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CSC GU Cabazitaxel(21D:1) VER 9-20-17 (HL 3536)

CSC GU Cabazitaxel(21D:1) VER 9-20-17 (HL 3536) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GU


CSC GU CABAZITAXEL(21D:1) VER: 9-20-17 – Properties
Pre-Cycle – 9/13/2017 through 9/19/2017 (7 days), Planned
Day 1, Pre-Cycle – Planned for 9/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Prostate Cancer (Advanced); THERAPY: cabazitaxel 20 to 25 mg/m2 IV Day 1, prednisone 5 mg by mouth twice daily;
CYCLE LENGTH: 21 days; COURSE: 10 cycles. NOTE: 20 mg/m2 is the standard dose.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Normal, Routine
PSA TOTAL, DIAGNOSTIC
Expected-S Approximate, Expires-S+365, Normal, 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 – 9/20/2017 through 10/10/2017 (21 days), Planned
Day 1, Cycle 1 – Planned for 9/20/2017
Treatment Plan Information
Reference Information (1)
PROSTATE CANCER: DeBono J, et al. J Clin Oncol. 2010; 28(15_suppl): Abstract 4508
Reference Information (2)
PROSTATE CANCER: DeBono JS, et al. J Clin Oncol. 2016;34(15_suppl): Abstract 5008
Treatment Plan Summary
DISEASE: Prostate Cancer (Advanced); THERAPY: cabazitaxel 20 to 25 mg/m2 IV Day 1, prednisone 5 mg by mouth twice daily;
CYCLE LENGTH: 21 days; COURSE: 10 cycles. NOTE: 20 mg/m2 is the standard dose.
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.
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ZZtestonc,Andrew [2428787]
9/20/2017 11:21:08 AM Page 1 of 14
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC, Platelets, Creatinine, Total Bilirubin, AST
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1500/µL, Platelets less than or equal to 75K/µL,
Creatinine Clearance less than 30 mL/min, Total Bilirubin greater than or equal to 1.5 mg/dL, AST greater than or equal to 1.5 X
ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to cabazitaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. ** Rush dextrose primed line with 18mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone).
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes.
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor vital signs every 15 minutes for the first and second dose. If previous doses tolerated, monitor vital signs every 30 minutes
for all subsequent doses.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Give 30 minutes prior to cabazitaxel.
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to cabazitaxel.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Give 30 minutes prior to cabazitaxel.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Emergency Medications
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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
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ZZtestonc,Andrew [2428787]
9/20/2017 11:21:08 AM Page 2 of 14
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
cabazitaxel (JEVTANA) 20 mg/m2 in dextrose 5 % 250 mL non-PVC bag
20 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity Risk. See emergency medications.
Administer via non-PVC tubing and 0.2 or 0.22 micron non-PVC in-line filter.
See Take Home Medication(s)
Refer to the Cycle 1 Day 1 take home medications section for the following treatment medication(s): predniSONE
Take Home Medications
prednisone (DELTASONE) 5 MG tab
Take 1 tab by mouth 2 times daily., 5 mg, Disp-60 tab, R-11, 2 X DAILY starting S
Follow-Up
MULTIPLE DAY FOLLOW-UP (1)
Day 8 and 15: LABS: CBC without DIFF, ANC (CBC with DIFF if drawn locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC (CBC with DIFF if drawn
locally), Creatinine, Total Bilirubin, AST, PSA; CHEMOTHERAPY ROOM APPOINTMENT: cabazitaxel for 120 minutes
Day 8 (Lab Only), Cycle 1 – Planned for 9/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Prostate Cancer (Advanced); THERAPY: cabazitaxel 20 to 25 mg/m2 IV Day 1, prednisone 5 mg by mouth twice daily;
CYCLE LENGTH: 21 days; COURSE: 10 cycles. NOTE: 20 mg/m2 is the standard dose.
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+7 Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Normal, Routine
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
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise, script will go to
nursing or tech pool. Invalid items: Pharmacy ...Details
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ZZtestonc,Andrew [2428787]
9/20/2017 11:21:08 AM Page 3 of 14
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15 (Lab Only), Cycle 1 – Planned for 10/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Prostate Cancer (Advanced); THERAPY: cabazitaxel 20 to 25 mg/m2 IV Day 1, prednisone 5 mg by mouth twice daily;
CYCLE LENGTH: 21 days; COURSE: 10 cycles. NOTE: 20 mg/m2 is the standard dose.
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+14 Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Normal, Routine
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.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 10/11/2017 through 10/31/2017 (21 days), Planned
Day 1, Cycle 2 – Planned for 10/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Prostate Cancer (Advanced); THERAPY: cabazitaxel 20 to 25 mg/m2 IV Day 1, prednisone 5 mg by mouth twice daily;
CYCLE LENGTH: 21 days; COURSE: 10 cycles. NOTE: 20 mg/m2 is the standard dose.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
9/20/2017 11:21:08 AM Page 4 of 14
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@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+21 Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
PSA TOTAL, DIAGNOSTIC
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC, Platelets, Creatinine, Total Bilirubin, AST
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1500/µL, Platelets less than or equal to 75K/µL,
Creatinine Clearance less than 30 mL/min, Total Bilirubin greater than or equal to 1.5 mg/dL, AST greater than or equal to 1.5 X
ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to cabazitaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. ** Rush dextrose primed line with 18mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone).
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes.
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor vital signs every 15 minutes for the first and second dose. If previous doses tolerated, monitor vital signs every 30 minutes
for all subsequent doses.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
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ZZtestonc,Andrew [2428787]
9/20/2017 11:21:08 AM Page 5 of 14
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

10 mg, Intravenous, ONCE, 1 dose Starting when released
Give 30 minutes prior to cabazitaxel.
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to cabazitaxel.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Give 30 minutes prior to cabazitaxel.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Emergency Medications
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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
cabazitaxel (JEVTANA) 20 mg/m2 in dextrose 5 % 250 mL non-PVC bag
20 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity Risk. See emergency medications.
Administer via non-PVC tubing and 0.2 or 0.22 micron non-PVC in-line filter.
See Take Home Medication(s)
Refer to the Cycle 1 Day 1 take home medications section for the following treatment medication(s): predniSONE
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC (CBC with DIFF if drawn
locally), Creatinine, Total Bilirubin, AST, PSA; CHEMOTHERAPY ROOM APPOINTMENT: cabazitaxel for 120 minutes
Cycle 3 – 11/1/2017 through 11/21/2017 (21 days), Planned
Day 1, Cycle 3 – Planned for 11/1/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Prostate Cancer (Advanced); THERAPY: cabazitaxel 20 to 25 mg/m2 IV Day 1, prednisone 5 mg by mouth twice daily;
CYCLE LENGTH: 21 days; COURSE: 10 cycles. NOTE: 20 mg/m2 is the standard dose.
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,Andrew [2428787]
9/20/2017 11:21:08 AM Page 6 of 14
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Expected-S+21 Approximate, Expires-S+365, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
PSA TOTAL, DIAGNOSTIC
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC, Platelets, Creatinine, Total Bilirubin, AST
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1500/µL, Platelets less than or equal to 75K/µL,
Creatinine Clearance less than 30 mL/min, Total Bilirubin greater than or equal to 1.5 mg/dL, AST greater than or equal to 1.5 X
ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to cabazitaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. ** Rush dextrose primed line with 18mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone).
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes.
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor vital signs every 15 minutes for the first and second dose. If previous doses tolerated, monitor vital signs every 30 minutes
for all subsequent doses.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Give 30 minutes prior to cabazitaxel.
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to cabazitaxel.
ranitidine (ZANTAC) injection 50 mg
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ZZtestonc,Andrew [2428787]
9/20/2017 11:21:08 AM Page 7 of 14
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Give 30 minutes prior to cabazitaxel.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Emergency Medications
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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
cabazitaxel (JEVTANA) 20 mg/m2 in dextrose 5 % 250 mL non-PVC bag
20 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity Risk. See emergency medications.
Administer via non-PVC tubing and 0.2 or 0.22 micron non-PVC in-line filter.
See Take Home Medication(s)
Refer to the Cycle 1 Day 1 take home medications section for the following treatment medication(s): predniSONE
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC (CBC with DIFF if drawn
locally), Creatinine, Total Bilirubin, AST, PSA; CHEMOTHERAPY ROOM APPOINTMENT: cabazitaxel for 120 minutes
Cycle 4 – 11/22/2017 through 12/12/2017 (21 days), Planned
Day 1, Cycle 4 – Planned for 11/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Prostate Cancer (Advanced); THERAPY: cabazitaxel 20 to 25 mg/m2 IV Day 1, prednisone 5 mg by mouth twice daily;
CYCLE LENGTH: 21 days; COURSE: 10 cycles. NOTE: 20 mg/m2 is the standard dose.
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, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
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ZZtestonc,Andrew [2428787]
9/20/2017 11:21:08 AM Page 8 of 14
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
PSA TOTAL, DIAGNOSTIC
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC, Platelets, Creatinine, Total Bilirubin, AST
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1500/µL, Platelets less than or equal to 75K/µL,
Creatinine Clearance less than 30 mL/min, Total Bilirubin greater than or equal to 1.5 mg/dL, AST greater than or equal to 1.5 X
ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to cabazitaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. ** Rush dextrose primed line with 18mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone).
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes.
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor vital signs every 15 minutes for the first and second dose. If previous doses tolerated, monitor vital signs every 30 minutes
for all subsequent doses.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Give 30 minutes prior to cabazitaxel.
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to cabazitaxel.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Give 30 minutes prior to cabazitaxel.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Emergency Medications
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ZZtestonc,Andrew [2428787]
9/20/2017 11:21:08 AM Page 9 of 14
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
cabazitaxel (JEVTANA) 20 mg/m2 in dextrose 5 % 250 mL non-PVC bag
20 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity Risk. See emergency medications.
Administer via non-PVC tubing and 0.2 or 0.22 micron non-PVC in-line filter.
See Take Home Medication(s)
Refer to the Cycle 1 Day 1 take home medications section for the following treatment medication(s): predniSONE
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC (CBC with DIFF if drawn
locally), Creatinine, Total Bilirubin, AST, PSA; CHEMOTHERAPY ROOM APPOINTMENT: cabazitaxel for 120 minutes
Cycle 5 – 12/13/2017 through 1/2/2018 (21 days), Planned
Day 1, Cycle 5 – Planned for 12/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Prostate Cancer (Advanced); THERAPY: cabazitaxel 20 to 25 mg/m2 IV Day 1, prednisone 5 mg by mouth twice daily;
CYCLE LENGTH: 21 days; COURSE: 10 cycles. NOTE: 20 mg/m2 is the standard dose.
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, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
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ZZtestonc,Andrew [2428787]
9/20/2017 11:21:08 AM Page 10 of 14
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

PSA TOTAL, DIAGNOSTIC
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: ANC, Platelets, Creatinine, Total Bilirubin, AST
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1500/µL, Platelets less than or equal to 75K/µL,
Creatinine Clearance less than 30 mL/min, Total Bilirubin greater than or equal to 1.5 mg/dL, AST greater than or equal to 1.5 X
ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to cabazitaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. ** Rush dextrose primed line with 18mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone).
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes.
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor vital signs every 15 minutes for the first and second dose. If previous doses tolerated, monitor vital signs every 30 minutes
for all subsequent doses.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Give 30 minutes prior to cabazitaxel.
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to cabazitaxel.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Give 30 minutes prior to cabazitaxel.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Emergency Medications
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 10 mg
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ZZtestonc,Andrew [2428787]
9/20/2017 11:21:08 AM Page 11 of 14
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
cabazitaxel (JEVTANA) 20 mg/m2 in dextrose 5 % 250 mL non-PVC bag
20 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity Risk. See emergency medications.
Administer via non-PVC tubing and 0.2 or 0.22 micron non-PVC in-line filter.
See Take Home Medication(s)
Refer to the Cycle 1 Day 1 take home medications section for the following treatment medication(s): predniSONE
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC (CBC with DIFF if drawn
locally), Creatinine, Total Bilirubin, AST, PSA; CHEMOTHERAPY ROOM APPOINTMENT: cabazitaxel for 120 minutes
Cycle 6 – 1/3/2018 through 1/23/2018 (21 days), Planned
Day 1, Cycle 6 – Planned for 1/3/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Prostate Cancer (Advanced); THERAPY: cabazitaxel 20 to 25 mg/m2 IV Day 1, prednisone 5 mg by mouth twice daily;
CYCLE LENGTH: 21 days; COURSE: 10 cycles. NOTE: 20 mg/m2 is the standard dose.
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, Normal, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
PSA TOTAL, DIAGNOSTIC
Expected-S+21 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
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ZZtestonc,Andrew [2428787]
9/20/2017 11:21:08 AM Page 12 of 14
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Verify pretreatment labs have been obtained: ANC, Platelets, Creatinine, Total Bilirubin, AST
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than or equal to 1500/µL, Platelets less than or equal to 75K/µL,
Creatinine Clearance less than 30 mL/min, Total Bilirubin greater than or equal to 1.5 mg/dL, AST greater than or equal to 1.5 X
ULN.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity reaction to cabazitaxel can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. ** Rush dextrose primed line with 18mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone).
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes.
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
SEE COMMENTS Starting when released Until Specified
Monitor vital signs every 15 minutes for the first and second dose. If previous doses tolerated, monitor vital signs every 30 minutes
for all subsequent doses.
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.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, ONCE, 1 dose Starting when released
Give 30 minutes prior to cabazitaxel.
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 1 Minutes
Give 30 minutes prior to cabazitaxel.
ranitidine (ZANTAC) injection 50 mg
50 mg, Intravenous, ONCE, 1 dose Starting when released, Administer over 5 Minutes
Give 30 minutes prior to cabazitaxel.
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Emergency Medications
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 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine in sodium chloride 0.9% (PEPCID) 2 MG/ML injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
Should be administered IV push over at least 2 minutes.
albuterol 2.5 mg/3 mL neb soln
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ZZtestonc,Andrew [2428787]
9/20/2017 11:21:08 AM Page 13 of 14
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
cabazitaxel (JEVTANA) 20 mg/m2 in dextrose 5 % 250 mL non-PVC bag
20 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity Risk. See emergency medications.
Administer via non-PVC tubing and 0.2 or 0.22 micron non-PVC in-line filter.
See Take Home Medication(s)
Refer to the Cycle 1 Day 1 take home medications section for the following treatment medication(s): predniSONE
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC (CBC with DIFF if drawn
locally), Creatinine, Total Bilirubin, AST, PSA; CHEMOTHERAPY ROOM APPOINTMENT: cabazitaxel for 120 minutes
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ZZtestonc,Andrew [2428787]
9/20/2017 11:21:08 AM Page 14 of 14
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org