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201706166

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CSC GU Sunitinib(42D:Daily 4 Weeks On/2 Weeks Off) VER 12-1-16 (HL 935)

CSC GU Sunitinib(42D:Daily 4 Weeks On/2 Weeks Off) VER 12-1-16 (HL 935) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GU


CSC GU SUNITINIB(42D:DAILY 4 WEEKS ON/2WEEKS OFF) VER: 12-1-16 (HL 935) – 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 Cancer (Advanced); THERAPY: sunitinib 50 mg by mouth once daily for 4 weeks followed by 2 weeks off;
CYCLE LENGTH: Cycle 1 = 28 days; Cycles 2 and greater = 42 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
BILIRUBIN, TOTAL
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
CALCIUM
Expected-S Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S Approximate, Expires-S+365, Routine
URINALYSIS, NO MICROSCOPY
Expected-S Approximate, Expires-S+365, Normal, Routine
TSH
Expected-S Approximate, Expires-S+365, Routine
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 CANCER: Motzer RJ, et al. N Engl J Med 2007;356:115-24.
Treatment Plan Summary
DISEASE: Renal Cell Cancer (Advanced); THERAPY: sunitinib 50 mg by mouth once daily for 4 weeks followed by 2 weeks off;
CYCLE LENGTH: Cycle 1 = 28 days; Cycles 2 and greater = 42 days; COURSE: until disease progression.
Consent
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Zztestonc,Jeff J [2507481]
6/15/2017 8:04:12 AM Page 1 of 8
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.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: CBC, ANC, Urinalysis (without microscopy).
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or Urine
protein greater than 100 mg/dL or Blood Pressure greater than 140/90 mmHg.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): sunitinib (dispensed on Day 1 of Cycle 1 only -
subsequent refills will be ordered through the medication activity).
Take Home Medications
sunitinib (SUTENT) 50 MG cap
Take 1 cap by mouth one time daily. Take for 28 days, followed by 14 days off., 50 mg, Disp-28 cap, R-0, 1 X DAILY starting S
Follow-Up
DAY 29 FOLLOW-UP
Schedule end-of-dosing period appointment(s) as follows: RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC
(DIFF if to be done locally), Creatinine, Calcium, Alkaline Phosphatase, AST, ALT, Albumin, Total Bilirubin, Phosphate, Urinalysis
without microscopy, TSH.
Cycle 2 – 7/13/2017 through 8/23/2017 (42 days), Planned
Day 1, Cycle 2 – Planned for 7/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cell Cancer (Advanced); THERAPY: sunitinib 50 mg by mouth once daily for 4 weeks followed by 2 weeks off;
CYCLE LENGTH: Cycle 1 = 28 days; Cycles 2 and greater = 42 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
BILIRUBIN, TOTAL
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Zztestonc,Jeff J [2507481]
6/15/2017 8:04:12 AM Page 2 of 8
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
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
CALCIUM
Expected-S+28 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+28 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+28 Approximate, Expires-S+365, Routine
URINALYSIS, NO MICROSCOPY
Expected-S+28 Approximate, Expires-S+365, Normal, Routine
TSH
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: CBC, ANC, Urinalysis (without microscopy).
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or Urine
protein greater than 100 mg/dL or Blood Pressure greater than 140/90 mmHg.
Treatment Medications
Oral Chemotherapy Order Management
For this regimen, sunitinib will be ordered through the medication activity after the initial order.
Follow-Up
DAY 43 FOLLOW-UP
Schedule end-of-dosing period appointment(s) as follows: RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC
(DIFF if to be done locally), Creatinine, Calcium, Alkaline Phosphatase, AST, ALT, Albumin, Total Bilirubin, Phosphate, Urinalysis
without microscopy, TSH.
Cycle 3 – 8/24/2017 through 10/4/2017 (42 days), Planned
Day 1, Cycle 3 – Planned for 8/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cell Cancer (Advanced); THERAPY: sunitinib 50 mg by mouth once daily for 4 weeks followed by 2 weeks off;
CYCLE LENGTH: Cycle 1 = 28 days; Cycles 2 and greater = 42 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
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Zztestonc,Jeff J [2507481]
6/15/2017 8:04:12 AM Page 3 of 8
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

CBC WITHOUT DIFFERENTIAL
Expected-S+42 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+42 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+42 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+42 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+42 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+42 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+42 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+42 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+42 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+42 Approximate, Expires-S+365, Routine
URINALYSIS, NO MICROSCOPY
Expected-S+42 Approximate, Expires-S+365, Normal, Routine
TSH
Expected-S+42 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: CBC, ANC, Urinalysis (without microscopy).
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or Urine
protein greater than 100 mg/dL or Blood Pressure greater than 140/90 mmHg.
Treatment Medications
Oral Chemotherapy Order Management
For this regimen, sunitinib will be ordered through the medication activity after the initial order.
Follow-Up
DAY 43 FOLLOW-UP
Schedule end-of-dosing period appointment(s) as follows: RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC
(DIFF if to be done locally), Creatinine, Calcium, Alkaline Phosphatase, AST, ALT, Albumin, Total Bilirubin, Phosphate, Urinalysis
without microscopy, TSH.
Cycle 4 – 10/5/2017 through 11/15/2017 (42 days), Planned
Day 1, Cycle 4 – Planned for 10/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cell Cancer (Advanced); THERAPY: sunitinib 50 mg by mouth once daily for 4 weeks followed by 2 weeks off;
CYCLE LENGTH: Cycle 1 = 28 days; Cycles 2 and greater = 42 days; COURSE: until disease progression.
Consent
Verify Consent
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Zztestonc,Jeff J [2507481]
6/15/2017 8:04:12 AM Page 4 of 8
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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+42 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+42 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+42 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+42 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+42 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+42 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+42 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+42 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+42 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+42 Approximate, Expires-S+365, Routine
URINALYSIS, NO MICROSCOPY
Expected-S+42 Approximate, Expires-S+365, Normal, Routine
TSH
Expected-S+42 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: CBC, ANC, Urinalysis (without microscopy).
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or Urine
protein greater than 100 mg/dL or Blood Pressure greater than 140/90 mmHg.
Treatment Medications
Oral Chemotherapy Order Management
For this regimen, sunitinib will be ordered through the medication activity after the initial order.
Follow-Up
DAY 43 FOLLOW-UP
Schedule end-of-dosing period appointment(s) as follows: RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC
(DIFF if to be done locally), Creatinine, Calcium, Alkaline Phosphatase, AST, ALT, Albumin, Total Bilirubin, Phosphate, Urinalysis
without microscopy, TSH.
Cycle 5 – 11/16/2017 through 12/27/2017 (42 days), Planned
Day 1, Cycle 5 – Planned for 11/16/2017
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Zztestonc,Jeff J [2507481]
6/15/2017 8:04:12 AM Page 5 of 8
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cell Cancer (Advanced); THERAPY: sunitinib 50 mg by mouth once daily for 4 weeks followed by 2 weeks off;
CYCLE LENGTH: Cycle 1 = 28 days; Cycles 2 and greater = 42 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+42 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+42 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+42 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+42 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+42 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+42 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+42 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+42 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+42 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+42 Approximate, Expires-S+365, Routine
URINALYSIS, NO MICROSCOPY
Expected-S+42 Approximate, Expires-S+365, Normal, Routine
TSH
Expected-S+42 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: CBC, ANC, Urinalysis (without microscopy).
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 75K/µL or Urine
protein greater than 100 mg/dL or Blood Pressure greater than 140/90 mmHg.
Treatment Medications
Oral Chemotherapy Order Management
For this regimen, sunitinib will be ordered through the medication activity after the initial order.
Follow-Up
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Zztestonc,Jeff J [2507481]
6/15/2017 8:04:12 AM Page 6 of 8
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

DAY 43 FOLLOW-UP
Schedule end-of-dosing period appointment(s) as follows: RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC
(DIFF if to be done locally), Creatinine, Calcium, Alkaline Phosphatase, AST, ALT, Albumin, Total Bilirubin, Phosphate, Urinalysis
without microscopy, TSH.
Cycle 6 – 12/28/2017 through 2/7/2018 (42 days), Planned
Day 1, Cycle 6 – Planned for 12/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Renal Cell Cancer (Advanced); THERAPY: sunitinib 50 mg by mouth once daily for 4 weeks followed by 2 weeks off;
CYCLE LENGTH: Cycle 1 = 28 days; Cycles 2 and greater = 42 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+42 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+42 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+42 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+42 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+42 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+42 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+42 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+42 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+42 Approximate, Expires-S+365, Routine
PHOSPHATE
Expected-S+42 Approximate, Expires-S+365, Routine
URINALYSIS, NO MICROSCOPY
Expected-S+42 Approximate, Expires-S+365, Normal, Routine
TSH
Expected-S+42 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: CBC, ANC, Urinalysis (without microscopy).
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Zztestonc,Jeff J [2507481]
6/15/2017 8:04:12 AM Page 7 of 8
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to
75K/µL or Urine protein greater than 100 mg/dL or Blood Pressure greater than 140/90 mmHg.
Treatment Medications
Oral Chemotherapy Order Management
For this regimen, sunitinib will be ordered through the medication activity after the initial order.
Follow-Up
DAY 43 FOLLOW-UP
Schedule end-of-dosing period appointment(s) as follows: RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC
(DIFF if to be done locally), Creatinine, Calcium, Alkaline Phosphatase, AST, ALT, Albumin, Total Bilirubin, Phosphate, Urinalysis
without microscopy, TSH.
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Zztestonc,Jeff J [2507481]
6/15/2017 8:04:12 AM Page 8 of 8
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org