/m2 by mouth once daily continuously up to Day 42; CYCLE LENGTH: 6 weeks concurrent XRT plus
4 weeks rest; COURSE: Length of radiotherapy.  
NOTE(1): May be followed by Maintenance Phase temozolomide (Health Link Protocol # 992 after a four week break).
Actions
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Zztestonc,Fiona F [2462287]
11/13/2017 10:30:19 AM Page 12 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

NOTE (2): If BSA greater than 2.2 m2, consider dosing at adjusted body weight.
Treatment Plan Summary (2)
DISEASE: High Grade Glioma (Adjuvant), High-Risk Low Grade Glioma (Adjuvant); THERAPY (Combs regimen):
temozolomide 50 mg/m2 by mouth once daily continuously up to Day 42; CYCLE LENGTH: 6 weeks concurrent with XRT
plus 4 weeks rest with no post-radiation temozolomide; COURSE: length of radiotherapy.
NOTE (1): this dose level is to be used in elderly patients or patients with poor performance status or multiple co-
morbidities.
NOTE (2): If BSA greater than 2.2 m2, consider dosing at adjusted body weight.
Note to All Staff (1)
Monitor for sudden and precipitous drop in Platelet count typically between week 3 to 5, as it is often followed by
precipitous drop in ANC and White Blood Cells 7 to 10 days later. If Platelet count drops suddenly (close to or below
100K/uL), stop temozolomide and consider using pegfilgrastim before ANC goes below 1200/µL to ensure adequate
stem cells available for stimulation. Most often seen in young women, can be life-threatening and may require many
weeks of Platelet support.
Note to All Staff (2)
Pneumocystis Carinii prophylaxis required during radiation. Consider using pentamidine, sulfamethoxazole-
trimethoprim, or dapsone.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected: S+63 Approximate, Expires: S+365, Routine
Treatment Conditions
Treatment Parameters
Notify authorizing prescriber to start Zoster prophylaxis for Absolute Lymphocyte Count less than 400/µL.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Actions
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Zztestonc,Fiona F [2462287]
11/13/2017 10:30:19 AM Page 13 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org