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

/clinical/cckm-tools/content/beacon-protocols/gi/name-119788-en.cckm

201708223

page

100

UWHC,UWMF,

Tools,

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

CSC GI Capecitabine(28D:1-14) Temozolomide(28D:10-14) VER 8-15-17 (HL 5054)

CSC GI Capecitabine(28D:1-14) Temozolomide(28D:10-14) VER 8-15-17 (HL 5054) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GI


CSC GI CAPECITABINE (28D:1-14)/ TEMOZOLOMIDE (28D:10-14) VER: 8-15-17 –  Properties
Pre-Cycle –  8/2/2017 through 8/8/2017 (7 days), Planned
Day 1, Pre-Cycle –  Planned for 8/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Pancreatic Endocrine Carcinoma (Advanced); THERAPY: capecitabine 750 mg/m2 by mouth twice daily Days 1
through 14, temozolomide 200 mg/m2 by mouth once daily Days 10 through 14; CYCLE LENGTH: 28 days; COURSE:
until disease progression.
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
Take Home Medications
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab orally every 8h as needed for nausea. Take 1 tab before temozolomide Day 10 thru 14., Disp-30 tab, R-5,
starting S, Local Printer
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/9/2017 3:22:41 PM Page 1 of 11
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Cycle 1 –  8/9/2017 through 9/5/2017 (28 days), Planned
Day 1, Cycle 1 –  Planned for 8/9/2017
Treatment Plan Information
Reference Information (1)
PANCREATIC ENDOCRINE CARCINOMA: Strosberg J, et al. Cancer 2011;117:268-75.
Treatment Plan Summary
DISEASE: Pancreatic Endocrine Carcinoma (Advanced); THERAPY: capecitabine 750 mg/m2 by mouth twice daily Days 1
through 14, temozolomide 200 mg/m2 by mouth once daily Days 10 through 14; CYCLE LENGTH: 28 days; COURSE:
until disease progression.
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.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 75K/µL.
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 section for the following treatment medications(s): capectibabine (Dispensed on
Day 1 of each cycle) and temozolomide (Dispensed on Day 1 of each cycle).
Take Home Medications (delete all that do not apply)
capecitabine (XELODA) 150 MG tab
Take 10 tabs by mouth 2 times daily. Take by mouth on Days 1 through 14 of Cycle., 1,500 mg (rounded from 1,470
mg = 750 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S, Local Printer
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/9/2017 3:22:41 PM Page 2 of 11
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

capecitabine (XELODA) 500 MG tab
Take 3 tabs by mouth 2 times daily. Take by mouth on Days 1 through 14 of Cycle., 1,500 mg
(rounded from 1,470 mg = 750 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X
DAILY starting S, Local Printer
temozolomide (TEMODAR) 5 MG cap
Take 78 caps by mouth one time daily. Take Day 10 thru 14. Swallow whole on empty stomach. Total daily dose =
*** mg, 390 mg (rounded from 392 mg = 200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X
DAILY starting S, Local Printer
temozolomide (TEMODAR) 20 MG cap
Take 20 caps by mouth one time daily. Take Day 10 thru 14. Swallow whole on empty stomach. Total daily dose =
*** mg, 400 mg (rounded from 392 mg = 200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X
DAILY starting S, Local Printer
temozolomide (TEMODAR) 100 MG cap
Take 4 caps by mouth one time daily. Take Day 10 thru 14. Swallow whole on empty stomach. Total daily dose = ***
mg, 400 mg (rounded from 392 mg = 200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY
starting S, Local Printer
temozolomide (TEMODAR) 250 MG cap
Take 2 caps by mouth one time daily. Take Day 10 thru 14. Swallow whole on empty stomach. Total daily dose = ***
mg, 500 mg (rounded from 392 mg = 200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY
starting S, Local Printer
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for an appointment with the provider; LABS: CBC with DIFF, Creatinine, Total
Bilirubin, ALT,
Cycle 2 –  9/6/2017 through 10/3/2017 (28 days), Planned
Day 1, Cycle 2 –  Planned for 9/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Pancreatic Endocrine Carcinoma (Advanced); THERAPY: capecitabine 750 mg/m2 by mouth twice daily Days 1
through 14, temozolomide 200 mg/m2 by mouth once daily Days 10 through 14; CYCLE LENGTH: 28 days; COURSE:
until disease progression.
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
CREATININE
200 mg/m2 (392 mg = 1.568 cap) cannot be prescribed using the selected product.
The nearest available dose is 500 mg (255 mg/m2).
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/9/2017 3:22:41 PM Page 3 of 11
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 75K/µL.
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 section for the following treatment medications(s): capectibabine (Dispensed on
Day 1 of each cycle) and temozolomide (Dispensed on Day 1 of each cycle).
Take Home Medications (delete all that do not apply)
capecitabine (XELODA) 150 MG tab
Take 10 tabs by mouth 2 times daily. Take by mouth on Days 1 through 14 of Cycle., 1,500 mg (rounded from 1,470
mg = 750 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S, Local Printer
capecitabine (XELODA) 500 MG tab
Take 3 tabs by mouth 2 times daily. Take by mouth on Days 1 through 14 of Cycle., 1,500 mg (rounded from 1,470
mg = 750 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S, Local Printer
temozolomide (TEMODAR) 5 MG cap
Take 78 caps by mouth one time daily. Take Day 10 thru 14. Swallow whole on empty stomach. Total daily dose =
*** mg, 390 mg (rounded from 392 mg = 200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X
DAILY starting S, Local Printer
temozolomide (TEMODAR) 20 MG cap
Take 20 caps by mouth one time daily. Take Day 10 thru 14. Swallow whole on empty stomach. Total daily dose =
*** mg, 400 mg (rounded from 392 mg = 200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X
DAILY starting S, Local Printer
temozolomide (TEMODAR) 100 MG cap
Take 4 caps by mouth one time daily. Take Day 10 thru 14. Swallow whole on empty stomach. Total daily dose = ***
mg, 400 mg (rounded from 392 mg = 200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY
starting S, Local Printer
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/9/2017 3:22:41 PM Page 4 of 11
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

temozolomide (TEMODAR) 250 MG cap
Take 2 caps by mouth one time daily. Take Day 10 thru 14. Swallow whole on empty stomach. Total
daily dose = *** mg, 500 mg (rounded from 392 mg = 200 mg/m2 × 1.96 m2 Treatment plan BSA from
recorded weight), R-0, 1 X DAILY starting S, Local Printer
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for an appointment with the provider; LABS: CBC with DIFF, Creatinine, Total
Bilirubin, ALT,
Cycle 3 –  10/4/2017 through 10/31/2017 (28 days), Planned
Day 1, Cycle 3 –  Planned for 10/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Pancreatic Endocrine Carcinoma (Advanced); THERAPY: capecitabine 750 mg/m2 by mouth twice daily Days 1
through 14, temozolomide 200 mg/m2 by mouth once daily Days 10 through 14; CYCLE LENGTH: 28 days; COURSE:
until disease progression.
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
CREATININE
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
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 75K/µL.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
200 mg/m2 (392 mg = 1.568 cap) cannot be prescribed using the selected product.
The nearest available dose is 500 mg (255 mg/m2).
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/9/2017 3:22:41 PM Page 5 of 11
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

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 section for the following treatment medications(s): capectibabine (Dispensed on
Day 1 of each cycle) and temozolomide (Dispensed on Day 1 of each cycle).
Take Home Medications (delete all that do not apply)
capecitabine (XELODA) 150 MG tab
Take 10 tabs by mouth 2 times daily. Take by mouth on Days 1 through 14 of Cycle., 1,500 mg (rounded from 1,470
mg = 750 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S, Local Printer
capecitabine (XELODA) 500 MG tab
Take 3 tabs by mouth 2 times daily. Take by mouth on Days 1 through 14 of Cycle., 1,500 mg (rounded from 1,470
mg = 750 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S, Local Printer
temozolomide (TEMODAR) 5 MG cap
Take 78 caps by mouth one time daily. Take Day 10 thru 14. Swallow whole on empty stomach. Total daily dose =
*** mg, 390 mg (rounded from 392 mg = 200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X
DAILY starting S, Local Printer
temozolomide (TEMODAR) 20 MG cap
Take 20 caps by mouth one time daily. Take Day 10 thru 14. Swallow whole on empty stomach. Total daily dose =
*** mg, 400 mg (rounded from 392 mg = 200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X
DAILY starting S, Local Printer
temozolomide (TEMODAR) 100 MG cap
Take 4 caps by mouth one time daily. Take Day 10 thru 14. Swallow whole on empty stomach. Total daily dose = ***
mg, 400 mg (rounded from 392 mg = 200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY
starting S, Local Printer
temozolomide (TEMODAR) 250 MG cap
Take 2 caps by mouth one time daily. Take Day 10 thru 14. Swallow whole on empty stomach. Total daily dose = ***
mg, 500 mg (rounded from 392 mg = 200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY
starting S, Local Printer
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for an appointment with the provider; LABS: CBC with DIFF, Creatinine, Total
Bilirubin, ALT,
Cycle 4 –  11/1/2017 through 11/28/2017 (28 days), Planned
Day 1, Cycle 4 –  Planned for 11/1/2017
Treatment Plan Information
200 mg/m2 (392 mg = 1.568 cap) cannot be prescribed using the selected product.
The nearest available dose is 500 mg (255 mg/m2).
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/9/2017 3:22:41 PM Page 6 of 11
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Pancreatic Endocrine Carcinoma (Advanced); THERAPY: capecitabine 750 mg/m2 by mouth twice daily Days 1
through 14, temozolomide 200 mg/m2 by mouth once daily Days 10 through 14; CYCLE LENGTH: 28 days; COURSE:
until disease progression.
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
CREATININE
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
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 75K/µL.
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 section for the following treatment medications(s): capectibabine (Dispensed on
Day 1 of each cycle) and temozolomide (Dispensed on Day 1 of each cycle).
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/9/2017 3:22:41 PM Page 7 of 11
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Take Home Medications (delete all that do not apply)
capecitabine (XELODA) 150 MG tab
Take 10 tabs by mouth 2 times daily. Take by mouth on Days 1 through 14 of Cycle., 1,500 mg (rounded from 1,470
mg = 750 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S, Local Printer
capecitabine (XELODA) 500 MG tab
Take 3 tabs by mouth 2 times daily. Take by mouth on Days 1 through 14 of Cycle., 1,500 mg (rounded from 1,470
mg = 750 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S, Local Printer
temozolomide (TEMODAR) 5 MG cap
Take 78 caps by mouth one time daily. Take Day 10 thru 14. Swallow whole on empty stomach. Total daily dose =
*** mg, 390 mg (rounded from 392 mg = 200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X
DAILY starting S, Local Printer
temozolomide (TEMODAR) 20 MG cap
Take 20 caps by mouth one time daily. Take Day 10 thru 14. Swallow whole on empty stomach. Total daily dose =
*** mg, 400 mg (rounded from 392 mg = 200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X
DAILY starting S, Local Printer
temozolomide (TEMODAR) 100 MG cap
Take 4 caps by mouth one time daily. Take Day 10 thru 14. Swallow whole on empty stomach. Total daily dose = ***
mg, 400 mg (rounded from 392 mg = 200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY
starting S, Local Printer
temozolomide (TEMODAR) 250 MG cap
Take 2 caps by mouth one time daily. Take Day 10 thru 14. Swallow whole on empty stomach. Total daily dose = ***
mg, 500 mg (rounded from 392 mg = 200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY
starting S, Local Printer
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for an appointment with the provider; LABS: CBC with DIFF, Creatinine, Total
Bilirubin, ALT,
Cycle 5 –  11/29/2017 through 12/26/2017 (28 days), Planned
Day 1, Cycle 5 –  Planned for 11/29/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Pancreatic Endocrine Carcinoma (Advanced); THERAPY: capecitabine 750 mg/m2 by mouth twice daily Days 1
through 14, temozolomide 200 mg/m2 by mouth once daily Days 10 through 14; CYCLE LENGTH: 28 days; COURSE:
until disease progression.
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
200 mg/m2 (392 mg = 1.568 cap) cannot be prescribed using the selected product.
The nearest available dose is 500 mg (255 mg/m2).
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/9/2017 3:22:41 PM Page 8 of 11
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

CBC WITH DIFFERENTIAL
Expected: S+28 Approximate, Expires: S+365, Routine
CREATININE
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
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 75K/µL.
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 section for the following treatment medications(s): capectibabine (Dispensed on
Day 1 of each cycle) and temozolomide (Dispensed on Day 1 of each cycle).
Take Home Medications (delete all that do not apply)
capecitabine (XELODA) 150 MG tab
Take 10 tabs by mouth 2 times daily. Take by mouth on Days 1 through 14 of Cycle., 1,500 mg (rounded from 1,470
mg = 750 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S, Local Printer
capecitabine (XELODA) 500 MG tab
Take 3 tabs by mouth 2 times daily. Take by mouth on Days 1 through 14 of Cycle., 1,500 mg (rounded from 1,470
mg = 750 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S, Local Printer
temozolomide (TEMODAR) 5 MG cap
Take 78 caps by mouth one time daily. Take Day 10 thru 14. Swallow whole on empty stomach. Total daily dose =
*** mg, 390 mg (rounded from 392 mg = 200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X
DAILY starting S, Local Printer
temozolomide (TEMODAR) 20 MG cap
Take 20 caps by mouth one time daily. Take Day 10 thru 14. Swallow whole on empty stomach. Total daily dose =
*** mg, 400 mg (rounded from 392 mg = 200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X
DAILY starting S, Local Printer
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/9/2017 3:22:41 PM Page 9 of 11
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

temozolomide (TEMODAR) 100 MG cap
Take 4 caps by mouth one time daily. Take Day 10 thru 14. Swallow whole on empty stomach. Total
daily dose = *** mg, 400 mg (rounded from 392 mg = 200 mg/m2 × 1.96 m2 Treatment plan BSA from
recorded weight), R-0, 1 X DAILY starting S, Local Printer
temozolomide (TEMODAR) 250 MG cap
Take 2 caps by mouth one time daily. Take Day 10 thru 14. Swallow whole on empty stomach. Total daily dose = ***
mg, 500 mg (rounded from 392 mg = 200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY
starting S, Local Printer
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for an appointment with the provider; LABS: CBC with DIFF, Creatinine, Total
Bilirubin, ALT,
Cycle 6 –  12/27/2017 through 1/23/2018 (28 days), Planned
Day 1, Cycle 6 –  Planned for 12/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Pancreatic Endocrine Carcinoma (Advanced); THERAPY: capecitabine 750 mg/m2 by mouth twice daily Days 1
through 14, temozolomide 200 mg/m2 by mouth once daily Days 10 through 14; CYCLE LENGTH: 28 days; COURSE:
until disease progression.
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
CREATININE
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
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
200 mg/m2 (392 mg = 1.568 cap) cannot be prescribed using the selected product.
The nearest available dose is 500 mg (255 mg/m2).
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/9/2017 3:22:41 PM Page 10 of 11
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 75K/µL.
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 section for the following treatment medications(s): capectibabine (Dispensed on
Day 1 of each cycle) and temozolomide (Dispensed on Day 1 of each cycle).
Take Home Medications (delete all that do not apply)
capecitabine (XELODA) 150 MG tab
Take 10 tabs by mouth 2 times daily. Take by mouth on Days 1 through 14 of Cycle., 1,500 mg (rounded from 1,470
mg = 750 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S, Local Printer
capecitabine (XELODA) 500 MG tab
Take 3 tabs by mouth 2 times daily. Take by mouth on Days 1 through 14 of Cycle., 1,500 mg (rounded from 1,470
mg = 750 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S, Local Printer
temozolomide (TEMODAR) 5 MG cap
Take 78 caps by mouth one time daily. Take Day 10 thru 14. Swallow whole on empty stomach. Total daily dose =
*** mg, 390 mg (rounded from 392 mg = 200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X
DAILY starting S, Local Printer
temozolomide (TEMODAR) 20 MG cap
Take 20 caps by mouth one time daily. Take Day 10 thru 14. Swallow whole on empty stomach. Total daily dose =
*** mg, 400 mg (rounded from 392 mg = 200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X
DAILY starting S, Local Printer
temozolomide (TEMODAR) 100 MG cap
Take 4 caps by mouth one time daily. Take Day 10 thru 14. Swallow whole on empty stomach. Total daily dose = ***
mg, 400 mg (rounded from 392 mg = 200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY
starting S, Local Printer
temozolomide (TEMODAR) 250 MG cap
Take 2 caps by mouth one time daily. Take Day 10 thru 14. Swallow whole on empty stomach. Total daily dose = ***
mg, 500 mg (rounded from 392 mg = 200 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 1 X DAILY
starting S, Local Printer
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for an appointment with the provider; LABS: CBC with DIFF, Creatinine, Total
Bilirubin, ALT,
200 mg/m2 (392 mg = 1.568 cap) cannot be prescribed using the selected product.
The nearest available dose is 500 mg (255 mg/m2).
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Jeff J [2507481]
8/9/2017 3:22:41 PM Page 11 of 11
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org