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/clinical/cckm-tools/content/beacon-protocols/gu/name-117512-en.cckm

201706166

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UWHC,UWMF,

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

CSC GU Axitinib(28D:1-28) VER 12-1-16 (HL 4628)

CSC GU Axitinib(28D:1-28) VER 12-1-16 (HL 4628) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GU


CSC GU AXITINIB(28D1-28) VER: 12-1-16 (HL 4628) – Properties
Pre-Cycle – 6/7/2017 through 6/13/2017 (7 days), Planned
Day 1, Pre-Cycle – Planned for 6/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cell Carcinoma (Advanced); THERAPY: axitinib 5 mg by mouth twice daily continuously; CYCLE LENGTH: 28
days; COURSE: until disease progression.
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
CALCIUM
Expected-S Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S Approximate, Expires-S+365, Routine
TSH
Expected-S Approximate, Expires-S+365, Routine
URINALYSIS, NO MICROSCOPY
Expected-S Approximate, Expires-S+365, Normal, Routine
Take Home Medications
loperamide 2 MG cap
Take 2 tab by mouth with 1st loose stool followed by 1 tab every 2h or 2 tab every 4h until no diarrhea x12h. Max dose=8 tab/day,
Disp-30 cap, R-5, starting S, Local Printer
Counsel patient to purchase over the counter if not covered by insurance and provide instructions for use.
Cycle 1 – 6/14/2017 through 7/11/2017 (28 days), Planned
Day 1, Cycle 1 – Planned for 6/14/2017
Treatment Plan Information
Reference Information (1)
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Zztestonc,Jeff J [2507481]
6/14/2017 4:16:12 PM Page 1 of 7
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

RENAL CELL CARCINOMA: Rini BI, et al. Lancet 2011; 378(9807):1931-9.
Treatment Plan Summary
DISEASE: Renal Cell Carcinoma (Advanced); THERAPY: axitinib 5 mg by mouth twice daily continuously; 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
Treatment Parameters
Hold and notify authorizing prescriber for Systolic Blood Pressure greater than 160 mmHg or Diastolic Blood Pressure greater than
90 mmHg.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication: axitinib (dispensed Day 1 of Cycle 1 only -
subsequent refills will be ordered through the medication activity).
Take Home Medications
axitinib (INLYTA) 5 MG tab
Take 1 tab by mouth 2 times daily., 5 mg, Disp-60 tab, R-0, 2 X DAILY starting S, Local Printer
Follow-Up
Day 29 Follow-Up
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC (DIFF if to be done
locally), Creatinine, Calcium, Albumin, AST, ALT, Alkaline Phosphatase, Total Bilirubin, LDH, TSH, Urinalysis without Microscopy.
Cycle 2 – 7/12/2017 through 8/8/2017 (28 days), Planned
Day 1, Cycle 2 – Planned for 7/12/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cell Carcinoma (Advanced); THERAPY: axitinib 5 mg by mouth twice daily continuously; 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 WITHOUT DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
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Zztestonc,Jeff J [2507481]
6/14/2017 4:16:12 PM Page 2 of 7
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+365, Routine
CALCIUM
Expected-S+28 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+28 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
TSH
Expected-S+28 Approximate, Expires-S+365, Routine
URINALYSIS, NO MICROSCOPY
Expected-S+28 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Treatment Parameters
Hold and notify authorizing prescriber for Systolic Blood Pressure greater than 160 mmHg or Diastolic Blood Pressure greater than
90 mmHg.
Treatment Medications
Oral Chemotherapy Order Management
For this regimen, axitinib will be ordered through the medication activity after the initial order.
Follow-Up
Day 29 Follow-Up
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC (DIFF if to be done
locally), Creatinine, Calcium, Albumin, AST, ALT, Alkaline Phosphatase, Total Bilirubin, LDH, TSH, Urinalysis without Microscopy.
Cycle 3 – 8/9/2017 through 9/5/2017 (28 days), Planned
Day 1, Cycle 3 – Planned for 8/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cell Carcinoma (Advanced); THERAPY: axitinib 5 mg by mouth twice daily continuously; 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 WITHOUT DIFFERENTIAL
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Zztestonc,Jeff J [2507481]
6/14/2017 4:16:12 PM Page 3 of 7
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+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+28 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+28 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
TSH
Expected-S+28 Approximate, Expires-S+365, Routine
URINALYSIS, NO MICROSCOPY
Expected-S+28 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Treatment Parameters
Hold and notify authorizing prescriber for Systolic Blood Pressure greater than 160 mmHg or Diastolic Blood Pressure greater than
90 mmHg.
Treatment Medications
Oral Chemotherapy Order Management
For this regimen, axitinib will be ordered through the medication activity after the initial order.
Follow-Up
Day 29 Follow-Up
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC (DIFF if to be done
locally), Creatinine, Calcium, Albumin, AST, ALT, Alkaline Phosphatase, Total Bilirubin, LDH, TSH, Urinalysis without Microscopy.
Cycle 4 – 9/6/2017 through 10/3/2017 (28 days), Planned
Day 1, Cycle 4 – Planned for 9/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cell Carcinoma (Advanced); THERAPY: axitinib 5 mg by mouth twice daily continuously; CYCLE LENGTH: 28
days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
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Zztestonc,Jeff J [2507481]
6/14/2017 4:16:12 PM Page 4 of 7
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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+28 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+28 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+28 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
TSH
Expected-S+28 Approximate, Expires-S+365, Routine
URINALYSIS, NO MICROSCOPY
Expected-S+28 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Treatment Parameters
Hold and notify authorizing prescriber for Systolic Blood Pressure greater than 160 mmHg or Diastolic Blood Pressure greater than
90 mmHg.
Treatment Medications
Oral Chemotherapy Order Management
For this regimen, axitinib will be ordered through the medication activity after the initial order.
Follow-Up
Day 29 Follow-Up
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC (DIFF if to be done
locally), Creatinine, Calcium, Albumin, AST, ALT, Alkaline Phosphatase, Total Bilirubin, LDH, TSH, Urinalysis without Microscopy.
Cycle 5 – 10/4/2017 through 10/31/2017 (28 days), Planned
Day 1, Cycle 5 – Planned for 10/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cell Carcinoma (Advanced); THERAPY: axitinib 5 mg by mouth twice daily continuously; CYCLE LENGTH: 28
days; COURSE: until disease progression.
Consent
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Zztestonc,Jeff J [2507481]
6/14/2017 4:16:12 PM Page 5 of 7
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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+28 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+28 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+28 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
TSH
Expected-S+28 Approximate, Expires-S+365, Routine
URINALYSIS, NO MICROSCOPY
Expected-S+28 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Treatment Parameters
Hold and notify authorizing prescriber for Systolic Blood Pressure greater than 160 mmHg or Diastolic Blood Pressure greater than
90 mmHg.
Treatment Medications
Oral Chemotherapy Order Management
For this regimen, axitinib will be ordered through the medication activity after the initial order.
Follow-Up
Day 29 Follow-Up
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC (DIFF if to be done
locally), Creatinine, Calcium, Albumin, AST, ALT, Alkaline Phosphatase, Total Bilirubin, LDH, TSH, Urinalysis without Microscopy.
Cycle 6 – 11/1/2017 through 11/28/2017 (28 days), Planned
Day 1, Cycle 6 – Planned for 11/1/2017
Treatment Plan Information
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Zztestonc,Jeff J [2507481]
6/14/2017 4:16:12 PM Page 6 of 7
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: axitinib 5 mg by mouth twice daily continuously; 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 WITHOUT DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+28 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+28 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
TSH
Expected-S+28 Approximate, Expires-S+365, Routine
URINALYSIS, NO MICROSCOPY
Expected-S+28 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Treatment Parameters
Hold and notify authorizing prescriber for Systolic Blood Pressure greater than 160 mmHg or Diastolic Blood Pressure greater than
90 mmHg.
Treatment Medications
Oral Chemotherapy Order Management
For this regimen, axitinib will be ordered through the medication activity after the initial order.
Follow-Up
Day 29 Follow-Up
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC (DIFF if to be done
locally), Creatinine, Calcium, Albumin, AST, ALT, Alkaline Phosphatase, Total Bilirubin, LDH, TSH, Urinalysis without Microscopy.
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Zztestonc,Jeff J [2507481]
6/14/2017 4:16:12 PM Page 7 of 7
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org