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Breast Letrozole(28D1-28) Ribocicib(28D1-21) VER 4-25-17 (HL 6453)

Breast Letrozole(28D1-28) Ribocicib(28D1-21) VER 4-25-17 (HL 6453) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Breast


CSC BREAST LETROZOLE (28D:1-28)/RIBOCICLIB (28D:1-21) VER: 4-25-17 – Properties
Pre-Cycle – 4/18/2017 through 4/24/2017 (7 days), Planned
Day 1, Pre-Cycle – Planned for 4/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: ribociclib 600 mg by mouth once daily Days 1 through 21, letrozole 2.5 mg by
mouth once daily continuously Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: until disease progression. NOTE: Provider
may substitute alternative aromatase inhibitor.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S Approximate, Expires-S+365, Routine
Treatment Conditions
Treatment Condition A
Verify ECG obtained.
Take Home Medications
prochlorperazine (COMPAZINE) 10 MG tab
Take 1 tab by mouth every 6 hours as needed for nausea/vomiting., 10 mg, Disp-30 tab, R-5, EVERY 6 HOURS PRN starting S,
Local Printer
Cycle 1 – 4/25/2017 through 5/22/2017 (28 days), Planned
Day 1, Cycle 1 – Planned for 4/25/2017
Treatment Plan Information
Reference Information (1)
BREAST CANCER: Hortobagyi GN, et al. N Engl J Med 2016;375(18):1738-48.
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: ribociclib 600 mg by mouth once daily Days 1 through 21, letrozole 2.5 mg by
mouth once daily continuously Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: until disease progression. NOTE: Provider
may substitute alternative aromatase inhibitor.
Consent
Verify Consent
Verify informed consent has been obtained.
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ZZtestonc,Beth B [2468878]
4/25/2017 3:12:26 PM Page 1 of 6
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

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: Total Bilirubin, ALT, AST, Electrolytes, Magnesium.
Treatment Condition A
Verify ECG obtained.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or AST greater than 3 X ULN or ALT greater than 3 X
ULN or Potassium less than 4 mmol/L or Magnesium less than 1.8 mg/dL or Total Bilirubin greater than 2 X ULN.
Treatment Parameters (2)
Initiate treatment with ribociclib only in patients with QTcF values less than 450 msec.
Nursing Procedure, Assessment and Monitoring
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.
Treatment Medications
See Take Home Medication(s)
Refer to the Take Home Medications category for the following treatment medication(s): ribociclib and letrozole dispensed Day 1 of
Cycle 1 only - subsequent refills will be ordered through the Medication Activity.
Take Home Medications
ribociclib succinate (KISQALI) 200 MG tab
Take 3 tabs by mouth one time daily. Take on Day 1 through 21 followed by 7 days off., 600 mg, Disp-63 tab, R-0, 1 X DAILY
starting S
letrozole (FEMARA) 2.5 MG tab
Take 1 tab by mouth one time daily., 2.5 mg, Disp-30 tab, R-0, 1 X DAILY starting S
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC with DIFF, Total Bilirubin, ALT, AST; PROCEDURE: ECG
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Total Bilirubin, ALT, AST,
Electrolytes, Magnesium, Phosphate.
Lab Only - Day 15, Cycle 1 – Planned for 5/9/2017
Treatment Plan Information
Treatment Plan Summary
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ZZtestonc,Beth B [2468878]
4/25/2017 3:12:26 PM Page 2 of 6
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

DISEASE: Breast Cancer (Advanced); THERAPY: ribociclib 600 mg by mouth once daily Days 1 through 21, letrozole 2.5 mg by
mouth once daily continuously Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: until disease progression. NOTE: Provider
may substitute alternative aromatase inhibitor.
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
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 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 – 5/23/2017 through 6/19/2017 (28 days), Planned
Day 1, Cycle 2 – Planned for 5/23/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: ribociclib 600 mg by mouth once daily Days 1 through 21, letrozole 2.5 mg by
mouth once daily continuously Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: until disease progression. NOTE: Provider
may substitute alternative aromatase inhibitor.
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+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+365, Routine
MAGNESIUM
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ZZtestonc,Beth B [2468878]
4/25/2017 3:12:26 PM Page 3 of 6
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

Expected-S+28 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin, ALT, AST, Electrolytes, Magnesium.
Treatment Condition A
Verify ECG obtained.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or AST greater than 3 X ULN or ALT greater than 3 X
ULN or Potassium less than 4 mmol/L or Magnesium less than 1.8 mg/dL or Total Bilirubin greater than 2 X ULN.
Treatment Parameters (2)
Hold and notify authorizing prescriber for QTcF exceeds 480 ms
Nursing Procedure, Assessment and Monitoring
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.
Treatment Medications
Oral Chemotherapy Order Management
For this regimen, ribociclib and letrozole will be ordered through the medication activity after the initial order.
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC with DIFF, Total Bilirubin, ALT, AST.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Total Bilirubin, ALT, AST,
Electrolytes, Magnesium, Phosphate.
Lab Only - Day 15, Cycle 2 – Planned for 6/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: ribociclib 600 mg by mouth once daily Days 1 through 21, letrozole 2.5 mg by
mouth once daily continuously Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: until disease progression. NOTE: Provider
may substitute alternative aromatase inhibitor.
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
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ZZtestonc,Beth B [2468878]
4/25/2017 3:12:26 PM Page 4 of 6
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 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 3 – 6/20/2017 through 7/17/2017 (28 days), Planned
Day 1, Cycle 3 – Planned for 6/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Advanced); THERAPY: ribociclib 600 mg by mouth once daily Days 1 through 21, letrozole 2.5 mg by
mouth once daily continuously Days 1 through 28; CYCLE LENGTH: 28 days; COURSE: until disease progression. NOTE: Provider
may substitute alternative aromatase inhibitor.
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+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+28 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Total Bilirubin, ALT, AST, Electrolytes, Magnesium.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/µL or AST greater than 3 X ULN or ALT greater than 3 X
ULN or Potassium less than 4 mmol/L or Magnesium less than 1.8 mg/dL or Total Bilirubin greater than 2 X ULN.
Nursing Procedure, Assessment and Monitoring
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ZZtestonc,Beth B [2468878]
4/25/2017 3:12:26 PM Page 5 of 6
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

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.
Treatment Medications
Oral Chemotherapy Order Management
For this regimen, ribociclib and letrozole will be ordered through the medication activity after the initial order.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Total Bilirubin, ALT, AST,
Electrolytes, Magnesium, Phosphate.
Cycle 4 – 7/18/2017 through 8/14/2017 (28 days), Planned
Cycle 5 – 8/15/2017 through 9/11/2017 (28 days), Planned
Cycle 6 – 9/12/2017 through 10/9/2017 (28 days), Planned
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ZZtestonc,Beth B [2468878]
4/25/2017 3:12:26 PM Page 6 of 6
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org