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201706157

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UWHC,UWMF,

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

CSC GYN Etoposide(28D:1-14 Oral) VER 1-11-17 (HL 4393)

CSC GYN Etoposide(28D:1-14 Oral) VER 1-11-17 (HL 4393) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GYN


CSC GYN ETOPOSIDE(28D:1-14 ORAL) VER: 1-11-17 – Properties
Pre-Cycle – 5/30/2017 through 6/5/2017 (7 days), Planned
Day 1, Pre-Cycle – Planned for 5/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian/Fallopian Tube/Peritoneal Cancer (Advanced);
THERAPY: etoposide 50 mg by mouth alternating with 100 mg by mouth Day 1 through 14; 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
BUN
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
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 – 6/6/2017 through 7/3/2017 (28 days), Planned
Day 1, Cycle 1 – Planned for 6/6/2017
Treatment Plan Information
Reference Information (1)
OVARIAN, FALLOPIAN TUBE, PERITONEAL: Suleyman A, et al. Am J Clin Oncol 2003;26:358-62
Reference Information (2)
OVARIAN, FALLOPIAN TUBE, PERITONEAL: Ozols RF. Drugs 1999;58 Suppl.3:43-9
Treatment Plan Summary
DISEASE: Ovarian/Fallopian Tube/Peritoneal Cancer (Advanced);
THERAPY: etoposide 50 mg by mouth alternating with 100 mg by mouth Day 1 through 14; 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,Edward E [2435061]
6/6/2017 6:21:47 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

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, Platelets, BUN, Creatinine, Total Bilirubin, AST.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than ULN or Total Bilirubin greater than 1.6 mg/dL
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): etoposide (dispensed Day 1 of each cycle)
Take Home Medications
etoposide (VEPESID) 50 MG cap
Take 1 cap (50mg) orally alternating every other day with 2 caps (100mg) for 14 days., Disp-21 cap, R-0, starting S
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), BUN, Creatinine,
Total Bilirubin, AST.
Cycle 2 – 7/4/2017 through 7/31/2017 (28 days), Planned
Day 1, Cycle 2 – Planned for 7/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian/Fallopian Tube/Peritoneal Cancer (Advanced);
THERAPY: etoposide 50 mg by mouth alternating with 100 mg by mouth Day 1 through 14; 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
BUN
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
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Zztestonc,Edward E [2435061]
6/6/2017 6:21:47 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

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Platelets, BUN, Creatinine, Total Bilirubin, AST.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than ULN or Total Bilirubin greater than 1.6 mg/dL
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): etoposide (dispensed Day 1 of each cycle)
Take Home Medications
etoposide (VEPESID) 50 MG cap
Take 1 cap (50mg) orally alternating every other day with 2 caps (100mg) for 14 days., Disp-21 cap, R-0, starting S
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), BUN, Creatinine,
Total Bilirubin, AST.
Cycle 3 – 8/1/2017 through 8/28/2017 (28 days), Planned
Day 1, Cycle 3 – Planned for 8/1/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian/Fallopian Tube/Peritoneal Cancer (Advanced);
THERAPY: etoposide 50 mg by mouth alternating with 100 mg by mouth Day 1 through 14; 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
BUN
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
Treatment Conditions
Verify Labs
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Zztestonc,Edward E [2435061]
6/6/2017 6:21:47 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

Verify pretreatment labs have been obtained: CBC, ANC, Platelets, BUN, Creatinine, Total Bilirubin, AST.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than ULN or Total Bilirubin greater than 1.6 mg/dL
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): etoposide (dispensed Day 1 of each cycle)
Take Home Medications
etoposide (VEPESID) 50 MG cap
Take 1 cap (50mg) orally alternating every other day with 2 caps (100mg) for 14 days., Disp-21 cap, R-0, starting S
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), BUN, Creatinine,
Total Bilirubin, AST.
Cycle 4 – 8/29/2017 through 9/25/2017 (28 days), Planned
Day 1, Cycle 4 – Planned for 8/29/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian/Fallopian Tube/Peritoneal Cancer (Advanced);
THERAPY: etoposide 50 mg by mouth alternating with 100 mg by mouth Day 1 through 14; 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
BUN
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
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Platelets, BUN, Creatinine, Total Bilirubin, AST.
Treatment Parameters
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Zztestonc,Edward E [2435061]
6/6/2017 6:21:47 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

Hold and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than ULN or Total Bilirubin greater than 1.6 mg/dL
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): etoposide (dispensed Day 1 of each cycle)
Take Home Medications
etoposide (VEPESID) 50 MG cap
Take 1 cap (50mg) orally alternating every other day with 2 caps (100mg) for 14 days., Disp-21 cap, R-0, starting S
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), BUN, Creatinine,
Total Bilirubin, AST.
Cycle 5 – 9/26/2017 through 10/23/2017 (28 days), Planned
Day 1, Cycle 5 – Planned for 9/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian/Fallopian Tube/Peritoneal Cancer (Advanced);
THERAPY: etoposide 50 mg by mouth alternating with 100 mg by mouth Day 1 through 14; 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
BUN
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
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Platelets, BUN, Creatinine, Total Bilirubin, AST.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than ULN or Total Bilirubin greater than 1.6 mg/dL
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Zztestonc,Edward E [2435061]
6/6/2017 6:21:47 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

Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): etoposide (dispensed Day 1 of each cycle)
Take Home Medications
etoposide (VEPESID) 50 MG cap
Take 1 cap (50mg) orally alternating every other day with 2 caps (100mg) for 14 days., Disp-21 cap, R-0, starting S
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), BUN, Creatinine,
Total Bilirubin, AST.
Cycle 6 – 10/24/2017 through 11/20/2017 (28 days), Planned
Day 1, Cycle 6 – Planned for 10/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Ovarian/Fallopian Tube/Peritoneal Cancer (Advanced);
THERAPY: etoposide 50 mg by mouth alternating with 100 mg by mouth Day 1 through 14; 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
BUN
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
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Platelets, BUN, Creatinine, Total Bilirubin, AST.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1000/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than ULN or Total Bilirubin greater than 1.6 mg/dL
Treatment Medications
See Take Home Medication(s)
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Zztestonc,Edward E [2435061]
6/6/2017 6:21:47 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

Refer to the take home medications section for the following treatment medication(s): etoposide (dispensed Day 1
of each cycle)
Take Home Medications
etoposide (VEPESID) 50 MG cap
Take 1 cap (50mg) orally alternating every other day with 2 caps (100mg) for 14 days., Disp-21 cap, R-0, starting S
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), BUN, Creatinine,
Total Bilirubin, AST.
Actions
Actions
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Zztestonc,Edward E [2435061]
6/6/2017 6:21:47 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