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

/clinical/cckm-tools/content/beacon-protocols/gu/name-103398-en.cckm

201706166

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100

UWHC,UWMF,

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

CSC GU Everolimus(28D:1-28) Lenvatinib(28D:1-28) VER 12-1-16 (HL 5865)

CSC GU Everolimus(28D:1-28) Lenvatinib(28D:1-28) VER 12-1-16 (HL 5865) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GU


CSC GU EVEROLIMUS(28D:1-28)/LENVATINIB(28D:1-28) VER: 12-1-16 (HL 5865) – Properties
Pre-Cycle – 6/8/2017 through 6/14/2017 (7 days), Planned
Day 1, Pre-Cycle – Planned for 6/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cell Carcinoma (Advanced); THERAPY: everolimus 5 mg by mouth once daily continuously, lenvatinib 18 mg by
mouth once daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Chemotherapy Review Council approved for patients that have failed prior antiangiogenic therapy.
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
TSH
Expected-S Approximate, Expires-S+365, Routine
CHOLESTEROL
Expected-S Approximate, Expires-S+365, Routine
TRIGLYCERIDE
Expected-S Approximate, Expires-S+365, Routine
Treatment Conditions
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Zztestonc,Jeff J [2507481]
6/15/2017 7:56:38 AM Page 1 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Verify Labs
Verify pretreatment labs have been obtained: Creatinine, AST, ALT, Urinalysis without Microscopy.
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 – 6/15/2017 through 7/12/2017 (28 days), Planned
Day 1, Cycle 1 – Planned for 6/15/2017
Treatment Plan Information
Reference Information (1)
RENAL CELL CARCINOMA: Motzer RJ, et al. Lancet Oncol 2015;16:1473-82.
Reference Information (2)
Lenvatinib (LENVIMA®) [package insert]. Easai Inc; 2016.
Treatment Plan Summary
DISEASE: Renal Cell Carcinoma (Advanced); THERAPY: everolimus 5 mg by mouth once daily continuously, lenvatinib 18 mg by
mouth once daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Chemotherapy Review Council approved for patients that have failed prior antiangiogenic therapy.
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
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/uL or Platelets less than 75K/uL or Creatinine greater than 3
X ULN or AST greater than 5 X ULN or ALT greater than 5 X ULN or Urine Protein greater than or equal to 100 mg/dL or Systolic
Blood Pressure greater than 160 mmHg or Diastolic Blood Pressure greater than 100 mmHg.
Treatment Condition A
Verify ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor blood pressure after 1 week, then every 2 weeks for the first 2 months, and then at least monthly thereafter during treatment
with lenvatinib.
Patient Instructions(1)
Patient to monitor blood pressure regularly and call clinic if Systolic Blood Pressure greater than or equal to 160 mmHg or Diastolic
Blood Pressure greater than or equal to 100 mmHg.
Patient Instructions(2)
Stomatitis is a common side effect of everolimus. Educate patient on the importance of good oral hygiene. If mouth sores become
severe, contact the clinic.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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Zztestonc,Jeff J [2507481]
6/15/2017 7:56:38 AM Page 2 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@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.
Treatment Medications
See Take Home Medication(s)
Refer to the Take Home Medications category for the following treatment medication(s): everolimus, lenvatinib dispensed Day 1 of
Cycle 1 only - subsequent refills will be ordered through the Medication Activity.
Take Home Medications
everolimus (AFINITOR) 5 MG tab
Take 1 tab by mouth one time daily., 5 mg, Disp-28 tab, R-0, 1 X DAILY starting S, Local Printer
lenvatinib 18 mg daily dose (LENVIMA) 10 & 4 (2) MG capsule therapy pack
Take one 10 mg and two 4 mg caps (18 mg total dose) by mouth once daily continuously., Disp-1 each, R-0, starting S, Print for Fax
Note to All Staff (1)
Lenvatinib must be ordered through a specialty pharmacy (Accredo Specialty Pharmacy or Biologics Specialty Pharmacy). Please
contact pharmacist for assistance in ordering. Pharmacist: see Reference Link section of Oncology Navigator for link to lenvatinib
ordering information.
Follow-Up
DAY 15 FOLLOW-UP
LABS: AST, ALT.
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, TSH,
Cholesterol, Triglycerides.
Lab Only - Day 15, Cycle 1 – Planned for 6/29/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cell Carcinoma (Advanced); THERAPY: everolimus 5 mg by mouth once daily continuously, lenvatinib 18 mg by
mouth once daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Chemotherapy Review Council approved for patients that have failed prior antiangiogenic therapy.
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
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
ALT/SGPT
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.
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Zztestonc,Jeff J [2507481]
6/15/2017 7:56:38 AM Page 3 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Cycle 2 – 7/13/2017 through 8/9/2017 (28 days), Planned
Day 1, Cycle 2 – Planned for 7/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cell Carcinoma (Advanced); THERAPY: everolimus 5 mg by mouth once daily continuously, lenvatinib 18 mg by
mouth once daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Chemotherapy Review Council approved for patients that have failed prior antiangiogenic therapy.
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
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+397, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+397, Routine
BUN
Expected-S+28 Approximate, Expires-S+397, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+397, Routine
CALCIUM
Expected-S+28 Approximate, Expires-S+397, Routine
ALBUMIN
Expected-S+28 Approximate, Expires-S+397, Routine
PROTEIN, TOTAL
Expected-S+28 Approximate, Expires-S+397, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+397, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+397, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+397, Routine
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+397, Routine
URINALYSIS, NO MICROSCOPY
Expected-S+28 Approximate, Expires-S+365, Normal, Routine
TSH
Expected-S+28 Approximate, Expires-S+365, Routine
CHOLESTEROL
Expected-S+28 Approximate, Expires-S+365, Routine
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Zztestonc,Jeff J [2507481]
6/15/2017 7:56:38 AM Page 4 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

TRIGLYCERIDE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Creatinine, AST, ALT, Urinalysis without Microscopy.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/uL or Platelets less than 75K/uL or Creatinine greater than 3
X ULN or AST greater than 5 X ULN or ALT greater than 5 X ULN or Urine Protein greater than or equal to 100 mg/dL or Systolic
Blood Pressure greater than 160 mmHg or Diastolic Blood Pressure greater than 100 mmHg.
Treatment Conditions (delete all that do not apply)
Treatment Condition A
Verify ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor blood pressure after 1 week, then every 2 weeks for the first 2 months, and then at least monthly thereafter during treatment
with lenvatinib.
Patient Instructions(1)
Patient to monitor blood pressure regularly and call clinic if Systolic Blood Pressure greater than or equal to 160 mmHg or Diastolic
Blood Pressure greater than or equal to 100 mmHg.
Patient Instructions(2)
Stomatitis is a common side effect of everolimus. Educate patient on the importance of good oral hygiene. If mouth sores become
severe, contact the clinic.
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, everolimus and lenvatinib will be ordered through the medication activity after the initial order.
Note to All Staff (1)
Lenvatinib must be ordered through a specialty pharmacy (Accredo Specialty Pharmacy or Biologics Specialty Pharmacy). Please
contact pharmacist for assistance ordering. Pharmacist: see Reference Link section of Oncology Navigator for link to lenvatinib
ordering information.
Follow-Up
DAY 15 FOLLOW-UP
LABS: AST, ALT.
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, TSH,
Cholesterol, Triglycerides.
Lab Only - Day 15, Cycle 2 – Planned for 7/14/2017
Treatment Plan Information
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Zztestonc,Jeff J [2507481]
6/15/2017 7:56:38 AM Page 5 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Renal Cell Carcinoma (Advanced); THERAPY: everolimus 5 mg by mouth once daily continuously,
lenvatinib 18 mg by mouth once daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease
progression.
Note to All Staff (1)
Chemotherapy Review Council approved for patients that have failed prior antiangiogenic therapy.
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
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
ALT/SGPT
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 – 8/10/2017 through 9/6/2017 (28 days), Planned
Day 1, Cycle 3 – Planned for 8/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cell Carcinoma (Advanced); THERAPY: everolimus 5 mg by mouth once daily continuously, lenvatinib 18 mg by
mouth once daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Chemotherapy Review Council approved for patients that have failed prior antiangiogenic therapy.
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
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+397, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+397, Routine
BUN
Expected-S+28 Approximate, Expires-S+397, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+397, Routine
CALCIUM
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Zztestonc,Jeff J [2507481]
6/15/2017 7:56:38 AM Page 6 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Expected-S+28 Approximate, Expires-S+397, Routine
ALBUMIN
Expected-S+28 Approximate, Expires-S+397, Routine
PROTEIN, TOTAL
Expected-S+28 Approximate, Expires-S+397, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+397, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+397, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+397, Routine
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+397, Routine
URINALYSIS, NO MICROSCOPY
Expected-S+28 Approximate, Expires-S+365, Normal, Routine
TSH
Expected-S+28 Approximate, Expires-S+365, Routine
CHOLESTEROL
Expected-S+28 Approximate, Expires-S+365, Routine
TRIGLYCERIDE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Creatinine, AST, ALT, Urinalysis without Microscopy.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/uL or Platelets less than 75K/uL or Creatinine greater than 3
X ULN or AST greater than 5 X ULN or ALT greater than 5 X ULN or Urine Protein greater than or equal to 100 mg/dL or Systolic
Blood Pressure greater than 160 mmHg or Diastolic Blood Pressure greater than 100 mmHg.
Treatment Conditions (delete all that do not apply)
Treatment Condition A
Verify ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor blood pressure after 1 week, then every 2 weeks for the first 2 months, and then at least monthly thereafter during treatment
with lenvatinib.
Patient Instructions(1)
Patient to monitor blood pressure regularly and call clinic if Systolic Blood Pressure greater than or equal to 160 mmHg or Diastolic
Blood Pressure greater than or equal to 100 mmHg.
Patient Instructions(2)
Stomatitis is a common side effect of everolimus. Educate patient on the importance of good oral hygiene. If mouth sores become
severe, contact the clinic.
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
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Zztestonc,Jeff J [2507481]
6/15/2017 7:56:38 AM Page 7 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@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.
Treatment Medications
Oral Chemotherapy Order Management
For this regimen, everolimus and lenvatinib will be ordered through the medication activity after the initial order.
Note to All Staff (1)
Lenvatinib must be ordered through a specialty pharmacy (Accredo Specialty Pharmacy or Biologics Specialty Pharmacy). Please
contact pharmacist for assistance ordering. Pharmacist: see Reference Link section of Oncology Navigator for link to lenvatinib
ordering information.
Follow-Up
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, TSH,
Cholesterol, Triglycerides.
Cycle 4 – 9/7/2017 through 10/4/2017 (28 days), Planned
Day 1, Cycle 4 – Planned for 9/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cell Carcinoma (Advanced); THERAPY: everolimus 5 mg by mouth once daily continuously, lenvatinib 18 mg by
mouth once daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Chemotherapy Review Council approved for patients that have failed prior antiangiogenic therapy.
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
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+397, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+397, Routine
BUN
Expected-S+28 Approximate, Expires-S+397, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+397, Routine
CALCIUM
Expected-S+28 Approximate, Expires-S+397, Routine
ALBUMIN
Expected-S+28 Approximate, Expires-S+397, Routine
PROTEIN, TOTAL
Expected-S+28 Approximate, Expires-S+397, Routine
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Zztestonc,Jeff J [2507481]
6/15/2017 7:56:38 AM Page 8 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+397, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+397, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+397, Routine
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+397, Routine
URINALYSIS, NO MICROSCOPY
Expected-S+28 Approximate, Expires-S+365, Normal, Routine
TSH
Expected-S+28 Approximate, Expires-S+365, Routine
CHOLESTEROL
Expected-S+28 Approximate, Expires-S+365, Routine
TRIGLYCERIDE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Creatinine, AST, ALT, Urinalysis without Microscopy.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/uL or Platelets less than 75K/uL or Creatinine greater than 3
X ULN or AST greater than 5 X ULN or ALT greater than 5 X ULN or Urine Protein greater than or equal to 100 mg/dL or Systolic
Blood Pressure greater than 160 mmHg or Diastolic Blood Pressure greater than 100 mmHg.
Treatment Conditions (delete all that do not apply)
Treatment Condition A
Verify ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor blood pressure after 1 week, then every 2 weeks for the first 2 months, and then at least monthly thereafter during treatment
with lenvatinib.
Patient Instructions(1)
Patient to monitor blood pressure regularly and call clinic if Systolic Blood Pressure greater than or equal to 160 mmHg or Diastolic
Blood Pressure greater than or equal to 100 mmHg.
Patient Instructions(2)
Stomatitis is a common side effect of everolimus. Educate patient on the importance of good oral hygiene. If mouth sores become
severe, contact the clinic.
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, everolimus and lenvatinib will be ordered through the medication activity after the initial order.
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Zztestonc,Jeff J [2507481]
6/15/2017 7:56:38 AM Page 9 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Note to All Staff (1)
Lenvatinib must be ordered through a specialty pharmacy (Accredo Specialty Pharmacy or Biologics Specialty Pharmacy). Please
contact pharmacist for assistance ordering. Pharmacist: see Reference Link section of Oncology Navigator for link to lenvatinib
ordering information.
Follow-Up
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, TSH,
Cholesterol, Triglycerides.
Cycle 5 – 10/5/2017 through 11/1/2017 (28 days), Planned
Day 1, Cycle 5 – Planned for 10/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cell Carcinoma (Advanced); THERAPY: everolimus 5 mg by mouth once daily continuously, lenvatinib 18 mg by
mouth once daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Chemotherapy Review Council approved for patients that have failed prior antiangiogenic therapy.
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
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+397, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+397, Routine
BUN
Expected-S+28 Approximate, Expires-S+397, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+397, Routine
CALCIUM
Expected-S+28 Approximate, Expires-S+397, Routine
ALBUMIN
Expected-S+28 Approximate, Expires-S+397, Routine
PROTEIN, TOTAL
Expected-S+28 Approximate, Expires-S+397, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+397, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+397, Routine
ALT/SGPT
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Zztestonc,Jeff J [2507481]
6/15/2017 7:56:38 AM Page 10 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Expected-S+28 Approximate, Expires-S+397, Routine
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+397, Routine
URINALYSIS, NO MICROSCOPY
Expected-S+28 Approximate, Expires-S+365, Normal, Routine
TSH
Expected-S+28 Approximate, Expires-S+365, Routine
CHOLESTEROL
Expected-S+28 Approximate, Expires-S+365, Routine
TRIGLYCERIDE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Creatinine, AST, ALT, Urinalysis without Microscopy.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/uL or Platelets less than 75K/uL or Creatinine greater than 3
X ULN or AST greater than 5 X ULN or ALT greater than 5 X ULN or Urine Protein greater than or equal to 100 mg/dL or Systolic
Blood Pressure greater than 160 mmHg or Diastolic Blood Pressure greater than 100 mmHg.
Treatment Conditions (delete all that do not apply)
Treatment Condition A
Verify ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor blood pressure after 1 week, then every 2 weeks for the first 2 months, and then at least monthly thereafter during treatment
with lenvatinib.
Patient Instructions(1)
Patient to monitor blood pressure regularly and call clinic if Systolic Blood Pressure greater than or equal to 160 mmHg or Diastolic
Blood Pressure greater than or equal to 100 mmHg.
Patient Instructions(2)
Stomatitis is a common side effect of everolimus. Educate patient on the importance of good oral hygiene. If mouth sores become
severe, contact the clinic.
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, everolimus and lenvatinib will be ordered through the medication activity after the initial order.
Note to All Staff (1)
Lenvatinib must be ordered through a specialty pharmacy (Accredo Specialty Pharmacy or Biologics Specialty Pharmacy). Please
contact pharmacist for assistance ordering. Pharmacist: see Reference Link section of Oncology Navigator for link to lenvatinib
ordering information.
Follow-Up
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Zztestonc,Jeff J [2507481]
6/15/2017 7:56:38 AM Page 11 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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, TSH, Cholesterol, Triglycerides.
Cycle 6 – 11/2/2017 through 11/29/2017 (28 days), Planned
Day 1, Cycle 6 – Planned for 11/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cell Carcinoma (Advanced); THERAPY: everolimus 5 mg by mouth once daily continuously, lenvatinib 18 mg by
mouth once daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Chemotherapy Review Council approved for patients that have failed prior antiangiogenic therapy.
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
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+397, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+397, Routine
BUN
Expected-S+28 Approximate, Expires-S+397, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+397, Routine
CALCIUM
Expected-S+28 Approximate, Expires-S+397, Routine
ALBUMIN
Expected-S+28 Approximate, Expires-S+397, Routine
PROTEIN, TOTAL
Expected-S+28 Approximate, Expires-S+397, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+397, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+397, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+397, Routine
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+397, Routine
URINALYSIS, NO MICROSCOPY
Expected-S+28 Approximate, Expires-S+365, Normal, Routine
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Zztestonc,Jeff J [2507481]
6/15/2017 7:56:38 AM Page 12 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

TSH
Expected-S+28 Approximate, Expires-S+365, Routine
CHOLESTEROL
Expected-S+28 Approximate, Expires-S+365, Routine
TRIGLYCERIDE
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Creatinine, AST, ALT, Urinalysis without Microscopy.
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 1000/uL or Platelets less than 75K/uL or Creatinine greater than 3
X ULN or AST greater than 5 X ULN or ALT greater than 5 X ULN or Urine Protein greater than or equal to 100 mg/dL or Systolic
Blood Pressure greater than 160 mmHg or Diastolic Blood Pressure greater than 100 mmHg.
Treatment Conditions (delete all that do not apply)
Treatment Condition A
Verify ECG obtained.
Nursing Procedure, Assessment and Monitoring
Monitoring Parameters (1)
Monitor blood pressure after 1 week, then every 2 weeks for the first 2 months, and then at least monthly thereafter during treatment
with lenvatinib.
Patient Instructions(1)
Patient to monitor blood pressure regularly and call clinic if Systolic Blood Pressure greater than or equal to 160 mmHg or Diastolic
Blood Pressure greater than or equal to 100 mmHg.
Patient Instructions(2)
Stomatitis is a common side effect of everolimus. Educate patient on the importance of good oral hygiene. If mouth sores become
severe, contact the clinic.
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, everolimus and lenvatinib will be ordered through the medication activity after the initial order.
Note to All Staff (1)
Lenvatinib must be ordered through a specialty pharmacy (Accredo Specialty Pharmacy or Biologics Specialty Pharmacy). Please
contact pharmacist for assistance ordering. Pharmacist: see Reference Link section of Oncology Navigator for link to lenvatinib
ordering information.
Follow-Up
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, TSH,
Cholesterol, Triglycerides.
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Zztestonc,Jeff J [2507481]
6/15/2017 7:56:38 AM Page 13 of 13
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org