/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/beacon-protocols/,/clinical/cckm-tools/content/beacon-protocols/brain/,

/clinical/cckm-tools/content/beacon-protocols/brain/name-96565-en.cckm

201711317

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100

UWHC,UWMF,

Tools,

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

CSC Brain Bevacizumab(28D:1,15)/Lomustine(28D:1) VER 10-25-17 (HL 5232)

CSC Brain Bevacizumab(28D:1,15)/Lomustine(28D:1) VER 10-25-17 (HL 5232) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Brain


CSC BRAIN BEVACIZUMAB(28D:1,15)/LOMUSTINE(28D:1) VER: 10-25-17 –  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: Glioma (Advanced/Recurrent High-grade); THERAPY: bevacizumab 10 mg/kg IV Day 1 and 15, lomustine 70
mg/m2 (max dose = 160 mg) by mouth Day 1; CYCLE LENGTH: 28 days; COURSE: 9 to 12 cycles.
NOTE: This protocol should only be used in patients with tumors demonstrating MGMT methylation.
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
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
URINALYSIS, NO MICROSCOPY
Expected: S Approximate, Expires: S+365, Normal, Routine
Take Home Medications
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Zztestonc,Fiona F [2462287]
11/13/2017 11:08:24 AM Page 1 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

ondansetron (ZOFRAN) 8 MG tab
Take 2 tablets 1 hour prior to lomustine and 1 tablet every 8 hours as needed. Max 3 tabs in 24
hours., Disp-30 tab, R-5, starting S
lorazepam (ATIVAN) 1 MG tab
Take 1 tab by mouth once at bedtime. Take with lomustine dose., 1 mg, Disp-6 tab, R-6, ONCE (HS) starting S, Local
Printer
Cycle 1 –  11/13/2017 through 12/10/2017 (28 days), Planned
Day 1, Cycle 1 –  Planned for 11/13/2017
Treatment Plan Information
Reference Information (1)
GLIOMA: Taal W, et al. Lancet Oncol 2014;15(9):943-53.
Treatment Plan Summary
DISEASE: Glioma (Advanced/Recurrent High-grade); THERAPY: bevacizumab 10 mg/kg IV Day 1 and 15, lomustine 70
mg/m2 (max dose = 160 mg) by mouth Day 1; CYCLE LENGTH: 28 days; COURSE: 9 to 12 cycles.
NOTE: This protocol should only be used in patients with tumors demonstrating MGMT methylation.
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, Creatinine, Urinalysis without Microscopy.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1500/uL or Platelets less than 100K/uL or Blood Pressure
greater than or equal to 160/90 mmHg or Urine Protein greater than 100 mg/dL or Creatinine greater than ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bevacizumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Verify patient has taken ondansetron 16 mg by mouth prior to lomustine.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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 11:08:24 AM Page 2 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

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.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bevacizumab (AVASTIN) 10 mg/kg in sodium chloride 0.9 % 100 mL bag
10 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Give first dose over 90 minutes. If tolerated, give 2nd dose over 60 minutes; if tolerated, give 3rd and subsequent doses
over 30 minutes. If infusion-related reactions occur, all subsequent infusions should be administered over the shortest
period that was well tolerated. Hypersensitivity risk. See Emergency Medications.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lomustine (Dispensed on Day 1
of each cycle)
Take Home Medications (delete all that do not apply)
lomustine (CEENU) 10 MG cap
Take 70 mg/m2 by mouth once at bedtime. Take on Day 1. Take on an empty stomach., 70 mg/m2, R-0, ONCE (HS)
starting S, Local Printer
Round dose to the available capsule size.
lomustine (CEENU) 40 MG cap
Take 70 mg/m2 by mouth once at bedtime. Take on Day 1. Take on an empty stomach., 70 mg/m2, R-0, ONCE (HS)
starting S, Local Printer
Round dose to the available capsule size.
lomustine (CEENU) 100 MG cap
Take 70 mg/m2 by mouth once at bedtime. Take on Day 1. Take on an empty stomach., 70 mg/m2, R-0, ONCE (HS)
starting S, Local Printer
Round dose to the available capsule size.
Follow-Up
DAY 15 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Urinalysis without Microscopy;
CHEMOTHERAPY ROOM APPOINTMENT:  bevacizumab for 90 minutes.
DAY 22 FOLLOW-UP
LABS: CBC with DIFF.
DAY 29 FOLLOW-UP
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Zztestonc,Fiona F [2462287]
11/13/2017 11:08:24 AM Page 3 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose,
BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Urinalysis without
Microscopy; CHEMOTHERAPY ROOM APPOINTMENT:  bevacizumab for 60 minutes.
Day 15, Cycle 1 –  Planned for 11/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Glioma (Advanced/Recurrent High-grade); THERAPY: bevacizumab 10 mg/kg IV Day 1 and 15, lomustine 70
mg/m2 (max dose = 160 mg) by mouth Day 1; CYCLE LENGTH: 28 days; COURSE: 9 to 12 cycles.
NOTE: This protocol should only be used in patients with tumors demonstrating MGMT methylation.
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+14 Approximate, Expires: S+365, Routine
URINALYSIS, NO MICROSCOPY
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Urinalysis without Microscopy.
Treatment Parameters
Hold and notify authorizing prescriber for Platelets less than 50K/uL or Blood Pressure greater than or equal to 160/90
mmHg or Urine Protein greater than 100 mg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bevacizumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
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.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
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Zztestonc,Fiona F [2462287]
11/13/2017 11:08:24 AM Page 4 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bevacizumab (AVASTIN) 10 mg/kg in sodium chloride 0.9 % 100 mL bag
10 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Give first dose over 90 minutes. If tolerated, give 2nd dose over 60 minutes; if tolerated, give 3rd and subsequent doses
over 30 minutes. If infusion-related reactions occur, all subsequent infusions should be administered over the shortest
period that was well tolerated. Hypersensitivity risk. See Emergency Medications.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lomustine (Dispensed on Day 1
of each cycle)
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: Glioma (Advanced/Recurrent High-grade); THERAPY: bevacizumab 10 mg/kg IV Day 1 and 15, lomustine 70
mg/m2 (max dose = 160 mg) by mouth Day 1; CYCLE LENGTH: 28 days; COURSE: 9 to 12 cycles.
NOTE: This protocol should only be used in patients with tumors demonstrating MGMT methylation.
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+7 Approximate, Expires: S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 –  12/11/2017 through 1/7/2018 (28 days), Planned
Day 1, Cycle 2 –  Planned for 12/11/2017
Treatment Plan Information
Treatment Plan Summary
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Zztestonc,Fiona F [2462287]
11/13/2017 11:08:24 AM Page 5 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

DISEASE: Glioma (Advanced/Recurrent High-grade); THERAPY: bevacizumab 10 mg/kg IV Day 1 and 15, lomustine 70
mg/m2 (max dose = 160 mg) by mouth Day 1; CYCLE LENGTH: 28 days; COURSE: 9 to 12 cycles.
NOTE: This protocol should only be used in patients with tumors demonstrating MGMT methylation.
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.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BUN
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CALCIUM
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALBUMIN
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
PROTEIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
URINALYSIS, NO MICROSCOPY
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained:  CBC with DIFF, Creatinine, Urinalysis without Microscopy.
Treatment Parameters
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Zztestonc,Fiona F [2462287]
11/13/2017 11:08:24 AM Page 6 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Hold and notify authorizing prescriber for ANC less than 1500/uL or Platelets less than 100K/uL or Blood Pressure
greater than or equal to 160/90 mmHg or Urine Protein greater than 100 mg/dL or Creatinine greater than ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bevacizumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Verify patient has taken ondansetron 16 mg by mouth prior to lomustine.
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.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bevacizumab (AVASTIN) 10 mg/kg in sodium chloride 0.9 % 100 mL bag
10 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Give first dose over 90 minutes. If tolerated, give 2nd dose over 60 minutes; if tolerated, give 3rd and subsequent doses
over 30 minutes. If infusion-related reactions occur, all subsequent infusions should be administered over the shortest
period that was well tolerated. Hypersensitivity risk. See Emergency Medications.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lomustine (Dispensed on Day 1
of each cycle)
Take Home Medications (delete all that do not apply)
lomustine (CEENU) 10 MG cap
Take 70 mg/m2 by mouth once at bedtime. Take on Day 1. Take on an empty stomach., 70 mg/m2, R-0, ONCE (HS)
starting S, Local Printer
Round dose to the available capsule size.
lomustine (CEENU) 40 MG cap
Take 70 mg/m2 by mouth once at bedtime. Take on Day 1. Take on an empty stomach., 70 mg/m2, R-0, ONCE (HS)
starting S, Local Printer
Round dose to the available capsule size.
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Zztestonc,Fiona F [2462287]
11/13/2017 11:08:24 AM Page 7 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

lomustine (CEENU) 100 MG cap
Take 70 mg/m2 by mouth once at bedtime. Take on Day 1. Take on an empty stomach., 70 mg/m2,
R-0, ONCE (HS) starting S, Local Printer
Round dose to the available capsule size.
Follow-Up
DAY 15 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Urinalysis without Microscopy;
CHEMOTHERAPY ROOM APPOINTMENT:  bevacizumab for 60 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose,
BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Urinalysis without
Microscopy; CHEMOTHERAPY ROOM APPOINTMENT:  bevacizumab for 60 minutes.
Day 15, Cycle 2 –  Planned for 12/25/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Glioma (Advanced/Recurrent High-grade); THERAPY: bevacizumab 10 mg/kg IV Day 1 and 15, lomustine 70
mg/m2 (max dose = 160 mg) by mouth Day 1; CYCLE LENGTH: 28 days; COURSE: 9 to 12 cycles.
NOTE: This protocol should only be used in patients with tumors demonstrating MGMT methylation.
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+14 Approximate, Expires: S+365, Routine
URINALYSIS, NO MICROSCOPY
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Urinalysis without Microscopy.
Treatment Parameters
Hold and notify authorizing prescriber for Platelets less than 50K/uL or Blood Pressure greater than or equal to 160/90
mmHg or Urine Protein greater than 100 mg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bevacizumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
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
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Zztestonc,Fiona F [2462287]
11/13/2017 11:08:24 AM Page 8 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

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.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bevacizumab (AVASTIN) 10 mg/kg in sodium chloride 0.9 % 100 mL bag
10 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Give first dose over 90 minutes. If tolerated, give 2nd dose over 60 minutes; if tolerated, give 3rd and subsequent doses
over 30 minutes. If infusion-related reactions occur, all subsequent infusions should be administered over the shortest
period that was well tolerated. Hypersensitivity risk. See Emergency Medications.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lomustine (Dispensed on Day 1
of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 –  1/8/2018 through 2/4/2018 (28 days), Planned
Day 1, Cycle 3 –  Planned for 1/8/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Glioma (Advanced/Recurrent High-grade); THERAPY: bevacizumab 10 mg/kg IV Day 1 and 15, lomustine 70
mg/m2 (max dose = 160 mg) by mouth Day 1; CYCLE LENGTH: 28 days; COURSE: 9 to 12 cycles.
NOTE: This protocol should only be used in patients with tumors demonstrating MGMT methylation.
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.
Pre-Labs
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Zztestonc,Fiona F [2462287]
11/13/2017 11:08:24 AM Page 9 of 35
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
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BUN
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CALCIUM
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALBUMIN
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
PROTEIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
URINALYSIS, NO MICROSCOPY
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained:  CBC with DIFF, Creatinine, Urinalysis without Microscopy.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1500/uL or Platelets less than 100K/uL or Blood Pressure
greater than or equal to 160/90 mmHg or Urine Protein greater than 100 mg/dL or Creatinine greater than ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bevacizumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Verify patient has taken ondansetron 16 mg by mouth prior to lomustine.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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Zztestonc,Fiona F [2462287]
11/13/2017 11:08:24 AM Page 10 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

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.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bevacizumab (AVASTIN) 10 mg/kg in sodium chloride 0.9 % 100 mL bag
10 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Give first dose over 90 minutes. If tolerated, give 2nd dose over 60 minutes; if tolerated, give 3rd and subsequent doses
over 30 minutes. If infusion-related reactions occur, all subsequent infusions should be administered over the shortest
period that was well tolerated. Hypersensitivity risk. See Emergency Medications.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lomustine (Dispensed on Day 1
of each cycle)
Take Home Medications (delete all that do not apply)
lomustine (CEENU) 10 MG cap
Take 70 mg/m2 by mouth once at bedtime. Take on Day 1. Take on an empty stomach., 70 mg/m2, R-0, ONCE (HS)
starting S, Local Printer
Round dose to the available capsule size.
lomustine (CEENU) 40 MG cap
Take 70 mg/m2 by mouth once at bedtime. Take on Day 1. Take on an empty stomach., 70 mg/m2, R-0, ONCE (HS)
starting S, Local Printer
Round dose to the available capsule size.
lomustine (CEENU) 100 MG cap
Take 70 mg/m2 by mouth once at bedtime. Take on Day 1. Take on an empty stomach., 70 mg/m2, R-0, ONCE (HS)
starting S, Local Printer
Round dose to the available capsule size.
Follow-Up
DAY 15 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Urinalysis without Microscopy;
CHEMOTHERAPY ROOM APPOINTMENT:  bevacizumab for 60 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose,
BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Urinalysis without
Microscopy; CHEMOTHERAPY ROOM APPOINTMENT:  bevacizumab for 60 minutes.
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Zztestonc,Fiona F [2462287]
11/13/2017 11:08:24 AM Page 11 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Day 15, Cycle 3 –  Planned for 1/22/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Glioma (Advanced/Recurrent High-grade); THERAPY: bevacizumab 10 mg/kg IV Day 1 and 15, lomustine 70
mg/m2 (max dose = 160 mg) by mouth Day 1; CYCLE LENGTH: 28 days; COURSE: 9 to 12 cycles.
NOTE: This protocol should only be used in patients with tumors demonstrating MGMT methylation.
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+14 Approximate, Expires: S+365, Routine
URINALYSIS, NO MICROSCOPY
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Urinalysis without Microscopy.
Treatment Parameters
Hold and notify authorizing prescriber for Platelets less than 50K/uL or Blood Pressure greater than or equal to 160/90
mmHg or Urine Protein greater than 100 mg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bevacizumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
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.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
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Zztestonc,Fiona F [2462287]
11/13/2017 11:08:24 AM Page 12 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bevacizumab (AVASTIN) 10 mg/kg in sodium chloride 0.9 % 100 mL bag
10 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Give first dose over 90 minutes. If tolerated, give 2nd dose over 60 minutes; if tolerated, give 3rd and subsequent doses
over 30 minutes. If infusion-related reactions occur, all subsequent infusions should be administered over the shortest
period that was well tolerated. Hypersensitivity risk. See Emergency Medications.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lomustine (Dispensed on Day 1
of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 –  2/5/2018 through 3/4/2018 (28 days), Planned
Day 1, Cycle 4 –  Planned for 2/5/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Glioma (Advanced/Recurrent High-grade); THERAPY: bevacizumab 10 mg/kg IV Day 1 and 15, lomustine 70
mg/m2 (max dose = 160 mg) by mouth Day 1; CYCLE LENGTH: 28 days; COURSE: 9 to 12 cycles.
NOTE: This protocol should only be used in patients with tumors demonstrating MGMT methylation.
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.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BUN
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
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Zztestonc,Fiona F [2462287]
11/13/2017 11:08:24 AM Page 13 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

CALCIUM
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALBUMIN
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
PROTEIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
URINALYSIS, NO MICROSCOPY
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained:  CBC with DIFF, Creatinine, Urinalysis without Microscopy.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1500/uL or Platelets less than 100K/uL or Blood Pressure
greater than or equal to 160/90 mmHg or Urine Protein greater than 100 mg/dL or Creatinine greater than ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bevacizumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Verify patient has taken ondansetron 16 mg by mouth prior to lomustine.
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.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
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Zztestonc,Fiona F [2462287]
11/13/2017 11:08:24 AM Page 14 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bevacizumab (AVASTIN) 10 mg/kg in sodium chloride 0.9 % 100 mL bag
10 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Give first dose over 90 minutes. If tolerated, give 2nd dose over 60 minutes; if tolerated, give 3rd and subsequent doses
over 30 minutes. If infusion-related reactions occur, all subsequent infusions should be administered over the shortest
period that was well tolerated. Hypersensitivity risk. See Emergency Medications.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lomustine (Dispensed on Day 1
of each cycle)
Take Home Medications (delete all that do not apply)
lomustine (CEENU) 10 MG cap
Take 70 mg/m2 by mouth once at bedtime. Take on Day 1. Take on an empty stomach., 70 mg/m2, R-0, ONCE (HS)
starting S, Local Printer
Round dose to the available capsule size.
lomustine (CEENU) 40 MG cap
Take 70 mg/m2 by mouth once at bedtime. Take on Day 1. Take on an empty stomach., 70 mg/m2, R-0, ONCE (HS)
starting S, Local Printer
Round dose to the available capsule size.
lomustine (CEENU) 100 MG cap
Take 70 mg/m2 by mouth once at bedtime. Take on Day 1. Take on an empty stomach., 70 mg/m2, R-0, ONCE (HS)
starting S, Local Printer
Round dose to the available capsule size.
Follow-Up
DAY 15 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Urinalysis without Microscopy;
CHEMOTHERAPY ROOM APPOINTMENT:  bevacizumab for 60 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose,
BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Urinalysis without
Microscopy; CHEMOTHERAPY ROOM APPOINTMENT:  bevacizumab for 60 minutes.
Day 15, Cycle 4 –  Planned for 2/19/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Glioma (Advanced/Recurrent High-grade); THERAPY: bevacizumab 10 mg/kg IV Day 1 and 15, lomustine 70
mg/m2 (max dose = 160 mg) by mouth Day 1; CYCLE LENGTH: 28 days; COURSE: 9 to 12 cycles.
NOTE: This protocol should only be used in patients with tumors demonstrating MGMT methylation.
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.
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Zztestonc,Fiona F [2462287]
11/13/2017 11:08:24 AM Page 15 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Pre-Labs
CBC WITH DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
URINALYSIS, NO MICROSCOPY
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Urinalysis without Microscopy.
Treatment Parameters
Hold and notify authorizing prescriber for Platelets less than 50K/uL or Blood Pressure greater than or equal to 160/90
mmHg or Urine Protein greater than 100 mg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bevacizumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
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.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bevacizumab (AVASTIN) 10 mg/kg in sodium chloride 0.9 % 100 mL bag
10 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Give first dose over 90 minutes. If tolerated, give 2nd dose over 60 minutes; if tolerated, give 3rd and subsequent doses
over 30 minutes. If infusion-related reactions occur, all subsequent infusions should be administered over the shortest
period that was well tolerated. Hypersensitivity risk. See Emergency Medications.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lomustine (Dispensed on Day 1
of each cycle)
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Zztestonc,Fiona F [2462287]
11/13/2017 11:08:24 AM Page 16 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 –  3/5/2018 through 4/1/2018 (28 days), Planned
Day 1, Cycle 5 –  Planned for 3/5/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Glioma (Advanced/Recurrent High-grade); THERAPY: bevacizumab 10 mg/kg IV Day 1 and 15, lomustine 70
mg/m2 (max dose = 160 mg) by mouth Day 1; CYCLE LENGTH: 28 days; COURSE: 9 to 12 cycles.
NOTE: This protocol should only be used in patients with tumors demonstrating MGMT methylation.
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.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BUN
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CALCIUM
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALBUMIN
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
PROTEIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
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Zztestonc,Fiona F [2462287]
11/13/2017 11:08:24 AM Page 17 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
URINALYSIS, NO MICROSCOPY
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained:  CBC with DIFF, Creatinine, Urinalysis without Microscopy.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1500/uL or Platelets less than 100K/uL or Blood Pressure
greater than or equal to 160/90 mmHg or Urine Protein greater than 100 mg/dL or Creatinine greater than ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bevacizumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Verify patient has taken ondansetron 16 mg by mouth prior to lomustine.
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.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bevacizumab (AVASTIN) 10 mg/kg in sodium chloride 0.9 % 100 mL bag
10 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Give first dose over 90 minutes. If tolerated, give 2nd dose over 60 minutes; if tolerated, give 3rd and subsequent doses
over 30 minutes. If infusion-related reactions occur, all subsequent infusions should be administered over the shortest
period that was well tolerated. Hypersensitivity risk. See Emergency Medications.
See Take Home Medication(s)
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Zztestonc,Fiona F [2462287]
11/13/2017 11:08:24 AM Page 18 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Refer to the take home medications section for the following treatment medication(s): lomustine
(Dispensed on Day 1 of each cycle)
Take Home Medications (delete all that do not apply)
lomustine (CEENU) 10 MG cap
Take 70 mg/m2 by mouth once at bedtime. Take on Day 1. Take on an empty stomach., 70 mg/m2, R-0, ONCE (HS)
starting S, Local Printer
Round dose to the available capsule size.
lomustine (CEENU) 40 MG cap
Take 70 mg/m2 by mouth once at bedtime. Take on Day 1. Take on an empty stomach., 70 mg/m2, R-0, ONCE (HS)
starting S, Local Printer
Round dose to the available capsule size.
lomustine (CEENU) 100 MG cap
Take 70 mg/m2 by mouth once at bedtime. Take on Day 1. Take on an empty stomach., 70 mg/m2, R-0, ONCE (HS)
starting S, Local Printer
Round dose to the available capsule size.
Follow-Up
DAY 15 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Urinalysis without Microscopy;
CHEMOTHERAPY ROOM APPOINTMENT:  bevacizumab for 60 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose,
BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Urinalysis without
Microscopy; CHEMOTHERAPY ROOM APPOINTMENT:  bevacizumab for 60 minutes.
Day 15, Cycle 5 –  Planned for 3/19/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Glioma (Advanced/Recurrent High-grade); THERAPY: bevacizumab 10 mg/kg IV Day 1 and 15, lomustine 70
mg/m2 (max dose = 160 mg) by mouth Day 1; CYCLE LENGTH: 28 days; COURSE: 9 to 12 cycles.
NOTE: This protocol should only be used in patients with tumors demonstrating MGMT methylation.
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+14 Approximate, Expires: S+365, Routine
URINALYSIS, NO MICROSCOPY
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Urinalysis without Microscopy.
Treatment Parameters
Hold and notify authorizing prescriber for Platelets less than 50K/uL or Blood Pressure greater than or equal to 160/90
mmHg or Urine Protein greater than 100 mg/dL.
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Zztestonc,Fiona F [2462287]
11/13/2017 11:08:24 AM Page 19 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bevacizumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
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.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bevacizumab (AVASTIN) 10 mg/kg in sodium chloride 0.9 % 100 mL bag
10 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Give first dose over 90 minutes. If tolerated, give 2nd dose over 60 minutes; if tolerated, give 3rd and subsequent doses
over 30 minutes. If infusion-related reactions occur, all subsequent infusions should be administered over the shortest
period that was well tolerated. Hypersensitivity risk. See Emergency Medications.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lomustine (Dispensed on Day 1
of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 –  4/2/2018 through 4/29/2018 (28 days), Planned
Day 1, Cycle 6 –  Planned for 4/2/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Glioma (Advanced/Recurrent High-grade); THERAPY: bevacizumab 10 mg/kg IV Day 1 and 15, lomustine 70
mg/m2 (max dose = 160 mg) by mouth Day 1; CYCLE LENGTH: 28 days; COURSE: 9 to 12 cycles.
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Zztestonc,Fiona F [2462287]
11/13/2017 11:08:24 AM Page 20 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

NOTE: This protocol should only be used in patients with tumors demonstrating MGMT methylation.
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.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BUN
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CALCIUM
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALBUMIN
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
PROTEIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
URINALYSIS, NO MICROSCOPY
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained:  CBC with DIFF, Creatinine, Urinalysis without Microscopy.
Treatment Parameters
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Zztestonc,Fiona F [2462287]
11/13/2017 11:08:24 AM Page 21 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Hold and notify authorizing prescriber for ANC less than 1500/uL or Platelets less than 100K/uL or Blood Pressure
greater than or equal to 160/90 mmHg or Urine Protein greater than 100 mg/dL or Creatinine greater than ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bevacizumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Verify patient has taken ondansetron 16 mg by mouth prior to lomustine.
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.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bevacizumab (AVASTIN) 10 mg/kg in sodium chloride 0.9 % 100 mL bag
10 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Give first dose over 90 minutes. If tolerated, give 2nd dose over 60 minutes; if tolerated, give 3rd and subsequent doses
over 30 minutes. If infusion-related reactions occur, all subsequent infusions should be administered over the shortest
period that was well tolerated. Hypersensitivity risk. See Emergency Medications.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lomustine (Dispensed on Day 1
of each cycle)
Take Home Medications (delete all that do not apply)
lomustine (CEENU) 10 MG cap
Take 70 mg/m2 by mouth once at bedtime. Take on Day 1. Take on an empty stomach., 70 mg/m2, R-0, ONCE (HS)
starting S, Local Printer
Round dose to the available capsule size.
lomustine (CEENU) 40 MG cap
Take 70 mg/m2 by mouth once at bedtime. Take on Day 1. Take on an empty stomach., 70 mg/m2, R-0, ONCE (HS)
starting S, Local Printer
Round dose to the available capsule size.
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Zztestonc,Fiona F [2462287]
11/13/2017 11:08:24 AM Page 22 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

lomustine (CEENU) 100 MG cap
Take 70 mg/m2 by mouth once at bedtime. Take on Day 1. Take on an empty stomach., 70 mg/m2,
R-0, ONCE (HS) starting S, Local Printer
Round dose to the available capsule size.
Follow-Up
DAY 15 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Urinalysis without Microscopy;
CHEMOTHERAPY ROOM APPOINTMENT:  bevacizumab for 60 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose,
BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Urinalysis without
Microscopy; CHEMOTHERAPY ROOM APPOINTMENT:  bevacizumab for 60 minutes.
Day 15, Cycle 6 –  Planned for 4/16/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Glioma (Advanced/Recurrent High-grade); THERAPY: bevacizumab 10 mg/kg IV Day 1 and 15, lomustine 70
mg/m2 (max dose = 160 mg) by mouth Day 1; CYCLE LENGTH: 28 days; COURSE: 9 to 12 cycles.
NOTE: This protocol should only be used in patients with tumors demonstrating MGMT methylation.
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+14 Approximate, Expires: S+365, Routine
URINALYSIS, NO MICROSCOPY
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Urinalysis without Microscopy.
Treatment Parameters
Hold and notify authorizing prescriber for Platelets less than 50K/uL or Blood Pressure greater than or equal to 160/90
mmHg or Urine Protein greater than 100 mg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bevacizumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
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
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Zztestonc,Fiona F [2462287]
11/13/2017 11:08:24 AM Page 23 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

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.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bevacizumab (AVASTIN) 10 mg/kg in sodium chloride 0.9 % 100 mL bag
10 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Give first dose over 90 minutes. If tolerated, give 2nd dose over 60 minutes; if tolerated, give 3rd and subsequent doses
over 30 minutes. If infusion-related reactions occur, all subsequent infusions should be administered over the shortest
period that was well tolerated. Hypersensitivity risk. See Emergency Medications.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lomustine (Dispensed on Day 1
of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 7 –  4/30/2018 through 5/27/2018 (28 days), Planned
Day 1, Cycle 7 –  Planned for 4/30/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Glioma (Advanced/Recurrent High-grade); THERAPY: bevacizumab 10 mg/kg IV Day 1 and 15, lomustine 70
mg/m2 (max dose = 160 mg) by mouth Day 1; CYCLE LENGTH: 28 days; COURSE: 9 to 12 cycles.
NOTE: This protocol should only be used in patients with tumors demonstrating MGMT methylation.
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.
Pre-Labs
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Zztestonc,Fiona F [2462287]
11/13/2017 11:08:24 AM Page 24 of 35
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
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BUN
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CALCIUM
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALBUMIN
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
PROTEIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
URINALYSIS, NO MICROSCOPY
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained:  CBC with DIFF, Creatinine, Urinalysis without Microscopy.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1500/uL or Platelets less than 100K/uL or Blood Pressure
greater than or equal to 160/90 mmHg or Urine Protein greater than 100 mg/dL or Creatinine greater than ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bevacizumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Verify patient has taken ondansetron 16 mg by mouth prior to lomustine.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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Zztestonc,Fiona F [2462287]
11/13/2017 11:08:24 AM Page 25 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

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.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bevacizumab (AVASTIN) 10 mg/kg in sodium chloride 0.9 % 100 mL bag
10 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Give first dose over 90 minutes. If tolerated, give 2nd dose over 60 minutes; if tolerated, give 3rd and subsequent doses
over 30 minutes. If infusion-related reactions occur, all subsequent infusions should be administered over the shortest
period that was well tolerated. Hypersensitivity risk. See Emergency Medications.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lomustine (Dispensed on Day 1
of each cycle)
Take Home Medications (delete all that do not apply)
lomustine (CEENU) 10 MG cap
Take 70 mg/m2 by mouth once at bedtime. Take on Day 1. Take on an empty stomach., 70 mg/m2, R-0, ONCE (HS)
starting S, Local Printer
Round dose to the available capsule size.
lomustine (CEENU) 40 MG cap
Take 70 mg/m2 by mouth once at bedtime. Take on Day 1. Take on an empty stomach., 70 mg/m2, R-0, ONCE (HS)
starting S, Local Printer
Round dose to the available capsule size.
lomustine (CEENU) 100 MG cap
Take 70 mg/m2 by mouth once at bedtime. Take on Day 1. Take on an empty stomach., 70 mg/m2, R-0, ONCE (HS)
starting S, Local Printer
Round dose to the available capsule size.
Follow-Up
DAY 15 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Urinalysis without Microscopy;
CHEMOTHERAPY ROOM APPOINTMENT:  bevacizumab for 60 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose,
BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Urinalysis without
Microscopy; CHEMOTHERAPY ROOM APPOINTMENT:  bevacizumab for 60 minutes.
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Zztestonc,Fiona F [2462287]
11/13/2017 11:08:24 AM Page 26 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Day 15, Cycle 7 –  Planned for 5/14/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Glioma (Advanced/Recurrent High-grade); THERAPY: bevacizumab 10 mg/kg IV Day 1 and 15, lomustine 70
mg/m2 (max dose = 160 mg) by mouth Day 1; CYCLE LENGTH: 28 days; COURSE: 9 to 12 cycles.
NOTE: This protocol should only be used in patients with tumors demonstrating MGMT methylation.
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+14 Approximate, Expires: S+365, Routine
URINALYSIS, NO MICROSCOPY
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Urinalysis without Microscopy.
Treatment Parameters
Hold and notify authorizing prescriber for Platelets less than 50K/uL or Blood Pressure greater than or equal to 160/90
mmHg or Urine Protein greater than 100 mg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bevacizumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
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.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
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Zztestonc,Fiona F [2462287]
11/13/2017 11:08:24 AM Page 27 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bevacizumab (AVASTIN) 10 mg/kg in sodium chloride 0.9 % 100 mL bag
10 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Give first dose over 90 minutes. If tolerated, give 2nd dose over 60 minutes; if tolerated, give 3rd and subsequent doses
over 30 minutes. If infusion-related reactions occur, all subsequent infusions should be administered over the shortest
period that was well tolerated. Hypersensitivity risk. See Emergency Medications.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lomustine (Dispensed on Day 1
of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 8 –  5/28/2018 through 6/24/2018 (28 days), Planned
Day 1, Cycle 8 –  Planned for 5/28/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Glioma (Advanced/Recurrent High-grade); THERAPY: bevacizumab 10 mg/kg IV Day 1 and 15, lomustine 70
mg/m2 (max dose = 160 mg) by mouth Day 1; CYCLE LENGTH: 28 days; COURSE: 9 to 12 cycles.
NOTE: This protocol should only be used in patients with tumors demonstrating MGMT methylation.
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.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BUN
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
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Zztestonc,Fiona F [2462287]
11/13/2017 11:08:24 AM Page 28 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

CALCIUM
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALBUMIN
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
PROTEIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
URINALYSIS, NO MICROSCOPY
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained:  CBC with DIFF, Creatinine, Urinalysis without Microscopy.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1500/uL or Platelets less than 100K/uL or Blood Pressure
greater than or equal to 160/90 mmHg or Urine Protein greater than 100 mg/dL or Creatinine greater than ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bevacizumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Verify patient has taken ondansetron 16 mg by mouth prior to lomustine.
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.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
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Zztestonc,Fiona F [2462287]
11/13/2017 11:08:24 AM Page 29 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bevacizumab (AVASTIN) 10 mg/kg in sodium chloride 0.9 % 100 mL bag
10 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Give first dose over 90 minutes. If tolerated, give 2nd dose over 60 minutes; if tolerated, give 3rd and subsequent doses
over 30 minutes. If infusion-related reactions occur, all subsequent infusions should be administered over the shortest
period that was well tolerated. Hypersensitivity risk. See Emergency Medications.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lomustine (Dispensed on Day 1
of each cycle)
Take Home Medications (delete all that do not apply)
lomustine (CEENU) 10 MG cap
Take 70 mg/m2 by mouth once at bedtime. Take on Day 1. Take on an empty stomach., 70 mg/m2, R-0, ONCE (HS)
starting S, Local Printer
Round dose to the available capsule size.
lomustine (CEENU) 40 MG cap
Take 70 mg/m2 by mouth once at bedtime. Take on Day 1. Take on an empty stomach., 70 mg/m2, R-0, ONCE (HS)
starting S, Local Printer
Round dose to the available capsule size.
lomustine (CEENU) 100 MG cap
Take 70 mg/m2 by mouth once at bedtime. Take on Day 1. Take on an empty stomach., 70 mg/m2, R-0, ONCE (HS)
starting S, Local Printer
Round dose to the available capsule size.
Follow-Up
DAY 15 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Urinalysis without Microscopy;
CHEMOTHERAPY ROOM APPOINTMENT:  bevacizumab for 60 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose,
BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Urinalysis without
Microscopy; CHEMOTHERAPY ROOM APPOINTMENT:  bevacizumab for 60 minutes.
Day 15, Cycle 8 –  Planned for 6/11/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Glioma (Advanced/Recurrent High-grade); THERAPY: bevacizumab 10 mg/kg IV Day 1 and 15, lomustine 70
mg/m2 (max dose = 160 mg) by mouth Day 1; CYCLE LENGTH: 28 days; COURSE: 9 to 12 cycles.
NOTE: This protocol should only be used in patients with tumors demonstrating MGMT methylation.
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.
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Zztestonc,Fiona F [2462287]
11/13/2017 11:08:24 AM Page 30 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Pre-Labs
CBC WITH DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
URINALYSIS, NO MICROSCOPY
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Urinalysis without Microscopy.
Treatment Parameters
Hold and notify authorizing prescriber for Platelets less than 50K/uL or Blood Pressure greater than or equal to 160/90
mmHg or Urine Protein greater than 100 mg/dL.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bevacizumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
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.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bevacizumab (AVASTIN) 10 mg/kg in sodium chloride 0.9 % 100 mL bag
10 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Give first dose over 90 minutes. If tolerated, give 2nd dose over 60 minutes; if tolerated, give 3rd and subsequent doses
over 30 minutes. If infusion-related reactions occur, all subsequent infusions should be administered over the shortest
period that was well tolerated. Hypersensitivity risk. See Emergency Medications.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lomustine (Dispensed on Day 1
of each cycle)
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Zztestonc,Fiona F [2462287]
11/13/2017 11:08:24 AM Page 31 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 9 –  6/25/2018 through 7/22/2018 (28 days), Planned
Day 1, Cycle 9 –  Planned for 6/25/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Glioma (Advanced/Recurrent High-grade); THERAPY: bevacizumab 10 mg/kg IV Day 1 and 15, lomustine 70
mg/m2 (max dose = 160 mg) by mouth Day 1; CYCLE LENGTH: 28 days; COURSE: 9 to 12 cycles.
NOTE: This protocol should only be used in patients with tumors demonstrating MGMT methylation.
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.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected: S+14 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
GLUCOSE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BUN
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CREATININE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
CALCIUM
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALBUMIN
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
PROTEIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
AST/SGOT
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALT/SGPT
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Zztestonc,Fiona F [2462287]
11/13/2017 11:08:24 AM Page 32 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Expected: S+14 Approximate, Expires: S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
URINALYSIS, NO MICROSCOPY
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained:  CBC with DIFF, Creatinine, Urinalysis without Microscopy.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1500/uL or Platelets less than 100K/uL or Blood Pressure
greater than or equal to 160/90 mmHg or Urine Protein greater than 100 mg/dL or Creatinine greater than ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bevacizumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
Patient Instructions(1)
Verify patient has taken ondansetron 16 mg by mouth prior to lomustine.
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.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bevacizumab (AVASTIN) 10 mg/kg in sodium chloride 0.9 % 100 mL bag
10 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Give first dose over 90 minutes. If tolerated, give 2nd dose over 60 minutes; if tolerated, give 3rd and subsequent doses
over 30 minutes. If infusion-related reactions occur, all subsequent infusions should be administered over the shortest
period that was well tolerated. Hypersensitivity risk. See Emergency Medications.
See Take Home Medication(s)
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Zztestonc,Fiona F [2462287]
11/13/2017 11:08:24 AM Page 33 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Refer to the take home medications section for the following treatment medication(s): lomustine
(Dispensed on Day 1 of each cycle)
Take Home Medications (delete all that do not apply)
lomustine (CEENU) 10 MG cap
Take 70 mg/m2 by mouth once at bedtime. Take on Day 1. Take on an empty stomach., 70 mg/m2, R-0, ONCE (HS)
starting S, Local Printer
Round dose to the available capsule size.
lomustine (CEENU) 40 MG cap
Take 70 mg/m2 by mouth once at bedtime. Take on Day 1. Take on an empty stomach., 70 mg/m2, R-0, ONCE (HS)
starting S, Local Printer
Round dose to the available capsule size.
lomustine (CEENU) 100 MG cap
Take 70 mg/m2 by mouth once at bedtime. Take on Day 1. Take on an empty stomach., 70 mg/m2, R-0, ONCE (HS)
starting S, Local Printer
Round dose to the available capsule size.
Follow-Up
DAY 15 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Urinalysis without Microscopy;
CHEMOTHERAPY ROOM APPOINTMENT:  bevacizumab for 60 minutes.
DAY 29 FOLLOW-UP
(Day 1 of next cycle)  RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose,
BUN, Creatinine, Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Urinalysis without
Microscopy; CHEMOTHERAPY ROOM APPOINTMENT:  bevacizumab for 60 minutes.
Day 15, Cycle 9 –  Planned for 7/9/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Glioma (Advanced/Recurrent High-grade); THERAPY: bevacizumab 10 mg/kg IV Day 1 and 15, lomustine 70
mg/m2 (max dose = 160 mg) by mouth Day 1; CYCLE LENGTH: 28 days; COURSE: 9 to 12 cycles.
NOTE: This protocol should only be used in patients with tumors demonstrating MGMT methylation.
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+14 Approximate, Expires: S+365, Routine
URINALYSIS, NO MICROSCOPY
Expected: S+14 Approximate, Expires: S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Urinalysis without Microscopy.
Treatment Parameters
Hold and notify authorizing prescriber for Platelets less than 50K/uL or Blood Pressure greater than or equal to 160/90
mmHg or Urine Protein greater than 100 mg/dL.
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Zztestonc,Fiona F [2462287]
11/13/2017 11:08:24 AM Page 34 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to bevacizumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. See Emergency Medications.
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.
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
bevacizumab (AVASTIN) 10 mg/kg in sodium chloride 0.9 % 100 mL bag
10 mg/kg, Intravenous, ONCE, 1 dose Starting when released
Give first dose over 90 minutes. If tolerated, give 2nd dose over 60 minutes; if tolerated, give 3rd and subsequent doses
over 30 minutes. If infusion-related reactions occur, all subsequent infusions should be administered over the shortest
period that was well tolerated. Hypersensitivity risk. See Emergency Medications.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): lomustine (Dispensed on Day 1
of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Fiona F [2462287]
11/13/2017 11:08:24 AM Page 35 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org