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

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201611306

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100

UWHC,UWMF,

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

CSC Breast ADO Trastuzumab Emtansine (Kadcyla) (21D1) VER 10-3-16 (HL 5096)

CSC Breast ADO Trastuzumab Emtansine (Kadcyla) (21D1) VER 10-3-16 (HL 5096) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Breast


CSC BREAST ADO-TRASTUZUMAB EMTANSINE (KADCYLA)(21D:1) VER: 10-3-16 – Properties
Pre-Cycle – 10/25/2016 through 10/31/2016 (7 days), Planned
Day 1, Pre-Cycle – Planned for 10/25/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast (Advanced); THERAPY: ADO-trastuzumab emtansine (KADCYLA) 3.6 mg/kg IV Day 1; CYCLE LENGTH: 21
days; COURSE: until disease progression
Note to All Staff (1)
Approved for use as a single agent in HER2-positive, metastatic breast cancer in patients who previously received trastuzumab and
a taxane, separately or in combination.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S Approximate, Expires-S+365, Routine
Take Home Medications
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS PRN starting S,
Local Printer
Cycle 1 – 11/1/2016 through 11/21/2016 (21 days), Planned
Day 1, Cycle 1 – Planned for 11/1/2016
Treatment Plan Information
Reference Information (1)
BREAST: Hurvitz SA, et al. J Clin Oncol. 2013;20;31(9):1157-63.
Reference Information (2)
BREAST: Verma S, et al. N Engl J Med. 2012;8;367(19):1783-91.
Reference Information (3)
BREAST: Burris HA, et al. J Clin Oncol. 2011;1;29(4):398-405.
Treatment Plan Summary
DISEASE: Breast (Advanced); THERAPY: ADO-trastuzumab emtansine (KADCYLA) 3.6 mg/kg IV Day 1; CYCLE LENGTH: 21
days; COURSE: until disease progression
Note to All Staff (1)
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ZZtestonc,Andrew [2428787]
11/1/2016 2:54:14 PM Page 1 of 12
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Approved for use as a single agent in HER2-positive, metastatic breast cancer in patients who previously received
trastuzumab and a taxane, separately or in combination.
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, ANC, Creatinine, AST, ALT, Total Bilirubin.
Treatment Parameters
Hold and notify prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to 100K/µL or Creatinine greater
than 1.5 X ULN or ALT greater than 3 x ULN or AST greater than 3 x ULN or Total Bilirubin greater than 2 x ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to ADO-trastuzumab emtansine (KADCYLA) can occur. For first and second dose, patient should be
treated in a location to optimize emergency care. Patient must be monitored for 90 minutes after the first dose of ADO-trastuzumab
and for 30 minutes after subsequent infusions.
Vital Signs
EVERY 30 MINUTES Starting when released Until Specified
Patient Instructions(1)
Advise patient to contact a health care professional immediately for any of the following: new onset or worsening shortness of
breath, cough, swelling of the ankles/legs, palpitations, weight gain of more than 5 pounds in 24 hours, dizziness or loss of
consciousness. Inform patients of the possibility of severe liver injury and advise patients to immediately seek medical attention if
they experience symptoms of acute hepatitis such as nausea, vomiting, abdominal pain (especially Right Upper Quadrant abdominal
pain), jaundice, dark urine, generalized pruritus, anorexia, etc.
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 10 UNIT/ML lock flush 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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
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 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
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ZZtestonc,Andrew [2428787]
11/1/2016 2:54:14 PM Page 2 of 12
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

10 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
ado-trastuzumab emtansine (KADCYLA) 286 mg in sodium chloride 0.9 % 250 mL bag
286 mg (rounded from 285.84 mg = 3.6 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Administer with a 0.22 micron filter. Administer first infusion over 90 minutes and subsequent infusions over 30 minutes if tolerated.
Hypersensitivity reaction to ADO-trastuzumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. Patient must be monitored for 90 minutes after the first dose of ADO-trastuzumab and for 30 minutes after
subsequent infusions.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
AST, ALT, Total Bilirubin, Potassium; CHEMOTHERAPY ROOM APPOINTMENT: ADO-trastuzumab emtansine (KADCYLA) for 90
minutes.
Cycle 2 – 11/22/2016 through 12/12/2016 (21 days), Planned
Day 1, Cycle 2 – Planned for 11/22/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast (Advanced); THERAPY: ADO-trastuzumab emtansine (KADCYLA) 3.6 mg/kg IV Day 1; CYCLE LENGTH: 21
days; COURSE: until disease progression
Note to All Staff (1)
Approved for use as a single agent in HER2-positive, metastatic breast cancer in patients who previously received trastuzumab and
a taxane, separately or in combination.
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 WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
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ZZtestonc,Andrew [2428787]
11/1/2016 2:54:14 PM Page 3 of 12
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT, Total Bilirubin.
Treatment Parameters
Hold and notify prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to 100K/µL or Creatinine greater
than 1.5 X ULN or ALT greater than 3 x ULN or AST greater than 3 x ULN or Total Bilirubin greater than 2 x ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to ADO-trastuzumab emtansine (KADCYLA) can occur. For first and second dose, patient should be
treated in a location to optimize emergency care. Patient must be monitored for 90 minutes after the first dose of ADO-trastuzumab
and for 30 minutes after subsequent infusions.
Patient Instructions(1)
Advise patient to contact a health care professional immediately for any of the following: new onset or worsening shortness of
breath, cough, swelling of the ankles/legs, palpitations, weight gain of more than 5 pounds in 24 hours, dizziness or loss of
consciousness. Inform patients of the possibility of severe liver injury and advise patients to immediately seek medical attention if
they experience symptoms of acute hepatitis such as nausea, vomiting, abdominal pain (especially Right Upper Quadrant abdominal
pain), jaundice, dark urine, generalized pruritus, anorexia, etc.
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 10 UNIT/ML lock flush 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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
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 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 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
ado-trastuzumab emtansine (KADCYLA) 286 mg in sodium chloride 0.9 % 250 mL bag
286 mg (rounded from 285.84 mg = 3.6 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Administer with a 0.22 micron filter. Administer first infusion over 90 minutes and subsequent infusions over 30 minutes if tolerated.
Hypersensitivity reaction to ADO-trastuzumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. Patient must be monitored for 90 minutes after the first dose of ADO-trastuzumab and for 30 minutes after
subsequent infusions.
Follow-Up
DAY 22 FOLLOW-UP
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ZZtestonc,Andrew [2428787]
11/1/2016 2:54:14 PM Page 4 of 12
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
AST, ALT, Total Bilirubin, Potassium; CHEMOTHERAPY ROOM APPOINTMENT: ADO-trastuzumab emtansine (KADCYLA) for 90
minutes.
Cycle 3 – 12/13/2016 through 1/2/2017 (21 days), Planned
Day 1, Cycle 3 – Planned for 12/13/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast (Advanced); THERAPY: ADO-trastuzumab emtansine (KADCYLA) 3.6 mg/kg IV Day 1; CYCLE LENGTH: 21
days; COURSE: until disease progression
Note to All Staff (1)
Approved for use as a single agent in HER2-positive, metastatic breast cancer in patients who previously received trastuzumab and
a taxane, separately or in combination.
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 WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT, Total Bilirubin.
Treatment Parameters
Hold and notify prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to 100K/µL or Creatinine greater
than 1.5 X ULN or ALT greater than 3 x ULN or AST greater than 3 x ULN or Total Bilirubin greater than 2 x ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to ADO-trastuzumab emtansine (KADCYLA) can occur. For first and second dose, patient should be
treated in a location to optimize emergency care. Patient must be monitored for 90 minutes after the first dose of ADO-trastuzumab
and for 30 minutes after subsequent infusions.
Patient Instructions(1)
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ZZtestonc,Andrew [2428787]
11/1/2016 2:54:14 PM Page 5 of 12
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Advise patient to contact a health care professional immediately for any of the following: new onset or worsening shortness of
breath, cough, swelling of the ankles/legs, palpitations, weight gain of more than 5 pounds in 24 hours, dizziness or loss of
consciousness. Inform patients of the possibility of severe liver injury and advise patients to immediately seek medical attention if
they experience symptoms of acute hepatitis such as nausea, vomiting, abdominal pain (especially Right Upper Quadrant abdominal
pain), jaundice, dark urine, generalized pruritus, anorexia, etc.
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 10 UNIT/ML lock flush 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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
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 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 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
ado-trastuzumab emtansine (KADCYLA) 286 mg in sodium chloride 0.9 % 250 mL bag
286 mg (rounded from 285.84 mg = 3.6 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Administer with a 0.22 micron filter. Administer first infusion over 90 minutes and subsequent infusions over 30 minutes if tolerated.
Hypersensitivity reaction to ADO-trastuzumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. Patient must be monitored for 90 minutes after the first dose of ADO-trastuzumab and for 30 minutes after
subsequent infusions.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
AST, ALT, Total Bilirubin, Potassium; CHEMOTHERAPY ROOM APPOINTMENT: ADO-trastuzumab emtansine (KADCYLA) for 90
minutes.
Cycle 4 – 1/3/2017 through 1/23/2017 (21 days), Planned
Day 1, Cycle 4 – Planned for 1/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast (Advanced); THERAPY: ADO-trastuzumab emtansine (KADCYLA) 3.6 mg/kg IV Day 1; CYCLE LENGTH: 21
days; COURSE: until disease progression
Note to All Staff (1)
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ZZtestonc,Andrew [2428787]
11/1/2016 2:54:14 PM Page 6 of 12
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Approved for use as a single agent in HER2-positive, metastatic breast cancer in patients who previously received trastuzumab and
a taxane, separately or in combination.
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 WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT, Total Bilirubin.
Treatment Parameters
Hold and notify prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to 100K/µL or Creatinine greater
than 1.5 X ULN or ALT greater than 3 x ULN or AST greater than 3 x ULN or Total Bilirubin greater than 2 x ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to ADO-trastuzumab emtansine (KADCYLA) can occur. For first and second dose, patient should be
treated in a location to optimize emergency care. Patient must be monitored for 90 minutes after the first dose of ADO-trastuzumab
and for 30 minutes after subsequent infusions.
Patient Instructions(1)
Advise patient to contact a health care professional immediately for any of the following: new onset or worsening shortness of
breath, cough, swelling of the ankles/legs, palpitations, weight gain of more than 5 pounds in 24 hours, dizziness or loss of
consciousness. Inform patients of the possibility of severe liver injury and advise patients to immediately seek medical attention if
they experience symptoms of acute hepatitis such as nausea, vomiting, abdominal pain (especially Right Upper Quadrant abdominal
pain), jaundice, dark urine, generalized pruritus, anorexia, etc.
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 10 UNIT/ML lock flush 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
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ZZtestonc,Andrew [2428787]
11/1/2016 2:54:14 PM Page 7 of 12
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
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 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 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
ado-trastuzumab emtansine (KADCYLA) 286 mg in sodium chloride 0.9 % 250 mL bag
286 mg (rounded from 285.84 mg = 3.6 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Administer with a 0.22 micron filter. Administer first infusion over 90 minutes and subsequent infusions over 30 minutes if tolerated.
Hypersensitivity reaction to ADO-trastuzumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. Patient must be monitored for 90 minutes after the first dose of ADO-trastuzumab and for 30 minutes after
subsequent infusions.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
AST, ALT, Total Bilirubin, Potassium; CHEMOTHERAPY ROOM APPOINTMENT: ADO-trastuzumab emtansine (KADCYLA) for 90
minutes.
Cycle 5 – 1/24/2017 through 2/13/2017 (21 days), Planned
Day 1, Cycle 5 – Planned for 1/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast (Advanced); THERAPY: ADO-trastuzumab emtansine (KADCYLA) 3.6 mg/kg IV Day 1; CYCLE LENGTH: 21
days; COURSE: until disease progression
Note to All Staff (1)
Approved for use as a single agent in HER2-positive, metastatic breast cancer in patients who previously received trastuzumab and
a taxane, separately or in combination.
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 WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
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ZZtestonc,Andrew [2428787]
11/1/2016 2:54:14 PM Page 8 of 12
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT, Total Bilirubin.
Treatment Parameters
Hold and notify prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to 100K/µL or Creatinine greater
than 1.5 X ULN or ALT greater than 3 x ULN or AST greater than 3 x ULN or Total Bilirubin greater than 2 x ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to ADO-trastuzumab emtansine (KADCYLA) can occur. For first and second dose, patient should be
treated in a location to optimize emergency care. Patient must be monitored for 90 minutes after the first dose of ADO-trastuzumab
and for 30 minutes after subsequent infusions.
Patient Instructions(1)
Advise patient to contact a health care professional immediately for any of the following: new onset or worsening shortness of
breath, cough, swelling of the ankles/legs, palpitations, weight gain of more than 5 pounds in 24 hours, dizziness or loss of
consciousness. Inform patients of the possibility of severe liver injury and advise patients to immediately seek medical attention if
they experience symptoms of acute hepatitis such as nausea, vomiting, abdominal pain (especially Right Upper Quadrant abdominal
pain), jaundice, dark urine, generalized pruritus, anorexia, etc.
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 10 UNIT/ML lock flush 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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
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 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
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ZZtestonc,Andrew [2428787]
11/1/2016 2:54:14 PM Page 9 of 12
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 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
ado-trastuzumab emtansine (KADCYLA) 286 mg in sodium chloride 0.9 % 250 mL bag
286 mg (rounded from 285.84 mg = 3.6 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Administer with a 0.22 micron filter. Administer first infusion over 90 minutes and subsequent infusions over 30 minutes if tolerated.
Hypersensitivity reaction to ADO-trastuzumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. Patient must be monitored for 90 minutes after the first dose of ADO-trastuzumab and for 30 minutes after
subsequent infusions.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
AST, ALT, Total Bilirubin, Potassium; CHEMOTHERAPY ROOM APPOINTMENT: ADO-trastuzumab emtansine (KADCYLA) for 90
minutes.
Cycle 6 – 2/14/2017 through 3/6/2017 (21 days), Planned
Day 1, Cycle 6 – Planned for 2/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast (Advanced); THERAPY: ADO-trastuzumab emtansine (KADCYLA) 3.6 mg/kg IV Day 1; CYCLE LENGTH: 21
days; COURSE: until disease progression
Note to All Staff (1)
Approved for use as a single agent in HER2-positive, metastatic breast cancer in patients who previously received trastuzumab and
a taxane, separately or in combination.
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 WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
POTASSIUM
Expected-S+21 Approximate, Expires-S+365, Routine
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ZZtestonc,Andrew [2428787]
11/1/2016 2:54:14 PM Page 10 of 12
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT, Total Bilirubin.
Treatment Parameters
Hold and notify prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to 100K/µL or Creatinine greater
than 1.5 X ULN or ALT greater than 3 x ULN or AST greater than 3 x ULN or Total Bilirubin greater than 2 x ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to ADO-trastuzumab emtansine (KADCYLA) can occur. For first and second dose, patient should be
treated in a location to optimize emergency care. Patient must be monitored for 90 minutes after the first dose of ADO-trastuzumab
and for 30 minutes after subsequent infusions.
Patient Instructions(1)
Advise patient to contact a health care professional immediately for any of the following: new onset or worsening shortness of
breath, cough, swelling of the ankles/legs, palpitations, weight gain of more than 5 pounds in 24 hours, dizziness or loss of
consciousness. Inform patients of the possibility of severe liver injury and advise patients to immediately seek medical attention if
they experience symptoms of acute hepatitis such as nausea, vomiting, abdominal pain (especially Right Upper Quadrant abdominal
pain), jaundice, dark urine, generalized pruritus, anorexia, etc.
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 10 UNIT/ML lock flush 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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
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 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 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
ado-trastuzumab emtansine (KADCYLA) 286 mg in sodium chloride 0.9 % 250 mL bag
286 mg (rounded from 285.84 mg = 3.6 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Administer with a 0.22 micron filter. Administer first infusion over 90 minutes and subsequent infusions over 30 minutes if tolerated.
Hypersensitivity reaction to ADO-trastuzumab can occur. For first and second dose, patient should be treated in a location to
optimize emergency care. Patient must be monitored for 90 minutes after the first dose of ADO-trastuzumab and for 30 minutes after
subsequent infusions.
Follow-Up
DAY 22 FOLLOW-UP
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ZZtestonc,Andrew [2428787]
11/1/2016 2:54:14 PM Page 11 of 12
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
AST, ALT, Total Bilirubin, Potassium; CHEMOTHERAPY ROOM APPOINTMENT: ADO-trastuzumab emtansine (KADCYLA) for 90
minutes.
ZZtestonc,Andrew [2428787]
11/1/2016 2:54:14 PM Page 12 of 12
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org