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CSC GYN Rucaparib (28D1-28) VER 5-17-17 (HL 6491)

CSC GYN Rucaparib (28D1-28) VER 5-17-17 (HL 6491) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GYN


CSC GYN RUCAPARIB (28D:1-28) VER 5-17-17 – Properties
Pre-Cycle – 5/10/2017 through 5/16/2017 (7 days), Planned
Day 1, Pre-Cycle – Planned for 5/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian Cancer (Advanced), Fallopian Tube (Advanced), Primary Peritoneal (Advanced); THERAPY: rucaparib 600 mg
by mouth twice daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
Chemotherapy Council approved rucaparib for second line monotherapy for patients with recurrent platinum sensitive advanced
ovarian, fallopian tube, primary peritoneal cancer and deleterious BRCA mutation (germline or somatic) who have been treated with
two or more prior chemotherapies.
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, Normal, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+365, Normal, Routine
CA 125
Expected-S Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE
Expected-S Approximate, Expires-S+365, 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 – 5/17/2017 through 6/13/2017 (28 days), Planned
Day 1, Cycle 1 – Planned for 5/17/2017
Treatment Plan Information
Reference Information (1)
OVARIAN CANCER: Swisher E, et al. Lancet Oncol 2017;18(1):75-87.
Treatment Plan Summary
DISEASE: Ovarian Cancer (Advanced), Fallopian Tube (Advanced), Primary Peritoneal (Advanced); THERAPY: rucaparib 600 mg
by mouth twice daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
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ZZtestonc,Diane D [2466374]
5/17/2017 3:38:41 PM Page 1 of 4
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2017CCKM@uwhealth.org

Chemotherapy Council approved rucaparib for second line monotherapy for patients with recurrent platinum
sensitive advanced ovarian, fallopian tube, primary peritoneal cancer and deleterious BRCA mutation (germline or
somatic) who have been treated with two or more prior chemotherapies.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold treatment and notify authorizing prescriber for: ANC less than 1000/uL or Platelets less than 100K/uL.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the Take Home Medications section for the following treatment medication(s): rucaparib (dispensed Day 1 of Cycle 1 only -
subsequent refills will be ordered through the medication activity).
Take Home Medications
rucaparib camsylate (RUBRACA) 300 MG tab
Take 2 tabs by mouth 2 times daily., 600 mg, Disp-120 tab, R-0, 2 X DAILY starting S, E-Prescribe
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
Total Bilirubin, AST, ALT.
Cycle 2 – 6/14/2017 through 7/11/2017 (28 days), Planned
Day 1, Cycle 2 – Planned for 6/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian Cancer (Advanced), Fallopian Tube (Advanced), Primary Peritoneal (Advanced); THERAPY: rucaparib 600 mg
by mouth twice daily continuously; CYCLE LENGTH: 28 days; COURSE: until disease progression.
Note to All Staff (1)
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,Diane D [2466374]
5/17/2017 3:38:41 PM Page 2 of 4
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2017CCKM@uwhealth.org

Chemotherapy Council approved rucaparib for second line monotherapy for patients with recurrent platinum
sensitive advanced ovarian, fallopian tube, primary peritoneal cancer and deleterious BRCA mutation (germline or
somatic) who have been treated with two or more prior chemotherapies.
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
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
CA 125
Expected-S+28 Approximate, Expires-S+365, Routine
For ovarian, fallopian tube, and primary peritoneal cancer only.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold treatment and notify authorizing prescriber for: ANC less than 1000/uL or Platelets less than 100K/uL.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
Oral Chemotherapy Order Management
For this regimen, rucaparib will be ordered through the medication activity after the initial order.
Follow-Up
DAY 29 FOLLOW-UP
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ZZtestonc,Diane D [2466374]
5/17/2017 3:38:41 PM Page 3 of 4
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2017CCKM@uwhealth.org

(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
Total Bilirubin, AST, ALT.
Cycle 3 – 7/12/2017 through 8/8/2017 (28 days), Planned
Cycle 4 – 8/9/2017 through 9/5/2017 (28 days), Planned
Cycle 5 – 9/6/2017 through 10/3/2017 (28 days), Planned
Cycle 6 – 10/4/2017 through 10/31/2017 (28 days), Planned
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ZZtestonc,Diane D [2466374]
5/17/2017 3:38:41 PM Page 4 of 4
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2017CCKM@uwhealth.org